Julie Stanik – Hutt PhD, CRNP, FAANP, FAAN
516 Bay Hills Drive, Arnold, MD 21012
10 March 2015
The Honorable Peter A. Hammen
Chairman – House HGO Committee
241 House Office Building
6 Bladen Street
Annapolis, MD 21401
RE: HB 999: Nurse Practitioner full Practice Authority Act of 2015 - SUPPORT
Dear Chairman Hammen and Members of the Committee;
I am writing in support of HB 999 Nurse Practitioner Full Practice Authority Act of 2015. The
bill streamlines documentation requirements for NP practice by repealing the requirement
that a nurse practitioner (NP) have an agreement to collaborate and consult with a specific
physician and that the NP must have an approved attestation in order to practice. HB 999
updates Maryland statute and brings Maryland practice requirements into alignment with
national recommendations for Nurse Practitioner practice and regulation. 1,2,,3 Over the last 5
years, similar legislation has been passed in 7 other states including Colorado, Hawaii, Nevada,
Connecticut, Minnesota, New York and Nebraska, where the statute changed just last week.
HB 999 does NOT change the scope of practice for NPs. Current Maryland statute [ Title 8-101
(k) and (m), and 8-508 (a)] delineates Nurse Practitioners scope of practice to include the
following independent actions: patient assessment; ordering, performing and interpreting
diagnostic tests; establishing a medical diagnosis; prescribing medications, and performing and
ordering therapeutic and corrective measures; referring to other health care providers; and
providing emergency care. Nurse Practitioners are currently authorized to perform all of these
services independently within their respective population scope of practice. This will not
change and NPs will still be expected to practice in accordance with the standards of practice
of the American Association of Nurse Practitioners 4 or another national certifying body
recognized by the Board of Nursing.
Historical Context for HB 999: Until 2010, in addition to completing a Board of Nursing
(BON) approved graduate educational program and earning national board certification,
applicants for NP practice had to identify a physician (MD) with whom to work and submit a 20
page written collaborative agreement which described: the MD and practice setting, patient
health problems, professional activities the NP would engage in, types of medications to be
prescribed, and how the NP would work with the designated collaborating MD. The agreement
was signed by all MD collaborators and had to be approved by the BON and Board of Medicine
1
(BOM). Once a collaborator was identified, it took months to gain all the required approvals.
These requirements added nothing to patient safety or NP care quality, decreased patient
access to NP services, and delayed NP licensure and ability to practice. In addition, if the NP
changed jobs or if the MD left the practice (retired, moved away, etc.) the NP had to
immediately stop practicing until the process was completed with a new MD and written
agreement.
In 2010, the legislature repealed these cumbersome and outdated requirements. An
attestation document was substituted for the written agreement but a NP still had to establish
an agreement to collaborate and consult with an MD. The BON still had to approve the
attestation before the NP could practice. The substituted attestation process continues to
unnecessarily delay NP licensure and deny patient’s access to NP services without adding
anything to care quality or safety. For example, I have completed 7 years of post-secondary
professional education, hold national certification as both a geriatric and an adult acute care
NP, have more than 15 years practice experience as an NP, and an active NP license, but I am
not currently able to see patients because I do not have a current agreement to collaborate and
consult with an MD. The Federal Trade Commission, writing in response to some legislative
proposals, has indicated that scope of practice restrictions and requirements for MD oversight
of NP practice may not be justified. They state that these practice restrictions stifle healthy
competition and its benefits to the consumer, and deny patients their choice of provider.3
Evidence in Support of HB 999: Nurse Practitioners are experienced Registered Nurses,
who have completed a Master’s degree which prepares them to perform physical
examinations, diagnose, treat and prescribe (medications and other therapies) for patients
with acute, chronic and critical illnesses within a defined scope of practice. Their training in
diagnostic reasoning and patient management is very similar to that provided to medical
students. In addition to completing at least 6 years of professional education including
hundreds of hours of clinical training under the supervision of physicians and NPs. They must
also pass rigorous national certification board examinations to obtain Maryland licensure.
