All the Information You
Need to Know about the
NY Nurse Practitioners
Modernization Act
Stephen A. Ferrara, DNP, RN, FNP-BC, FAANP
Executive Director, The Nurse Practitioner Association NYS
Associate Dean, Clinical Affairs & Assistant Professor
Columbia University, NY
The Nurse Practice Act
• Qualifications for licensure
• Nursing titles that are allowed to be used
• Scope of practice (what the nurse is allowed
to do)
• Actions that can or will happen if the nurse
does not follow the nursing law
• Passed by each State Legislature
History of New York’s Nurse Practice Act
• 1903: enacted
• 1938: defined nursing scope of practice
• 1988: Nurse Practitioners granted Title and Scope
History of New York’s Nurse Practice Act
• 1992: Midwifery* Practice Act (*Midwifery is not a
nursing profession in NY State)
• 2010: Written practice Agreement Eliminated
between a physician and midwife
• 2013: Clinical Nurse Specialist received Title
• 2014: Passage of Nurse Practitioners Modernization
Act (via the Budget Process)
Other Key Dates for NPs in New York
1992 – NPs acquire full DEA prescriptive authority
1992 – Emergency room practice and hospital coverage rights enacted
1993 – NPs gain the ability to make referrals for physical and occupational therapy
1993 – Medicaid reimbursement at 100% of the physicians' rate enacted
1997 – Medicare reimbursement at 85% of the physicians’ rate enacted
2002 – The Practice Area Bill is passed, allowing NPs to certify bus drivers physical
examinations
2003 – Respiratory Therapists now able to accept orders from NPs
2004 – Clinical Lab bill passed
2006 – Medical Emergency Utility Services Bill and Handicap License Plates Bill signed into
law
2008 – Introduction of legislation to remove Statutory Collaboration (Nurse Practitioner
Modernization Act)
2010 – NPs authorized to conduct eye examinations and complete loss of consciousness
forms with NYS DMV
2011 – Death Certificate bill signed into law
2011 – NPs included in NYSHIP Empire Plan providing 121,000 state employees and
families with access to NPs
2011 – Governor’s Medicaid Redesign Team (MRT) begins work plan; NPA was asked to
participate in MRT
2011 – NPA Proposal to remove statutory collaboration recognized by the MRT
2012 – Nurse Practitioner Modernization Act (NPMA) passed by Assembly
Old Nurse Practitioner Statute
• The practice of registered professional nursing by a nurse practitioner, may include the diagnosis
of illness and physical conditions and the performance of therapeutic and corrective measures
within a specialty area of practice, in collaboration with a licensed physician qualified to
collaborate in the specialty involved, provided such services are performed in accordance with a
written practice agreement and written practice protocols.
• 16 NP Specialties in New York State
Acute Care
Obstetrics & Gynecology
Adult Health
Oncology
College Health
Palliative Care
Community Health
Pediatrics
Family Health
Perinatology
Gerontology
Psychology
Holistic Nursing
School Health
Neonatology
Women’s Health
Old Nurse Practitioner Statute
• The written practice agreement shall include explicit provisions for the
resolution of any disagreement between the collaborating physician and the
nurse practitioner regarding a matter of diagnosis or treatment that is
within the scope of practice of both. To the extent the practice agreement
does not so provide, then the collaborating physician's diagnosis or
treatment shall prevail.
• Prescriptions for drugs, devices and immunizing agents may be issued by a
nurse practitioner in accordance with the practice agreement and practice
protocols.
• The nurse practitioner shall obtain a certificate from the department upon
successfully completing a program including an appropriate pharmacology
component, or its equivalent, as established by the commissioner's
regulations, prior to prescribing
• Each practice agreement shall provide for patient records review by the
collaborating physician in a timely fashion but in no event less often than
every 3 months. The names of the nurse practitioner and the collaborating
physician shall be clearly posted in the practice setting of the nurse
practitioner.
Old Nurse Practitioner Statute
• No physician shall enter into practice agreements with more than 4
nurse practitioners who are not located on the same physical
premises as the collaborating physician.
• Practice agreements & practice protocols shall be maintained in the
practice setting of the nurse practitioner and collaborating physician
and shall be available to the department for inspection.
• Practice agreements shall include provisions for referral and
consultation, coverage for emergency absences of either the nurse
practitioner or collaborating physician, resolution of disagreements
between the nurse practitioner and collaborating physician
regarding matters of diagnosis and treatment, and the review of
patient records at least every three months by the collaborating
physician; and may include such other provisions as determined by
the nurse practitioner and collaborating physician to be appropriate.
Old Nurse Practitioner Statute
• Practice protocols shall reflect current accepted medical and nursing
practice. The protocols shall be filed with the department within 90 days of
the commencement of the practice and may be updated periodically (Form
4NP).
