American Academy of Family Physicians @AAFP Errs on Website Criticizing #Nurses @NCSBN

The American Association of Family Physicians website had a glaringly obvious spelling goof in their headline criticizing Board Certified Advanced Practice Registered Nurses.

In a strangely ironic, even cruel twist, the American Academy of Family Physicians (AAFP) authored a letter dated 10 May 2018 criticizing the efforts of the National Council of State Boards of Nursing (NCSBN) to encourage states to expand their Nursing Scope of Practice laws to more accurately reflect uniformity of standards, and allow professionally Board Certified Advanced Practice Registered Nurses (APRN-BC) with ability, education, and training to practice to the fullest extent of their license for the benefit of patients and Public Health. News of the AAFP’s letter was published on their website 16 May.

However, since that news item’s publication, the website contained an obviously glaring spelling error, which negatively reflects upon the physicians’ professional organization, and has neither been noticed, nor corrected as of the date of publication of this entry – Saturday, 26 May 2018.

The ostensible purpose of the AAFP letter, which also carried the endorsement of 80+ professional physician organizations, was to “reconsider certain provisions” of the compact law which they claim would “alter state laws related to the scope of practice of APRNs.”

The NCSBN has encouraged states’ legislatures to author legislation to enable Nurses in member states to practice Nursing across state lines. In a sense, membership in the Nursing License Compact may be thought of in a manner similar to a Driver License – a DL in one state is valid in 49 other states, and moving violations (traffic tickets) issued by another state to the driver will be reported to the driver’s home state.

Nursing License Compact States, showing also states with pending member legislation.

According to the NCSBN “the Enhanced Nurse Licensure Compact (eNLC) increases access to care while maintaining public protection at the state level. Under the eNLC, nurses are able to provide care to patients in other eNLC states, without having to obtain additional licenses.”

Presently, there are 29 member states in the eNLC (Enhanced Nursing License Compact).

Physicians have a similar compact agreement called the Interstate Medical License Compact which was initiated 2014, and includes 22 member states. The NCSBN Nursing License Compact was initiated in 2000.

While the NCSBN and AAFP are both advocacy groups for their respective professions, there is one minor yet significantly notable exception, that being the NCSBN advocates also for patients, while the AAFP does not.

Nurses have long been patient advocates from the development of the profession some thousands of years ago, and even more so in modernity with demonstration of its importance to patient health.

It should not be misunderstood that Nurses oppose Physicians, for they do not. Rather, however, over a period of years, a “turf war” has been developing between Physicians and Nurses, especially Advanced Practice Nurses, in which Physicians oppose the delivery of healthcare services to patients, especially by Board Certified Advance Practice Registered Nurses (APRN-BC).

In their 2009 document “Changes In Healthcare Professions’ Scope of Practice: Legislative Considerations” the NCSBN referenced the October 1998 Pew Health Professions Commission report entitled “Strengthening Consumer Protection: Priorities for Healthcare Workforce Regulation” and wrote in part that “The scope of practice of a licensed healthcare profession is statutorily defined in each state’s laws in the form of a practice act. State legislatures have the authority to adopt or modify practice acts and therefore adopt or modify a particular scope of practice of a healthcare profession. Sometimes such modifications of practice acts are just the formalization of changes already occurring in education or practice within a profession, due to the results of research, advances in technology, and changes in societal healthcare demands, among other things.

“This process sometimes pits one profession against another before the state legislature. As an example, one profession may perceive another profession as “encroaching” into their area of practice. The profession may be economically or otherwise threatened and therefore opposes the other profession’s legislative effort to change scope of practice. Proposed changes in scopes of practice that are supported by one profession but opposed by other professions may be perceived by legislators and the public as “turf battles.” These turf battles are often costly and time consuming for the regulatory bodies, the professions and the legislators involved.”

The Health Resources & Services Administration (HRSA) develops shortage designation criteria to determine whether a geographic area, population group or facility is a Health Professional Shortage Area (HPSA) or a Medically Underserved Area/Population (MUA/P). HPSAs may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups, or medical or other public facilities. MUAs may be a whole county or a group of contiguous counties, a group of counties or civil divisions, or a group of urban census tracts in which residents have a shortage of health services. MUPs may include groups of persons who face economic, cultural or linguistic barriers to health care.

