Virginia Academy Helps Craft State Legislation Clarifying Physician, NP Roles

The interests of family physicians and nurse practitioners (NPs) used to collide regularly in the Virginia General Assembly, largely because the Virginia Council of Nurse Practitioners (VCNP) and their legislative allies had for a few years been advocating legislation that would grant NPs independent practice authority.

During those years, the Virginia Academy of Family Physicians (VAFP), the Medical Society of Virginia (MSV) and their legislative allies argued successfully against the measures, resulting in a prolonged legislative stalemate that diverted time and resources away from other pressing issues, such as physician payment and removing administrative barriers to patient care.

"Scope of practice issues always descend into a turf war that does nothing to advance family medicine," said Hunter Jamerson, lobbyist for the VAFP. "We end up on the defensive, and we are distracted from where our attention ought to be focused -- patient care and reimbursement issues."

Over time, however, the NPs started making inroads in the general assembly, convincing many lawmakers that giving NPs independent practice authority would help solve the state's ongoing shortage of health care professionals.

"Nearly two-thirds of Virginia's geographic area is designated as a health care professional shortage area, and a proposal to fill the void was the expansion of nurse practitioner scope of practice," said Jamerson.

By 2011, the general assembly was on the verge of deciding to grant NPs independent practice authority, prompting the VAFP and the MSV to take a more proactive approach by getting in front of the issue and defining NP's scope of practice on their own terms, according to Jamerson. "The physician community didn't want to risk letting others drive the conversation in the general assembly and miss the opportunity to offer a solution that we felt better served patients," he said.

Gov. Robert McDonnell and the state's secretary of health also urged physicians and NPs to solve the issue, providing an impetus for negotiations that eventually led to legislation establishing multidisciplinary patient care teams in which the physician provides leadership and management of the team. The legislation, H.B. 346, which went into effect on July 1, also prohibits NPs from practicing independently.

"The legislation clarifies that nurse practitioners shall only practice as part of a patient care team," said Jamerson. "Every NP member of the patient care team is required to have a practice agreement with the patient-care-team physician. It can be written or electronic, but it has to be retained and produced on demand if requested by the board of medicine and the board of nursing. The agreement lays out how the physician and NP will collaborate and communicate, especially about complex patient cases."

The AAFP recognized the efforts of the VAFP in the legislative battle by awarding the chapter a State Advocacy Leadership Award during the AAFP's State Legislative Conference in Memphis, Tenn., in early November. During the conference, Jamerson and Jesus Lizarzaburu, M.D., the former president of the VAFP and its current legislative chair, gave a presentation on the lobbying efforts that resulted in the enactment of H.B. 346.

In introducing the Virginia contingent, Tom Banning, CEO of the Texas AFP, described the Virginia measure as "model legislation" used in Texas and other states to "drive the debate on team-based care in a collaborative model."

It is important to note, however, that the VCNP also considers the legislation a victory for the state's NPs, making H.B. 346 a true compromise that underscores the importance of negotiation and collaboration. "We think H.B. 346 is a step in the right direction as we work toward advancing our common goal of maximizing access to safe, high-quality and affordable health care for citizens of Virginia," said Mark Coles, the government relations chair for the VCNP.

"We are pleased with the feedback we are hearing from NPs and physicians," he added.

Negotiations regarding the legislative proposal took place via conference calls and face-to-face meetings that stretched from early 2011 to the start of 2012, ending just a few weeks before the start of the 2012 legislative session. They were marked by a high level of family physician involvement and leadership.

The VAFP and the MSV both sent physician representatives to the negotiations. Lizarzaburu, who was president of the VAFP at the time, was present for all but one of the six negotiating sessions, serving as lead negotiator. VAFP member Lynne Deane, M.D., substituted for Lizarzaburu during the one meeting he could not attend because of patient obligations.

"What is best for our patients is to increase access to care under the leadership of a physician, so that our patients will benefit from that arrangement," Lizarzaburu told others during the negotiations.

Family physician Cynthia Romero, M.D., of Virginia Beach, Va., was the president of the state's medical society at the time; in this role, she was able to choose other members of the medical society -- who happened to be family physicians -- as part of the physician negotiating team, including Sterling Ransone, M.D., former president of the VAFP and an MSV board member.

"Family physicians are the best at seeking what is ideal for patients and patient care," said Romero. "We constantly seek solutions for the best outcomes in the most collaborative way, and that is exactly what we did in this case."

Within the framework of the discussion, the physician and NP representatives quickly agreed that team-based care represents the most effective means of managing and delivering patient care.

In many ways, said Romero, the law simply reflects what was already occurring in medical practice. "We are already working in teams, and we know that patients will benefit from a coordinated effort of teams. That is how we were able to make progress and move forward."

That is the not to say the process was easy, however. As Romero points out, "it took a significant amount of discussion, dialogue and compromise."

During the negotiations, the physicians soon learned that the NPs objected to a provision in the previous law that described physicians as having a supervisory role over NPs.

"That term 'supervision' was a mental road block for the nurse practitioners," said Lizarzaburu.

The physicians agreed to drop the terminology and replace it with language that characterized physicians as managers and leaders of the health care team. "This is now more about the doctor providing leadership and management of the care that is delivered by the team rather than the doctor providing the management of the NP," said Coles of the VCNP.

The talks yielded other concessions, as well. For example, Lizarzaburu stressed the importance of NPs carrying their own liability insurance as part of the patient care team. As a result, the physicians were able to secure a provision in the legislation requiring NPs to carry liability insurance if requested by the patient-care-team physician.

The previous statute also said one physician could supervise up to four NPs, but the new law says one physician can consult with up to six NPs, a loosening of the physician-to-NP ratio requirement that the VCNP sought.

The physicians, meanwhile, walked away with perhaps the biggest victory of all -- that the NPs would work within the physician-led health care team.

The final legislation sailed through the general assembly's House and Senate, effectively putting an end to legislative attempts to obtain independent practice authority for NPs for the next several years, according to Jamerson.

"My sense is that the governor and general assembly are very satisfied with the result," he said about the law.

The law has been in effect for about five months, meaning it is too early to determine its true effect on the practice of medicine in the state, according to Jamerson and family physicians interviewed by AAFP News Now. But Jamerson and others are convinced that the legislative process has provided key lessons for other AAFP chapters.

"I think the most important lesson is to keep the discussion local," said Jamerson. "There is a lot of heated rhetoric that occurs on the national level and which you hear about from other states. We quickly found that once we had doctors and nurses who work on the ground in Virginia talking to one another, we were able to cut through a lot of the nonsense pretty quickly."

Jamerson described the conference calls and, in particular, the face-to-face meetings as critical to the process because they enabled the physicians and NPs to find common ground.

Coles of the VCNP expounded on that same point, saying, "the face-to-face meetings were very crucial to clarifying misunderstandings and in building trust between the professions."

Finally, Jamerson said it is important to involve all stakeholders in the process as soon as possible. "You don't want to arrive at a solution that suits family medicine and nurse practitioners and then find out that other stakeholders have gone to the legislature seeking something different," Jamerson said.

He stressed that the proposal was not just an initiative of the VAFP. "The MSV was leading this process as well," he said. "I view this effort as a case study in how state family medicine academies and state medical societies can pool their legislative resources and influence in order to accomplish great things for family medicine and family practice patients."