• Protocols shall identify the area of practice to be performed by the nurse
practitioner in collaboration with the physician and shall reflect accepted
standards of nursing and medical practice. Such protocols may be updated
periodically.
• In addition to the requirements of Section 6810 of the Education Law,
prescription forms used by nurse practitioners shall be printed with the
name, nurse practitioner certificate number, office address, and office
telephone number of the nurse practitioner.
The Impetus for Change
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The Affordable Care Act (“ACA”) has resulted in approximately one million
consumers obtaining health insurance in New York State
NPs provide access to both urban and rural populations, and are often the only
primary care providers to Medicaid recipients in those areas
The Center of Health Workforce Studies (CHWS), School of Public Health,
University of Albany, noted “[w]hile the demand for primary care physicians has
increased in recent years, the in-State retention of primary care physicians in
New York has declined.”
In addition, according to the CHWS report on 2012 New York Residency Training
Outcomes, “only 44% of newly trained physicians” plan to practice in New York,
with more than 40% of physicians stating that they plan to enter a specialty (not
provide primary care).
NPs have worked for over 25 years without any physician presence, yet the
ability to practice in New York continues to be tied to a physician’s willingness to
sign a written practice agreement
The Impetus for Change
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The Institute of Medicine (IOM) The Future of Nursing: Leading Change,
Advancing Health (2010) report emphasized the importance of empowering
“advanced practice registered nurses” (i.e., NPs) to be able to “fulfill their
potential as primary care providers to the full extent of their education and
training” and that “restrictions on scope of practice…undermine the nursing
professions’ ability to provide and improve both general and advanced
care.”
Similarly, the Federal Trade Commission has repeatedly recommended that
states eliminate similar collaborative agreement requirements for NPs. In
fact, in recognition that NPs are health care professionals who work in a
collaborative environment without a statutory mandate, 19 jurisdictions
already allow nurse practitioners to practice without any written practice
agreement requirement.
The Nurse Practitioners
Modernization Act
Provisions of the NPMA as Enacted
April 1, 2014
HIGHLIGHTS OF THE NEW LAW
• Newly licensed Nurse Practitioners with less than 3,600 hours of practice
continue to be subject to current requirements, including:
• Maintaining a Written Practice Agreement (WPA) signed by the NP and physician
• Identifying practice protocols approved by the State Education Department
• Chart reviews
• For Nurse Practitioners with greater than 3600 hours of practice
(approximately 2 years full-time), pursuant to the laws of New York or another state
or practicing as an NP while employed by the United States veteran’s
administration, the United States armed forces or the Unites States public health
service.
• No signed written practice agreement is required
• No practice protocols need to be identified
• NP shall maintain collaborative relationships
• Collaborative relationships.
• Are consistent with Medicare's billing requirement about NPs and collaboration
Provisions of the NPMA as Enacted
April 1, 2014
Medicare-Defined Collaborative Relationships
Pub 100-02 Medicare Benefit Policy
Collaboration is a process in which an NP works with one or more
physicians (MD/DO) to deliver health care services, with medical
direction and appropriate supervision as required by the law of the
State in which the services are furnished.
In the absence of State law governing collaboration, collaboration
is to be evidenced by NPs documenting their scope of practice and
indicating the relationships that they have with physicians to deal
with issues outside their scope of practice.
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r75bp.pdf
Provisions of the NPMA as Enacted
April 1, 2014
In New York, this is defined as:
when an Nurse Practitioner communicates, by phone, in
person in writing or electronically with a physician qualified
to collaborate in the specialty involved or in the case of a
licensed health care facility, communicates with a physician
qualified to collaborate in specialty involved who has
privileges at such health care facility for the purpose of
exchanging information in order to provide comprehensive
care or to make referrals, as necessary.
Provisions of the NPMA as Enacted
April 1, 2014
NPs must maintain evidence of such collaborative relationships
• Such documentation may include, but is not limited to, the following:
• documentation of an agreement or an arrangement with a hospital or
physician practice, pursuant to which an NP may transfer or refer patients for
care;
• documentation of communication between the NP and a physician qualified
to collaborate in the specialty involved relating to the care of the NP’s patients
or referral of the NP’s patients;
• documentation of an employment relationship between an NP and a
physician practice or a hospital, hospice program, licensed home care services
agency or licensed mental health care facility with a physician medical
director; or,
• documentation of a contractual relationship with a physician, physician
practice or a hospital pursuant to which the NP provides professional services.
Provisions of the NPMA as Enacted
April 1, 2014
SED Attestation Form (NP-CR)
• An attestation form will be maintained in the NP's files, and is NOT filed with
SED. The NP attests that they hold one or more collaborative relationships.