With a well-documented nationwide shortage of Nurses, and a decreasing interest in Family Practice and General Medicine by Medical Students, in a February 12, 2008 report entitled “PRIMARY CARE PROFESSIONALS Recent Supply Trends , Projections, and Valuation of Services” the Government Accountability Office (GAO) found “an ongoing decline in the nation’s financial support for primary care medicine,” and that “the supply of primary care professionals increased, with the supply of nonphysicians increasing faster than physicians.” They noted particularly that “Nurse practitioners accounted for most of the increase in nonphysician primary care professionals.”

The report noted specifically that a decline in the earning potential for a General/Family Practice, or Internal Medicine Physician was significantly less than specialty practices, which is also to account for the reduction in Primary Practice Physician supply. Noting that the “the predominant method of paying physicians in the U.S., encourages growth in specialty services,” the GAO also found that “the conventional pricing of physician services also disadvantages primary care physicians.”

The GAO’s concluding observation was that “payment system reforms… should not be strictly about raising fees but rather about recalibrating the value of all services, both specialty and primary care.”

Simply put, reduced physician payments by the Centers for Medicare and Medicaid Service (CMS), the nation’s largest health insurance payer – which translates as physician income – have frustrated rural healthcare, and exacerbated rural public health needs. For graduating medical students who often have significant debt, that can be the difference between pursuing low-paying Family/Primary Care/General Medicine versus a more profitable specialty like gastroenterology, or sub-specialty, such as pediatric cardiology.

Naturally, Advanced Practice Nurses have stepped up to the plate to fill the void created by the abandonment of Primary/Family Health by medical students. So for APRNs who already have advanced education and training, and most often have Board Certification, that has typically meant increased opportunity, income, responsibility, and respectability in the communities they serve, as well as an improvement of Rural Public Health.

The American Association of Nurse Anesthetists (AANA) acknowledges that “CRNAs are the primary providers of anesthesia care in rural America” and enable healthcare facilities in  “medically underserved areas to offer obstetrical, surgical, pain management and trauma stabilization services.” They note especially that “in some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals.”

As a professional organization, the AANA represents over 52,000 Certified Registered Nurse Anesthetists (CRNAs), and “promulgates education and practice standards and guidelines, and affords consultation to both private and governmental entities regarding nurse anesthetists and their practice.”

The American Medical Association (AMA), which was formed in 1847, guides, but does not establish, medical education criteria or guidelines, and historically, has opposed Medicare, Medicaid, and even private health insurance. (See: American Medical Assn. v. United States, 317 U.S. 519 (1943)
See also:
“Operation Coffeecup”: Reagan, the AMA, And the First ‘Viral Marketing’ Campaign … Against Medicare)

The AMA also continues to oppose the legalization, regulation, and taxation of cannabis (aka marijuana), and considers it a dangerous drug. As recently as 2013, Stuart Gitlow, MD, then-Chair-Elect of the AMA Council on Science and Health, and President of the American Society of Addiction Medicine, said, “The AMA today reiterated the widely held scientific view that marijuana is dangerous and should not be legalized.” Even more recently as September 2016, the AMA officially stated that “the AMA overtly opposes legalization of marijuana,” and has not changed their official position despite the January 2017, publication by the National Academies of Sciences, Engineering, and Medicine cumulative findings on the scientific research on cannabis since 1995 in “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research,” which examined “the health impacts of cannabis and cannabis-derived products – such as marijuana and active chemical compounds known as cannabinoids – ranging from their therapeutic effects to their risks for causing certain cancers, diseases, mental health disorders, and injuries,” and found little – if any – evidence to substantiate the claim made by the AMA. (See: National Academies #Marijuana Findings @theNASEM)

The AAFP’s May 10, 2018 letter asks that the NCSBN, which approved their document May 4, 2015, to “remove or substantially revise APRN Compact Article III, Sections (f) and (h), which grant prescriptive authority and allow APRNs to practice independent of a supervisory or collaborative relationship with a physician, notwithstanding state law to the contrary.”

Sections (f) and (h) of Article III of the APRN Compact read as follows:

“f. Issuance of an APRN multistate license shall include prescriptive authority for noncontrolled prescription drugs, unless the APRN was licensed by the home state prior to the home state’s adoption of this Compact and has not previously held prescriptive authority.