NPs provide critically needed primary care services. State practice requirements which provide
NPs full practice authority have been show to increase the number of NPs per 100,000
population, and to increase the likelihood that an NP will practice as a primary care provider in
a rural and or medically underserved area.5
A substantial body of evidence to support the safety, quality and effectiveness of Nurse
Practitioner care has been accumulated over the last 50 years. Several published
comprehensive reviews of the research literature 6-8, governmental evaluations 9, 10, ,
systematic reviews 11-15 , and a meta-analysis 16 have evaluated NP practice. These analyses
have repeatedly found that patient outcomes of care are essentially the same whether cared
for by an NP or an MD. Lifting regulatory barriers to NP practice (providing NPs full practice
authority) has been shown to increase Medicare and Medicaid patients’ access to care.5 In
addition, two recent studies have shown that overall patient outcomes are better in states
2
where NPs have full practice authority. Patients in those states experienced fewer avoidable
hospital admissions and readmissions, and nursing home residents were less likely to be
hospitalized. 17, 18
Compared to physicians, there is a very low rate of malpractice claims against Nurse
Practitioners, both in Maryland and throughout the nation. In 2005, the largest malpractice
insurer for NPs reported that between 1994 and 2004, only 288 malpractice payouts were
made to patients of NPs they insured. 19 The National Practitioner Database (NPDB), which
tracks rates of malpractice claims and adverse actions (regulatory board complaints and
disciplinary actions, etc.) for all health care providers, reports that since its founding (1990) NP
account for only 0.3 % (2, 338) of all medical malpractice claims, whereas physician assistants
(PAs) account for 0.6 % (4,982) and physicians (MDs) account for 45 % (397,789) of claims. 20
The most recent data continue to indicate that claim rates are lower for NPs (0.11 %, 190 claims
for 180,233 practicing NPs) than for PAs (0.23 %, 237 claims for 86,500 PAs) or MDs (1.23 %,
10,240 claims for 834,769 practicing MDs). 21 It is important in interpreting these data to
remember that there are less than half as many PAs as NPs and the practice of all PAs is
supervised by physicians. A 2004 study found that NPs working in Full Practice Authority states,
compared to more restrictive states, were at no higher risk for a medical malpractice claim. 23
In contrast, NPs who work in states with required physician supervision or oversight have been
found to incur the highest number of medical malpractice claims (e.g. Florida, Texas, and
California). The safety and efficacy of Nurse Practitioners is unrefutable.6-23
Potential Opposition to HB 999: Organized medicine is likely to oppose the bill as written.
They may claim that removing the language regarding an agreement to collaborate will
“destroy working relationships” among MDs and Nurse Practitioners. They may offer an
amendment to make “failure to collaborate” a cause for disciplinary action. Collaboration and
consultation among health care professionals is a norm. It does not require codification, as a
written declaration nor as a threat of discipline. To do so would be redundant as this
behavior is already included in the Standards of Practice of the American Association of Nurse
Practitioners.5
“Standard IV. Interdisciplinary and Collaborative Responsibilities: As a
licensed,Independent practitioner, the nurse practitioner participates as a team leader
and member in the provision of health and medical care, interacting with professional
colleagues to provide comprehensive care. “
Nurse practitioners do better than other providers on measures of patient care coordination,
consultation and follow up. 24 Indeed, NPs have always collaborated and consulted with all
kinds of health care providers (including MDs). When HB 999 becomes law NPs will continue to
have positive working relationships and to collaborate and consult with the same network of
MD colleagues that they work with today. To imply otherwise, and suggest NPs be disciplined
3
for “failure to collaborate” when this requirement is not imposed by statute on any other
health care provider is hypocritical.
Organized medicine may also offer an amendment to require a transition to practice for new
graduate NPs. Transition to practice schemes are not based on evidence but are political
compromises. They generally exceed current norms for onboarding of a new provider and
produce unintended, problematic consequences. Two states where these schemes were
implemented are in the process of repealing or dramatically revising them. In one state a
majority of both MDs and health care systems administrators support legislative
repeals/revisions. 25 A review by an independent governmental advisory committee in one
state found that: employers, governmental officials, NPs and MDs were confused regarding
requirements and implementation; new graduate NPs were not able to find work in the state
and moved away; experienced NPs considering coming to the state opted to do otherwise; the
transition period did not provide any standardized learning or curriculum; there were not
adequate numbers of physician collaborators; and potential collaborators were concerned
regarding liability implications etc.25 These transitions to practice proposals are not good
policy.
Conclusion: The quality, access and cost of healthcare in the United States is a concern as
the nation experiences high healthcare costs, and continuing care disparities among people of
specific races and ages, those without adequate insurance, and those who live in medically
underserved locations. Nurse Practitioners are highly qualified health care providers, with a
long record of providing safe, high quality care.6 - 23 Nurse Practitioners have assumed an
increasing role as primary care providers in Maryland and could have an even greater impact on
the state’s health if unnecessary practice restrictions were removed. Passage of HB 999 is
essential to patients continued access to Nurse Practitioners in Maryland. I hope that you will
support this bill.
Sincerely,
Julie Stanik – Hutt, PhD, CRNP, FAAN
Associate Professor
Past President, American College of Nurse Practitioners
Fellow of the American Association of Nurse Practitioners
Fellow of the American Academy of Nursing
1. APRN Joint Dialogue Group. (2008). Consensus Model for APRN Regulation: Licensure, Accreditation,
Certification & Education. Available at www.aacn.nche.edu/education/pdf/APRNReport.PDF
2. Institute of Medicine.(2011). The Future of Nursing: Leading Change, Advancing Health. Washington,
DC: The National Academies Press.