• Includes a dispute resolution process
• Dispute resolution process is established by NP and physician, but, if conflict,
physician prevails (similar to prior law). The NP always has the option of
consulting with another physician.
• NP to produce attestation form/collaborative relationship evidence upon SED's
request
• Failure to do so is considered professional misconduct
• This is consistent with midwives' statute
Provisions of the NPMA as Enacted
April 1, 2014
The new law does not require NPs who practice and have legally
authorized collaborative relationships to:
• sign an agreement with a physician;
• practice in accordance with a written agreement or written practice
protocols;
• be supervised by a physician; or,
• have a physician to co-sign or review any of the NP’s orders, prescriptions,
or other clinical records
• The new law does not prohibit NPs who practice and have
legally authorized collaborative relationships from:
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practicing pursuant to clinical guidelines, policies or protocols;
entering into agreements or other clinical or business arrangements;
communicating with purveyors of health care services; or
engaging in any quality assurance or other care related activities.
Provisions of the NPMA as Enacted
April 1, 2014
• There will be Data Collection and a Report on the NP
Profession Issued
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SED to collect data about profession and availability of NPs as part of triennial
certification process (via SurveyMonkey)
Enables the department of health to evaluate access to needed services in
this state, including but not limited to the location and type of setting wherein
the nurse practitioner practices; if the nurse practitioner has practiced for
fewer than three thousand six hundred hours and is practicing pursuant to a
written practice agreement with a physician; if the nurse practitioner practices
pursuant to collaborative relationships with a physician or hospital; and other
information the department of education, in consultation with the
department of health, deems relevant.
De-identified information posted to website via DOH
SED to submit this report to the governor, the speaker of the assembly, the
temporary president of the senate, and the chairs of the assembly and senate
higher education committees September 1, 2018
Provisions of the NPMA as Enacted
April 1, 2014
NPMA Effective Date
January 1, 2015
Sunset
•
NPMA will expire on June 30th, 2021, in order to provide opportunity to
revisit, and determine further expansions
•
This is NOT a demonstration project.
•
The NPA will continue to work with all stakeholders throughout the time
period to recommend enhancements as needed.
Major Differences between WPA &
Collaborative Relationships
Practice Requirements for New York State Certified Nurse Practitioners (“NPs”)
Criteria for
Collaboration
Education Law Requirements
for Practicing Pursuant to a
Written Practice Agreement
and Written Practice Protocols
Education Law
Requirements for
Collaborative Relationships
(effective 1/1/2015)
Nurse
Practitioner
(NP)
Qualifications
All NPs must practice in
accordance with written
practice protocols and a written
practice agreement with a
collaborating physician, unless
they practice and have
collaborative relationships (as
described in the next column).
In order for an NP to practice
and have collaborative
relationships, the NP must have
more than 3,600 hours
experience practicing as a
licensed or certified NP
pursuant to the laws of New
York or another state or
practicing as an NP while
employed by the US veteran’s
administration, the US armed
forces or the US public health
service.
Major Differences between WPA &
Collaborative Relationships
Practice Requirements for New York State Certified Nurse Practitioners (“NPs”)
Criteria for
Collaboration
Education Law Requirements
for Practicing Pursuant to a
Written Practice Agreement
and Written Practice
Protocols
Education Law
Requirements for
Collaborative Relationships
(effective 1/1/2015)
Qualifications
of
Collaborator(s)
A New York State licensed and
registered physician must be
qualified to collaborate in the
NP’s specialty area of practice.
The physician must enter into
a written practice agreement
with the NP. The physician
cannot enter into written
practice agreements with
more than 4 NPs who are not
located on the same physical
premises as the physician.
1. One or more New York State licensed
and registered physicians who must be
qualified to collaborate in the specialty
involved. -or2. A health care facility that:
i. is licensed by the New York State
Department of Health as a hospital,
nursing home, diagnostic and
treatment center, extension clinic
or ambulatory surgery center; and,
ii. provides services through New
York State licensed and registered
physicians who are qualified to
collaborate in the specialty involved
and who have professional
privileges at the health care facility.
Major Differences between WPA &
Collaborative Relationships
Practice Requirements for New York State Certified Nurse Practitioners (“NPs”)
Criteria for
Collaboration
Education Law Requirements
for Practicing Pursuant to a
Written Practice Agreement
and Written Practice
Protocols
Education Law
Requirements for
Collaborative Relationships
(effective 1/1/2015)
Nature of
Collaboration
Contractual - The NP practices
in accordance with a written
practice agreement with a
collaborating physician.
Communication - The NP
practices independently and
must communicate with a
collaborating physician in
order to provide
comprehensive care or to
make referrals, as necessary.