1. An APRN granted prescriptive authority for noncontrolled prescription drugs in the home state may exercise prescriptive authority for noncontrolled prescription drugs in any remote state while exercising a multistate licensure privilege under an APRN multistate license; the APRN shall not be required to meet any additional eligibility requirements imposed by the remote state in exercising prescriptive authority for noncontrolled prescription drugs.
2. Prescriptive authority in the home state for an APRN who was not granted prescriptive authority at the time of initial licensure by the home state, prior to the adoption of this Compact, shall be determined under home state law.
3. Prescriptive authority eligibility for an APRN holding a single-state license shall be determined under the law of the licensing state.

“h. An APRN issued a multistate license is authorized to assume responsibility and accountability for patient care independent of a supervisory or collaborative relationship with a physician.

“This authority may be exercised in the home state and in any remote state in which the APRN exercises a multistate licensure privilege.

“For an APRN issued a single state license in a party state, the requirement for a supervisory or collaborative relationship with a physician shall be determined under applicable party state law.”

It is equally tragic and sadly ironic that it has taken the AAFP a full three years to respond after the NCSBN published their proceedings. The AAFP has apparently long ignored actions taken other states to expand autonomous APN practice long before the NCSBN published their recommendations.

States such as Kentucky, Massachusetts, and Alaska had already been moving toward authorizing autonomous practice by APNs and Physician Assistants (PA) as early as the late-1980’s to early 2000’s. In 2009, in order to contain escalating healthcare costs in Massachusetts, the RAND Corporation made numerous recommendations among which included that, “Given widespread agreement that there is a critical shortage of primary care physicians in the Commonwealth, expanding scope-of-practice laws could be a viable mechanism for increasing primary care capacity and reducing health care costs.”

In 2013, Nathan Goldman, General Counsel for the Kentucky Board of Nursing, issued an opinion on October 2, which stated in concluding part that, “The APRN is individually responsible and accountable for his or her acts and decisions independent of the physician signing the APRN’s collaborative agreement for prescriptive authority. KRS 314.021. Neither the statutes nor the regulations set forth a requirement of physician supervision. In my opinion, the APRN is an independent practitioner in Kentucky.”

And as early as the 1980s, in order to increase the supply of primary care providers, especially in remote areas, “Alaska, New Hampshire, Oregon and Washington were the first states to adopt broader licensing authority for nurses.” In the 1990s, other, largely rural states – many with severe physician shortages – followed suit. And by 2013, the following states, and the District of Columbia, had autonomous practice provisions for Advance Practice Nurses:
1.) Alaska
2.) Arizona
3.) Colorado
4.) Hawaii
5.) Idaho
6.) Iowa
7.) Maine
8.) Montana
9.) Nevada
10.) New Hamphire
11.) New Mexico
12.) North Dakota
13.) Oregon
14.) Rhode Island
15.) Vermont
16.) Washington
17.) Wyoming
18.) District of Columbia

Research by the same name published in the January 2018 edition of Journal of Nursing Regulation found “Full Scope-of-Practice Regulation Is Associated With Higher Supply of Nurse Practitioners in Rural and Primary Care Health Professional Shortage Counties.”

The American Nurses Credentialing Center (ANCC), which is a subsidiary of the American Nurses Association (ANA), exists “to promote excellence in nursing and health care globally through credentialing programs,” and has not opposed improvement of Public Health through promotion of Advanced Nursing Education, and continues to promote practice with physicians for the betterment of their patients.

In fact, Nurses and the Nursing Profession have high regard for physicians, and the practice of medicine, as evidenced by this statement made by the ANCC on a brochure for the 32nd Annual Contemporary Issues in Obstetrics and Gynecology, July 17-21, 2018 which will be held in Sandestin, FL: “Nurses and Nurse Practitioners certified by the American Nurses Credentialing Association (ANCC) may use AMA credit toward certification renewal. AMA credit is acceptable by nurse practitioners certified by the American Academy of Nurse Practitioners (AANP).”

