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With the coming health care reforms, many states are going to be hit with an increased demand for primary health care providers. Kentucky, is one of those states, with much of it's population living in rural areas where the number of primary care providers is particularly low. In areas like these, health care professionals such as Advanced practice registered nurses (APRNs) who are trained diagnosis and treatment can assist in meeting the growing demand. But there is a problem. APRNs are graduate educated registered nurses who have passed a board certifying examination in their speciality (Family practice, Acute care, Adult or pediatric care, etc) and are licensed by their state. Rules governing what a APRN and different from state to state, with the majority of states not allowing them full scope of practice to reflect their education and training.

For weeks, the Kentucky Coalition of Nurse Practitioners and Nurse Midwives has been engaged in an effort to expand their scope of practice to be more representative of their educational training, by removing what is called the CAPA-NS collaborative agreement requirement. What this means is they would not have to have a contract with a physician for prescriptive authority over non-scheduled medications here. As current law is, a APRN needs one for non-scheduled and another for scheduled medications. These collaborative agreements in no way make a physician legally liable for the actions of the APRN, nor do they mandate that the physician supervise or even review a single chart. Should a physician end the contract, lose their license or die, the APRN loses their ability to prescribe until they can get another, and their patients are left to suffer that.

This has been a recent battle in the Kentucky legislature. If you are curious about more, or how to help, keep reading below.

So, the battle started in the Kentucky Republican controlled Senate, with Senate bill (SB 51)....

Amend KRS 314.042 to eliminate the requirement for advanced practice registered nurses to have a "Collaborative Agreement for the Advanced Practice Registered Nurse's Prescriptive Authority for Nonscheduled Legend Drugs."

Where it got stuck in committee, never brought up for a vote by the Licensing and Occupations committee chairman John Schickel, despite having enough votes to get it out of committee. The Kentucky Medical Association (much like the AMA) is generally opposed to allowing someone else to get in their domain, regardless of research showing comparative quality of care. Medical boards do not supervise APRN practice remember, nursing boards do. In any event, they had a health bill in the Democratically controlled house, SB 43, which the KMA really wanted to pass and which passed the Senate, which reads as follows...

"Amend KRS 311.860 to give the supervising physician or the credentialing facility oversight of physician assistant nonseparate location practice; allow a newly graduated physician assistant to practice in either a separate on nonseparate location as delegated by the supervising physician or the credentialing facility; eliminate the 18 month waiting period before a physician assistant may practice in a separate location; remove the board's authority to modify or waive the separate location practice privileges."

Got that? "Ease up on the PAs! APRNs, what APRNs? Oppose!" But I digress....

The past two years the Democratically controlled Kentucky House was able to pass a bill similar to the APRN bill of SB 51. So we changed tactics, and had a democratic supporter in the house add our APRN bill to their PA bill, SB 43. And it passed the House Health & Welfare Committee with four not voting because they had 'issue' with combining the bills.

".....The measure relating to nurse practitioners was added to Senate Bill 43, which passed from the Senate previously and was brought to the House committee for consideration Tuesday. The version that passed the Senate involved altering the collaborative agreements for physician assistants and reducing the waiting period for them to practice in a separate location from 18 months to 3 months. That would allow physician assistants to work in offices even if their supervising physician is not there.

Some committee members expressed concern about combining the two bills because physician assistants and nurse practitioners are different types of providers. Physician assistants operate under the license of the doctor that supervises them, while nurse practitioners are independently licensed and do not need doctor supervision....


Members of the Kentucky Medical Association oppose removing those collaborative agreements with nurse practitioners but support the changes to the agreements with physician assistants.


....The new version of the bill will now have to go to the full House for consideration and would be sent back to the Senate because of the changes."

We have the votes in the House, if they call it for a vote, we can pass it there. But, it seems the Republican controlled Senate, and probably the KMA, are not happy about the piggyback ride. And recent word I seen in my email from one of the Senators and PA bill cosponsors to his constituent was...
"I support both the PA's and The Nurse Prac. However; I feel the amendment will kill both pieces of legislation.. It is expected the senate will let both die when it returns.  Most regrettable." Senator Tom Buford (R)

Ok, so they support both, BUT, they don't like the tactic so they will just let them both die in the Senate the year before the exchanges. Way to prep for the greater good, or for the coming changes! Both bills, would improve health care access without costing the state a dime. Here, HERE they want to make a procedural stance? Uggh

I am just disgusted tonight. We are going to keep pushing, but my optimism just got punched in the gut. If you want to learn more on this, or how to help, please check out my previous two diaries, as I have been kinda concentrated on this lately.

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Comment Preferences

  •  I can say with some degree of confidence... (2+ / 0-)
    Recommended by:
    ekyprogressive, afisher

    ...that the Affordable Care Act will be an unmitigated disaster if state and federal legislatures don't pass laws enabling mid-level providers to administer care to the millions of additional patients that will be flooding our nation's health care system over the next several years.

    Like you said, rural areas are already hampered by a shortage of MDs and those docs will become even more swamped once Medicaid expansion is implemented, as it is likely to in Kentucky (Beshear hasn't explicitly committed to it, but all indications are that KY will accept Medicaid expansion).

    The AMA--and I suppose state organizations like KMA, although I'm not familiar enough with them to comment--is holding our nation hostage, artificially limiting the number of admissions to med schools so that their graduates and future constituents will be able to drive their salaries into the stratosphere.

    Any viable health care solution rests on the backs of mid level providers like APRNs. I hope your cynicism about the bill is not validated.

  •  My insurance (0+ / 0-)

    ...won't cover care by a physician's assistant or nurse practioner on their own.  They must be connected with a doctor.  This is a union plan through the Maryland BCBS outfit.  I've gotten excellent care from a couple of PAs, and my wife has gotten excellent care from a NP.  I support them.

    Too many titles.  Regardless of their path to certification, let's have PAs and NPs get the same high level training and have the same title.

    •  This is because... (1+ / 0-)
      Recommended by:

      Of this "state by state" differences in regulation. Currently APRNs and their organizations are working toward the "Consensus Model" to standardize training, scope of practice and capabilities in all 50 states. Some states NPs can bill insurance like physicians, while some of the more restrictive states like say Indiana they have to "bill" under a physician.

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