In an attempt to reduce the backlog of military veterans waiting for medical care, the Department of Veterans Affairs (VA) is seeking to unilaterally expand the scope of practice for advanced practice registered nurses (APRNs), but the AAFP is sharply criticizing the plan.
In May, the VA announced in a proposed rule(www.federalregister.gov) that it would grant APRNs in VA facilities independent practice authority. The rule removes provisions that require nurses to work in patient-centered care teams supervised by a physician.
In a forceful letter sent July 13, AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., argues that such action could jeopardize patient safety and would certainly override states' authority to regulate medical and nursing practice.
"The AAFP strongly opposes this unprecedented proposal to dismiss state practice authority via administrative rulemaking and to undermine physician-led team-based care models that have proven to be most effective in improving quality and efficiency," he says in the letter.
- The Department of Veterans Affairs (VA) is seeking to expand the scope of practice for advanced practice registered nurses (APRNs).
- The AAFP is objecting to a rule the VA has proposed that would essentially create a national nursing license, overriding states' authority to regulate the nursing profession and medical practice standards.
- In 28 states, APRNs are required to collaborate with or be supervised by physicians.
The VA's action is intended to expand access to care for the nation's veterans, many of whom have had to wait several months to obtain an appointment with a physician at a VA facility. The rule would essentially create a national nursing license that overrides states' authority to regulate the nursing profession and medical practice standards within their own borders.
According to the most recent statistics(www.aanp.org) from the American Association of Nurse Practitioners, in 29 states, nurse practitioners are required to collaborate with or be supervised by physicians. Advanced practice nurses currently have independent practice authority with no restrictions in only 21 states plus the District of Columbia.
"It is clear that states are divided on this issue of independent authority, and most do not believe it to be in the best interest of their citizens. States that have rejected these proposals have continuously cited concerns for patient safety," Wergin says in the letter.
"Having the VA overrule state laws will place veterans in an unfair position, receiving a different quality of care deemed unacceptable by state legislators for other civilians," the AAFP letter adds.
Moreover, if finalized, physicians and APRNs who practice both within and outside of the VA system would be following separate sets of rules for each setting -- a sure recipe for confusion.
The problem the VA is seeking to address stretches back to 2014, when media reports revealed that veterans who sought an appointment inside a VA facility often had to wait several months to see a physician. At that time, the AAFP offered a number of policy suggestions(2 page PDF) on how to address the patient backlog at VA facilities. That letter included a provision specifically calling for the agency to allow civilian family physicians to provide primary care for veterans.
Two months later, the Veterans Access, Choice and Accountability Act was enacted with the goal of expanding medical access for veterans. As part of the Veterans Choice Program established by the act, veterans would be eligible to seek care from a physician who is not affiliated with the VA if they could not obtain a physician appointment at the nearest VA facility within 30 days or if they lived more than 40 miles from the nearest VA facility.
Subsequent difficulties implementing the law, however, have had a chilling effect on the department's ability to achieve its goals, leading the Academy to again urge the VA to adjust its policies to smooth the way for non-VA physicians to participate in the Veterans Choice Program.
"The AAFP recognizes that access to health care for veterans is a priority and limitations to that access should be removed wherever possible," Wergin states in his letter. But, he adds, the VA has a number of options to improve access that it should pursue "rather than this unprecedented rulemaking."
"The AAFP recognizes that nurses are an integral and valuable part of a physician-led team," the letter concludes. "However, we believe that independent practice authority within the VA health system is not the answer.
"Physicians offer an unmatched service to patients and, without their skills, patients' safety would be at risk."
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