The NP is not required to
have a written agreement
with a physician or a
hospital.
Major Differences between WPA &
Collaborative Relationships
Practice Requirements for New York State Certified Nurse Practitioners (“NPs”)
Criteria for
Collaboration
Education Law Requirements
for Practicing Pursuant to a
Written Practice Agreement
and Written Practice
Protocols
Education Law
Requirements for
Collaborative Relationships
(effective 1/1/2015)
Written Practice The NP must practice in
Protocols
accordance with written
practice protocols that reflect
current nursing and medical
practice in the specialty area
in which the NP is certified.
The written practice protocols
must be acceptable to the
New York State Education
Department.
The NP is NOT required to
practice in accordance with
written practice protocols.
Major Differences between WPA &
Collaborative Relationships
Practice Requirements for New York State Certified Nurse Practitioners (“NPs”)
Criteria for
Collaboration
Education Law Requirements
for Practicing Pursuant to a
Written Practice Agreement
and Written Practice
Protocols
Education Law
Requirements for
Collaborative Relationships
(effective 1/1/2015)
Chart Review by A collaborating physician must Not required.
Collaborating
review an NP’s charts at least
Physician
once every 3 months, or more
often, as warranted
Major Differences between WPA &
Collaborative Relationships
Practice Requirements for New York State Certified Nurse Practitioners (“NPs”)
Criteria for
Collaboration
Education Law Requirements
for Practicing Pursuant to a
Written Practice Agreement
and Written Practice
Protocols
Education Law
Requirements for
Collaborative Relationships
(effective 1/1/2015)
Resolving
Clinical
Differences
The written practice
agreement between the NP
and physician must include
provisions for the resolution
of matters of diagnosis and
treatment. If the agreement
lacks such a provision, then
the collaborating physician’s
clinical recommendation
prevails.
The collaborating physician’s
clinical opinion prevails.
Major Differences between WPA &
Collaborative Relationships
Practice Requirements for New York State Certified Nurse Practitioners (“NPs”)
Criteria for
Collaboration
Education Law Requirements
for Practicing Pursuant to a
Written Practice Agreement
and Written Practice
Protocols
Education Law
Requirements for
Collaborative Relationships
(effective 1/1/2015)
Resolving
Clinical
Differences
The written practice
agreement between the NP
and physician must include
provisions for the resolution
of matters of diagnosis and
treatment. If the agreement
lacks such a provision, then
the collaborating physician’s
clinical recommendation
prevails.
The NP must maintain a
copy of a "Collaborative
Relationships Attestation
Form" and other
documentation supporting
collaborative relationships
and must them available to
the New York State
Education Department for
inspection.
Finding New Forms/Regulations
Form NP-CR
Next NPMA Challenges
• Gaining Institutional Support for changing Medical Board bylaws
• Working with NYS Medicaid to update regulations
• Third-party insurer recognition
• Data Collection/Additional Studies
• Has access to care improved?
• Consider revisions/enhancements for future
The NPA NYS 2015 Legislative
Agenda
http://www.thenpa.org/?page=LegislativeAgenda
2015 Legislative Agenda
Bill S2300 (Hannon)/A.4140 (Gottfried) "Relates to the scope
of practice of nurse practitioners." Amend the public health law, the
education law, the general business law and the vehicle and traffic law,
in relation to making conforming changes reflecting the previously authorized scope of
practice of nurse practitioners
• Under Education Law, section 6902(3), nurse practitioners may diagnose illness and
physical conditions and perform therapeutic and corrective measures. Prior to 2015,
the nurse practitioners could only provide these health care services in collaboration
with a physician in accordance with a written practice agreement and written practice
protocols.
• Pursuant to Part D of Chapter 56 of the Laws of 2014, a nurse practitioner with 3,600
hours of practice is not required to maintain a written practice agreement, if the
nurse practitioner complies with the rest of the requirements of section
6902(3). Under current law and everyday actual practice, nurse practitioners conduct
physical examinations of patients, order tests, prescribe drugs, devices and
immunizing agents and, when appropriate, refer patients to other health care
providers. This change would simply make technical changes to a variety of provisions
of law to eliminate the reference to the written practice agreement.
Other “Scope” Issues for NPs in
New York
• Inability to prescribe buprenorphine (Federal
Restriction)
• Inability to certify home health care services
• Inability to provide Worker’s Compensation Care
• Federal Restrictions on Durable Medical Equipment
• Passed as part of SGR Legislation, April 2015
• Inability to sign “Do Not Resuscitate” & MOLST
orders
• Inability to perform Barber/Cosmetology Physical
Exams for license application
• Inability to admit involuntary mental health patients
• Others?
Questions?