Interim Study Proposal 2013-199
Presented to Joint Public Health and Welfare
Committee
November 25th, 2014
The health care system is changing
 “A number of barriers prevent nurses from being able to
respond effectively to rapidly changing health care settings
and an evolving health care system.” (IOM, 2010)
So must current state laws and regulatory rules
 “The power to improve the current regulatory, business,
and organizational conditions does not rest solely with
nurses...”
 Government, businesses, health care organizations,
professional associations, and the insurance industry all
must play a role.” (IOM, 2010)
Pressures on Arkansas Healthcare
 AR Center for Health Improvement study (ACHI, 2012)
showed 15% fewer primary care physicians than are
currently needed
 Projected a shortage of 1000 primary care physicians within
5 years
 HRSA (2014) data shows an even greater shortage, which
indicates a shortage of all primary care providers
 Arkansas has currently only about 65% of needed primary
care providers
Arkansas needs more primary care
providers
Source: Bureau of Clinician Recruitment and Service, Health Resources and Services Administration (HRSA),
U.S. Department of Health & Human Services, HRSA Data Warehouse: Designated Health Professional
Shortage Areas Statistics, as of April 28, 2014.
Rural Arkansans Most at Risk
 Approximately 40% of the
state’s population live in
rural areas.
 2011- UAMS Center for Rural
Health: 514 vacancies for
primary care physicians
2017 - Expected to reach 860
vacancies
NPs more likely to practice in
rural areas (AANP, 2013)
Nationally, 18% of NPs
practice in communities of less
than 25,000
Arkansas
Demographics
 In 2014, Arkansas - 75 total
primary care Health Professional
Shortage Areas (HPSA)
designations
 Thirty-six entire Arkansas
counties are designated as primary
care HPSAs, representing almost
half of the counties in the state
 In 61 of 75 counties in Arkansas –
demand for primary care exceeds
supply of health care providers
 Most severe in 5 counties were
demand outpaces supply by 75%
to 85%
How can the APRN help?
 By improving access to care through APRN clinics
 By recognition of APRNs as Primary Care Providers
 By leading a Patient Centered Medical Home.
 By authorizing qualified APRNs to prescribe Schedule II
controlled substances
 By parity in third party reimbursement
 By authorizing APRN hospital admitting privileges
Educational Preparation
 APRNs already have RN preparation prior to starting
advanced practice education
 Minimum education is a master’s degree. Many
pursue doctoral degrees.
 NP education is competency-based; not time-based.
Percentages of APRNs in Arkansas
CNM
1%
CNS
6%
CRNA
30%
CNP
63%
There are 2,376 APRNs in Arkansas
 Certified Nurse Practitioners (CNP)
 1503 CNPs
 Certified Registered Nurse Anesthetist (CRNA)
 708 CRNAs
 Certified Nurse Midwife (CNM)
 28 CNMs
 Clinical Nurse Specialist (CNS)
 137 CNS
(Arkansas State Board of Nursing, 2013)
Clinical Outcomes
 Head-to-head comparison of educational models is
not the appropriate measure of clinical success or
patient safety.
 The appropriate measure is patient outcomes.
 Forty years of patient outcomes and clinical research
demonstrates that APRNs consistently provide highquality and safe care.
Improving Access to Care
 The APRN can:
 Improve access to care:
 In rural areas
 In other healthcare provider shortage areas
 Augment the healthcare workforce
 Reduce delay of care
 Coordinate care, creating a more effective delivery
model
 Reduce cost by decreasing duplication and
repetition
APRNs as a Primary Care Provider
 APRNS could directly provide care without physician
referral.
 Patients in underserved areas could see APRNs who may be
much closer to where they live.
 Lack of PCP recognition for APRNs adds cost and
inconvenience for patients without adding to quality or
safety.
Leading in a Patient Centered Medical
Home model
 Center for Medicare and Medicaid (CMS) through the
Comprehensive Primary Care Initiative (CPCI) define a primary
care practitioner as:




a physician OR
nurse practitioner
clinical nurse specialist
physician assistant
 CMS through CPCI recognizes APRNs as a team leader of the
PCMH, as does the National Committee for Quality Assurance
(NCQA).
 Arkansas’ VA system also recognizes APRNs as team leaders in
the PCMH model Arkansas.
Arkansas’ VA PCMH model
 The VA’s patient-centered medical home model was
launched in April of 2010 to:
“increase access and clinical effectiveness by identifying
and removing barriers to high-quality care”
 Patient centered care, increased access, and care
coordination are the main principles of the model
referred to as:
Patient Aligned Care Team or PACT
VA APRN led PACT
 What does a PACT do? Provides total primary care
and comprehensive women’s health care
 Each PACT serves about 950-1600 patients
 Team members: APRN team leader, RN, LPN, and
unit clerk
 Awards for “high performing PACT teams, 2012
 Fayetteville Silver Medal
 North Little Rock Gold Medal
VA PACT teams led by APRNs
Central AR VA system
Northwest AR VA system
 Mountain Home
 VISN 16/Fayetteville
 3 APRNs with panel sizes of ~600
to 1000
 Mena
 2 APRNs with panel sizes of ~850
 El Dorado
 1 APRN with panel size of ~500
 Hot Springs
 2 APRNs with panel sizes of ~1550
 Searcy
 1 APRN with panel size of ~1300
 NLR/LR
 2 APRNs with panel size of ~800
 total of 7 APRNs in PACTs –
4 floats APRNs in Primary
Care
 1 Primary Care/Home-Based
Primary Care
 1 Women’s Health Primary
Care
 1 Primary Care
.
