WSNA Statement of Support for VA Rule Change as Regards Utilization of Advanced Practice Registered Nurses

July 13, 2016

Dear Secretary McDonald:

I am writing to support the proposed rule [RIN: 2900-AP44 - Proposed Rule - Advanced Practice Registered Nurses (81 Fed. Reg. 33155, May 25, 2016)] which takes an important step in allowing our nation’s veterans direct access to high quality health care delivered by APRNs (nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists and certified nurse midwives).

As you know, over 6,000 APRNs currently provide a full range of services to our veterans in the VHA. Implementation of this rule would expand access to high quality health care and improve the VA’s capacity to provide timely, effective and efficient care that they have earned.

Washington State was the second state in the nation to authorize advanced nursing practice and has been a leader in independent practice, prescriptive authority, nurse reimbursement and for setting standards for entry into practice since the early 1970s. Washington has a track record of steady and persistent progress that culminated in successfully achieving legal authority for advanced registered nurse practitioners to have fully autonomous practice that includes full prescriptive authority, including Schedule II-V drugs. The Washington Nurse Practice Act authorizes independent practice for ARNPs who assume responsibility and accountability for comprehensive patient care. There is no requirement for supervision by, or joint practice with, a physician in Washington and ARNPs, Nurse Anesthetists and Psychiatric Clinical Nurse Specialists have been delivering safe, quality and cost-effective care ever since. (Note: APRNs are called ARNPs in Washington State).

This was accomplished through excellent policy development and more than 40 years steady progress as evidenced by the following milestones:

• In March 1973, the Washington Governor signed Senate Bill 2213 into law, amending the Nurse Practice Act and authorizing the Board of Nursing to develop rules to implement an expanded scope of nursing practice.
• In November 1974, the Washington State Board of Nursing adopted rules authorizing advanced registered nurse (ARN) practice, effective Feb. 1, 1975. (The current title, Advanced Registered Nurse Practitioner (ARNP), was adopted in 1985).
• A bill passed in 1977 amended the pharmacy law and added advanced practice nurses to the list of individuals whose prescriptions could be lawfully processed, and the Board of Nursing adopted rules that were effective in 1979 allowing ARNPs to prescribe legend drugs.
• In 1982, prescribing Schedule V controlled substances was authorized, and the restriction to dispense drugs was removed in 1983.
• In 1983, Washington laws were amended requiring health care contractors to provide reimbursement parity among licensed health care providers performing the same health care service.
• In 1994, the rules for ARNPs were amended to require a graduate degree, rather than a master’s degree, with a concentration in advanced nursing practice.
• In 2000, a law authorized prescribing Schedule II-IV controlled substances if the ARNP obtained a Joint Practice Agreement (JPA) with a physician. The law also limited ARNPs to dispensing a 72-hour supply of Schedule II-IV drugs. The law was implemented in 2001 after rules were adopted.
• In November 2003, Washington became the ninth state to opt out of the federal physician supervision requirements for Nurse Anesthetists.
• In 2005, the requirement for a JPA was eliminated and created fully autonomous practice for Washington ARNPs.
• In 2008, the limitation on dispensing Schedule II-IV drugs was eliminated.

Based on the more than 40 years of evidence-based experience with APRNs in Washington State, the Washington State Nurses Association (WSNA) strongly endorses and supports the proposed rule [RIN: 2900-AP44 - Proposed Rule - Advanced Practice Registered Nurses (81 Fed. Reg. 33155, May 25, 2016)]
In particular, we are pleased that this rule:

• Is based on careful study and stakeholder engagement. In particular, the proposed rule implements the recommendations of the Institute of Medicine (IOM) of the National Academy of Sciences to remove scope-of-practice barriers.
• Is consistent with other efforts to improve access to high value patient-centered care. The VA notes that the proposed changes in this rulemaking would not be “completely novel or unexpected to the general public or other Federal entities that provide health care services to beneficiaries.”
• Recognizes that supervision requirements are unnecessary and costly. The FTC and the Bay Area Council Economic Institute have noted that unsubstantiated supervision increases health care costs and may exacerbate existing and projected health care workforce shortages.
• Includes each of the four APRN roles.

Thank you for moving forward with implementing this rule. It is past time that APRNs be allowed to provide safe, high quality health care that our nation’s veterans deserve.

Judy Huntington

Judy Huntington, MN, RN
Executive Director
Washington State Nurses Association