AAFP Joins Push Against Greater Authority for APRNs in VA Facilities

Proposed Rule Would Undermine Physician-led, Team-based Care

July 26, 2016 12:10 pm News Staff

The AAFP has joined a long list of medical organizations in pushing back against a proposal by the Department of Veterans Affairs (VA) that would allow some nurses to practice independently inside VA facilities. The groups' letter comes on the heels of a letter the AAFP sent earlier this month protesting the VA's move.

In its May 25 proposed rule,(www.federalregister.gov) the VA sought to address the widespread shortage of physicians inside its facilities and alleviate the long wait times veterans encounter when seeking an appointment. Some veterans reported having to wait several months or longer for an appointment, which triggered legislative action by Congress in 2014.

Regulators have since followed up with further attempts to boost veterans' unfettered access to timely, appropriate care, but problems continue to plague those efforts.

In their letter to VA Under Secretary for Health David Shulkin, M.D.,(7 page PDF) the AAFP and other groups point out that the current proposed rule represents a stark change to current VA policy. Citing numerous concerns about patient safety, the wide variation in educational standards for advanced practice registered nurses (APRNs) and scope-of-practice differences among APRNs from state to state, they urge the agency to find alternative solutions.

Story Highlights
  • The AAFP joined the AMA and dozens of other groups in sending a letter to the Department of Veterans Affairs urging the agency to find alternative solutions to expanding the practice authority of nurses inside its facilities.
  • Nurses are a vital part of the medical team, as the AAFP and other signatories point out, but they should not be considered substitutes for physicians as leaders of the care team.
  • In a recent survey conducted by the AMA, four out of five patients indicated they prefer a physician to have primary responsibility for leading and coordinating their health care.

"Our nation's veterans deserve high-quality health care that is overseen by physicians," the July 22 letter reads. "The undersigned organizations strongly oppose the proposed rule and urge the VHA (Veterans Health Administration) to consider policy alternatives that prioritize team-based care rather than independent nursing practice."

Although nurses are a vital part of the health care team, the AAFP and other signatories point out, they should not be considered substitutes for physicians as leaders of the care team. The VA proposed rule also would override states' authority to regulate medical practice and the stature of health care professionals in each state, the groups add.

"APRN education and training simply does not provide the same experience (as that of physician), and as such, independent practice is not appropriate," the letter reads.

According to the most recent figures(www.aanp.org) from the American Association of Nurse Practitioners, only 21 states and the District of Columbia currently allow nurse practitioners the authority to practice independently with no restrictions, a clear indication that the majority of states are hesitant to expand nurses' roles in medical care.

"Taken together, these laws are a further indication that the proposed rule is misguided and out of step with state law and trends," the letter reads.

In a recent survey conducted by the AMA, four out of five patients indicated they prefer a physician to have primary responsibility for leading and coordinating their health care, and 78 percent of respondents agreed that nurse practitioners should not be allowed to run their own medical practices without physician involvement.

The VA's proposed rule attempted to justify its position by citing policy used in areas of the Military Health System, but a close comparison reveals gaps in the agency's argument. The Air Force Medical Service, for example, allows APRNs to act independently in their demonstrated areas of expertise, but nowhere does the Air Force state that they can operate without clinical supervision by or collaboration with a physician.

The VA even published a paper addressing the quality of care provided by APRNs, says the letter, with the authors concluding that there is insufficient evidence to support "strong conclusions or policy changes relating to extension of autonomous APRN practice."

If the rule is finalized as written, the AAFP and other signatories argue that patients should be advised about whether they will be seen by a physician or a nonphysician health professional before their appointment, and they should be permitted to reschedule the appointment with the health professional of their choice, if desired.

Finally, although the VA did consult with state nursing boards before announcing its proposed rule, it does not appear that agency officials consulted with physician organizations or state medical boards before the proposal's release, another point the AAFP and other groups criticize in their letter. In the end, they say, the rule will serve to undermine the concept of team-based care supervised by a physician.

"Patients deserve to have a physician on their team, whether that is for the treatment and management of chronic conditions, or for surgery. Nowhere is this more important than in the VHA, which delivers highly complex medical care to our nation's veterans," the letter reads.

Related AAFP News Coverage
Letter to President, Congressional Leaders
Family Physicians 'Stand Ready to Assist' Nation's Veterans

(6/11/2014)


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