APRNS and Schedule II
APRNs in 43 states may prescribe schedule II controlled
drugs. Arkansas is NOT one of those.
Since 1995 Arkansas State Board of
Nursing as disciplined under 5 APRNs
for over prescribing hydrocodone drugs.
APRNs are educationally prepared to prescribe for patients
with legitimate need for this drug class.
Prescriptive Authority for Qualified APRNs
In Arkansas:
20 year history of APRNs prescribing: APRNs have been
prescribing scheduled III –V medications with a good
safety record.
Federal DEA guidelines changed in October, moving some
medications from schedule III to schedule II, making them
unavailable for APRNs to prescribe in Arkansas.
We need to change Arkansas law to reflect
contemporary practice needs.
Six Aims of Quality Health Care (IOM, 2001):
timely, patient-centered, effective, safe, efficient,
& equitable
Interrupt process
and find another
prescriber
“Work around” of
electronic record
Involving 2nd
provider who may
not know the
patient
Delay of care
Increases risk
of errors
Disrupts
continuity
Not timely;
less effective
Not safe or
efficient
Not equitable
or patient
centered
APRNs and Schedule II prescribing
Patient population
APRN role in providing care
Terminally ill/hospitalized with
moderate to severe pain control
needs
 Providing palliative
Acutely injured; Severe acute
pain control
 Acute care pain control in
Children and adolescents with
ADHD
 Stimulants are still mainstay
care/hospice care/post op
care/inpatient
emergent/urgent care
of treatment
The PCMH concept coincides with the
strengths of the APRN
 Coordination of care and patient follow-up
 Patient teaching and communication
 Management of chronic disease
 A “whole-person” orientation, focusing on prevention
Reimbursement Parity
Amend Insurance statue 23-79-114 to include the APRN
with prescriptive authority.
The APRN is entitled to payment or reimbursement for
health services on an equal basis for the services when:
 The health service is provided by an APRN with
prescriptive authority
 Practicing within his or her area of competence
Reimbursement Parity
Lack of direct payment or low payment rates
….. discourages many APRNs from establishing new clinics;
……particularly given high overhead and costs associated with
investments in electronic health records and other fixed costs
……Business costs are largely the same whether provided by
physician or an APRN
THIS CREATES A BARRIER TO ACCESS TO CARE
Hospital admitting privileges
 In Arkansas, there is no federal or state statute which
prevents hospital privileges for APRNs.
 Qualified APRNs are already being credentialed in
Arkansas hospitals as hospitalists.
 The VA system specifically includes hospital admitting
privileges for APRNs.
Who agrees…
The Federal Trade Commission.
 “Relative to primary care physicians, APRNs are more likely to practice
in underserved areas and care for large numbers of minority patients,
Medicaid beneficiaries and uninsured patients.” (FTC, 2014)
 “Additional scope of practice restrictions, such as physician supervision
requirements, may hamper APRNs’ ability to provide primary care
services that are well within the scope of their educations and training.”
(FTC, 2014)
 “Based on our extensive knowledge of health care markets, economic
principles, and competitions theory, we {conclude}: expanded APRN
scope of practice is good for competition and American consumers.”
(FTC, 2014)
And…
 By using non-physician primary care providers to the fullest
extent of the education…. States can potentially work toward
meeting growing healthcare needs of their rural populations”
National Conference of State Legislatures. (2013)
 “Expanded utilization of NPs has the potential to increase access
to health care, particularly in historically underserved areas”
National Governors Association. (2012)
 “Now is the time to eliminate the outdated regulations and
organizational and cultural barriers that limit the ability of
nurses to practice to the full extent of their education, training
and competence”
Institutes of Medicine. (2010)
And….
 NCQA Patient-Centered Medical Home Recognition is
the most widely-used way to transform all clinician
lead, primary care practices into medical homes.
National Centers Quality Assurance (2014)
 States should amend current scope of practice laws
and regulations to allow APRNs to perform duties for
which they have been educated and certified.”
AARP. (2014)
Supporting Opinions
 Federal Trade Commission (2014)
 “well-intentioned laws and regulations may impose
unnecessary, unintended or overbroad restrictions on
competition, thereby depriving healthcare consumers of
the benefits of vigorous competition.”
 United State Supreme Court. (2014)
 “Abuses happen when professions exploit licensing laws
to augment their interest while claiming to speak with
the regulatory power of the state.”
References:
 Patient Centered Medical Home

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Rhonda Finnie, DNP, APRN, AGACNP-BC, RNFA
President, Arkansas Nurses Association
Mary Garnica, DNP, APRN, FNP-BC, MPH
Health Policy Chair, Arkansas Nurses Association