However, the words “collaborate” and “collaborative” – which defined by Merriam-Webster dictionary means “to work jointly with others or together especially in an intellectual endeavor” – as used in the sense of the relationship between a Advanced Nurse Practitioner and a Physician, is not not what it initially appears to be to the casual observer. In the sense which is used by Physicians and NPs, is it almost exclusively as a supervisory role by Physicians over NPs, in which the Physician oversees and manages, and sometimes employs, the Advanced Practice Nurse, who in many – if not most, cases – has earned, and actively holds Professional Board Certification(s) in their area of practice, whereas many Physicians do not, nor are they required to hold Board Certification by any organization, administrative rule, or state law. Whether an Engineer, Attorney, or Healthcare Professional, Board Certification is a hallmark of excellence, and credential of expertise, in one’s profession. Typically, enumeration or citation of Professional Board Certification is seen appended to one’s Professional Title, i.e., RN, MD, DO, etc., as BC. So a Board Certified Family Nurse Practitioner (FNP) would be written as Firstname Lastname, CRNP, FNP-BC. The letters CRNP stand for Certified Registered Nurse Practitioner.

It is important, even critical, to the improvement of the quality of American Healthcare and Public Health to allow Board Certified APNs to practice to the fullest extent of their education and training because while health needs have been significantly increasing, the supply of Healthcare Professionals has been diminishing. Physicians and Advanced Practice Nurses are both necessary to, and complement each other in an effort to bring healing, wholeness, cures, and care to sick people.

Nurses typically first earn a BSN (Bachelor of Science Nursing), and then pursue advanced education and training by earning a Master’s Degree in a particular area, or areas, of practice, such as Anesthesia, Family Practice, Critical Care, Cardiology, etc., which often takes up to two full years, or more, to complete. Entrance into the programs is competitive, and in some cases requires some years of work in preparation for entry. And following completion of the program(s), which includes  didactic or classroom instruction and clinical rotations, they sit for State, and or National Licensing Board examinations, in addition to taking Professional Board Certification examinations, and follow through with additional clinical practice.

Physicians, MDs and DOs, are similarly prepared, insofar as they earn an undergraduate degree, graduate from Medical School (most often 4 years), and then begin training in their area of practice which time is called a “Residency.” Depending upon the area of practice, the term of residency can endure from two, to six years. During their residency, Physicians are, once again, students, albeit with Professional Licenses, though they do not take examinations. And they are not required to be Board Certified.

The National Academies of Science, Engineering and Medicine published a report in 2010 entitled “The Future of Nursing: Leading Change, Advancing Health,” which demonstrated significant support for improvement of Public Health and delivery of American Healthcare because it acknowledged the role that Nurses, especially APNs, have had, and continue to have in delivering safe, effective, and cost-competitive healthcare in the United States. The report made key recommendations, and in part stated that:

• Nurses should practice to the full extent of their education and training.

• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

• Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

Recommendation 1: Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following actions.

For the Congress:
• Expand the Medicare program to include coverage of advanced practice registered nurse services that are within the scope of practice under applicable state law, just as physician services are now covered.

• Amend the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities.

• Extend the increase in Medicaid reimbursement rates for primary care physicians included in the ACA to advanced practice registered nurses providing similar primary care services.

• Limit federal funding for nursing education programs to only those programs in states that have adopted the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18).

For state legislatures:
• Reform scope-of-practice regulations to conform to the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18).

• Require third-party payers that participate in fee-for-service payment arrangements to provide direct reimbursement to advanced practice registered nurses who are practicing within their scope of practice under state law.

For the Centers for Medicare and Medicaid Services:
• Amend or clarify the requirements for hospital participation in the Medicare program to ensure that advanced practice registered nurses are eligible for clinical privileges, admitting privileges, and membership on medical staff.

The U.S. Departments of Veteran’s Affairs (VA), and of Defense (DOD), have long recognized and acknowledged APRNs as independent professional colleagues, and for quite some time, have authorized them to practice to the fullest scope of their practice, and with autonomy. (See: https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847; See also: https://www.federalregister.gov/documents/2016/05/25/2016-12338/advanced-practice-registered-nurses)

Regarding the United States’ model of earning a 4-year Undergraduate degree BEFORE proceeding into a profession, not all nations have, nor require an Undergraduate degree before matriculating a Professional education program. Some go directly from High School into Medical School. Like their American counterparts and professional colleagues, they too must pass examinations demonstrating their competency, and if they seek licensure in the United States (which many do), must pass the United States Medical Licensing Exam – “a three-step examination for medical licensure in the United States sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners® (NBME®)” – before being licensed in the United States. The greatest advantage, per se, to that model, is one of savings – time and money.

As evidenced by these numerous highly problematic findings, it would behoove the AAFP to reconsider their statement, and instead of complaining about trivially inconsequential matters, genuinely collaborate – work together with everyone on an equal footing – for the healing of patients, and improvement of Public Health.