3. Author (2014) Competition and the Regulation of Advanced Practice Nurses. Washington, D.C.:
4
Federal Trade Commission Available at https://www.ftc.gov/reports/policy-perspectivescompetition-regulation-advanced-practice-nurses
4. Kuo, YF, Loresto, F., Rounds, L. & Goodwin, J. (2013). States with least restrictive regulations
experienced largest increase in patients seen by nurse practitioners. Health Affairs, 32 (7),
1236 – 1243.
5. Author (2013). Standards of Practice for Nurse Practitioners. American Association of Nurse
Practitioners. Available at
http://www.aanp.org/images/documents/publications/standardsofpractice.pdf
6. Edmunds MW. (1978). Evaluation of nurse practitioner effectiveness: An overview of the literature.
Evaluation of Health Professions, 1(1), 69-82.
7. Sox HC Jr. (1979). Quality of patient care by nurse practitioners and physician's assistants: A ten-year
perspective. Annals of Internal Medicine, 91(3), 459-68.
8. LaRochelle DR. (1987). Research studies on nurse practitioners in ambulatory health care: a review
1980-1985. Journal of Ambulatory Care Management, 10(3). 65-75.
9. Office of Technology Assessment. (1981). The costs and effectiveness of nurse practitioners. Library
of Congress Card Catalogue #80-600161. Washington, D.C.: U.S. Government Printing Office.
10. Office of Technology Assessment. (1986). Nurse practitioners, physician assistants, and certified
nurse midwives: A policy analysis. Library of Congress Card Catalogue #85-600596. Washington,
D.C.: U.S. Government Printing Office.
11. Ventura MR, Crosby F, Feldman MJ. (1991). An information synthesis to evaluate nurse practitioner
effectiveness. Military Medicine, 156(6), 286-91.
12. Horrocks S, Anderson E, Salisbury C. (2002). Systematic review of whether nurse practitioners
working in primary care can provide equivalent care to doctors. British Medical Journal,
324(7341), 819-23.
13. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. (2005). Substitution of doctors by
nurses in primary care. Cochrane Database of Systematic Reviews, (2):CD001271.
14. Newhouse, R., Stanik-Hutt, J., White, K., Johantgen, M., Zangaro, G., Heindel, L., Steinwachs, D.,
Weiner, J., Bass, E., Wilson, R., Fountain, L. (2011). Advanced practice nurse outcomes 1990 –
2008: A systematic review. Nursing Economics, 29 (5), 230 – 250.
15. Stanik-Hutt, J., Newhouse, R., White, K., Johantgen, M., Bass, E., Zangaro, G.,… Weiner, J. (2013).
The quality and effectiveness of care provided by nurse practitioners: A systematic review of US
research studies, 1990-2009. The Journal for Nurse Practitioners, 9(8), 492-500.
16. Brown SA, Grimes DE. (1995). A meta-analysis of nurse practitioners and nurse midwives in primary
care. Nursing Research, 44(6), 332-9.
17. Oliver, G., Pennington, L. & Revelle, S. (2014). Nurse Practitioners and national health outcomes.
Missouri Nurse, 81(3), 13-16.
18. Oliver, G., Pennington, L., Revelle, S. & Rantz, M. (2014). Impact of nurse practitioners on health
outcomes of Medicare and Medicaid patients. Nursling Outlook, 62, 440-447.
19. Author (2005). Nurse Practitioner Claims Study: An Analysis of Claims with Risk Management
Recommendations. Chicago, IL: Nurses Service Organization/CAN HealthPro. Available at
https://www.cna.com/vcm_content/CNA/internet/Static%20File%20for%20Download/Risk%20
Control/Medical%20Services/NursePractitionerClaimsStudy.pdf
20. Miller, K (2012) The National Practtiioner Data Bank: History and data. Journal for Nurse
Practitioners, 8 (9), 698–701.
21. Miller K. (2013). The National Practitioner Data Bank: An Annual Update. Journal for Nurse
Practitioners, 9(9), 576 – 580.
22. Knudtson, M. (2004). The relationship between reported malpractice cases for nurse practitionoers
5
and the type of supervision mandated by state law. UMI Order AAI3148995.
24. Author. (2012). Health Policy Brief. Nurse Practitioners and Primary Care: Federal and state laws and
other policies limit how these professionals can help meet the growing need for primary care.
Health Affairs, October 25, 2012. Available at
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=79
25. Author (2014). The Nurse Physician Advisory Taskforce for Colorado Healthcare. Final Report
and Recommendations on the Requirements for Advanced Practice Registered Nurses Seeking
Prescriptive Authority. Denver, CO: Colorado Department of Regulatory Agencies: Division of
Professions and Occupations.
6