March 10, 2015
The Honorable Peter A., Chairman
House Health & Government Operations Committee
240 House Office Building
Annapolis, MD 21401
RE: HB 999 – The Nurse Practitioner Full Practice Authority Act of 2015(SUPPORT)
Dear Chairman Hammen and Members of the Committee,
On behalf of the Nurse Practitioner Association of Maryland (NPAM), the oldest and largest statewide professional
association which represents nearly 4,000 nurse practitioners in Maryland, we offer our strong support of HB 999 which
would repeal the requirement that nurse practitioners have an approved attestation for collaboration and consultation with
a physician in order to practice in Maryland.
Nurse Practitioners are independent healthcare providers who serve the citizens of Maryland. As patient advocates, it is
our duty to promote health and prevent illness in our communities. As an organization with 650 members, NPAM works
with legislators to support bills that enhance the well-being of the citizens of Maryland.
Background
In 2010, this body, the Maryland General Assembly unanimously repealed the antiquated requirement for nurse
practitioners to have a collaborative agreement with a physician which was a cumbersome and outdated 27 page document
that delayed entry to practice by many months, in some cased nine months for approval.1
In order to pass that legislation, this committee asked NPAM for a compromise. That compromise repealed the
collaborative agreement and replaced it with an attestation which continues to require Board of Nursing approval with a
documented licensed physician name for collaboration and consultation. NPAM agreed to the compromise in good faith
that it would not remain in statute forever.
In the ensuing five years, what was supposed to be a streamlined process has again created unintended consequences for
nurse practitioners in Maryland. For example, several insurance carriers have asked nurse practitioners to provide their
attestation in order to become credentialed on the provider panel which has delayed reimbursement payments. Also, other
carriers have categorized nurse practitioners as “physician extenders” which is not the proper category for independent
providers.
Other negative consequences of the compromise from 2010: nurse practitioners have encountered physicians unwilling or
unavailable to be named on their attestation in a geographically reasonable area; practices have been suddenly suspended
when an attestation-named physician leaves employment resulting in patients being denied access to their nurse
CHAPTER 78 OF THE ACTS OF 2010 (H.B. 319: STATE BOARD OF NURSING – NURSE PRACTITIONERS – CERTIFICATION REQUIREMENTS AND
AUTHORITY TO PRACTICE), Maryland General Assembly, (2010).
The Nurse Practitioner Association of Maryland, Inc.
P.O. Box 540, Ellicott City, MD 21041
Toll Free: 888-405-6726 Fax: 410-772-7915
www.npamonline.org NPAM@npedu.com
1
practitioner; and financial hardship to nurse practitioners who have not been able to freely move into new jobs due to the
attestation problems.
Where are we now?
To date 20 states and the District of Columbia have already removed arbitrary and outdated restrictions and grant nurse
practitioners full practice authority, which allows them to practice to the full extent of their education. In these states,
nurse practitioners continue to be accountable for their patients for treating and referring to other providers as warranted
by patient needs.23
There are full practice authority bills pending in California and Texas with Nebraska being the latest to pass and sign into
law full practice authority on March 6, 2015.4
“Collaboration”
The advance practice registered nurse (“APRN”) profession encompasses a wide variety of advanced nursing specialties;
hence a wide variety of scope of practice issues is associated with this profession. However, the main scope of practice
issue across all specialties is independent practice. This means enabling APRNs to provide direct patient care services
without supervision by or forced collaboration with physicians, whether the services are provided in a hospital, a private
office, a clinic, an outpatient center, or a patient’s home. All APRNs collaborate, consult with, or refer to physicians.
Many APRNs practice in health care teams with physicians and other types of health care providers.
Collaboration is not dependent on the existence of a written document. All health care providers collaborate and consult
with, refer patients to, all physicians and other health care providers through variable health care delivery systems
(hospitals, clinics, FQHCs) without formal collaborative agreements. The system would collapse if providers didn’t
collaborate with each other.
Nurse Practitioners are required by national standards as well as state statute to collaborate under the American
Association of Nurse Practitioners Standards of Practice,5 the Nurse Practitioner Core Competencies,6 and the American
Nurses Association Code of Ethics;7 each requiring collaboration and consultation with health care providers as national
2
AMERICAN ASSOCIATION OF NURSE PRACTITIONERS, Issues at a Glance: Full Practice Authority,
http://www.aanp.org/images/documents/policy-toolbox/fullpracticeauthority.pdf, (October 2014).
3
States with Full Practice Authority: Alaska, Arizona, Colorado, Connecticut, District of Columbia, Hawaii, Idaho,
4
NURSE PRACTITIONERS SALUTE NEBRASKA FOR NEW HEALTH CARE LAW, PR Newswire, http://www.prnewswire.com/newsreleases/nurse-practitioners-salute-nebraska-for-new-health-care-law-300046505.html, March 5, 2015 (Referencing L.B. 107 signed
by Nebraska Governor Ricketts making Nebraska the 20th state to authorize nurse practitioners to provide the full scope of services
they’re educated and clinically trained to deliver.)
5
AMERICAN ASSOCIATION OF NURSE PRACTITIONERS, Standards of Practice for Nurse Practitioners,
http://www.aanp.org/images/documents/publications/standardsofpractice.pdf, (Revised 2013) (Referencing III(B): Consultation with
other appropriate health care personnel. And IV:…interacting with professional colleagues to provide comprehensive care.).
6
THE NATIONAL ORGANIZATION OF NURSE PRACTITIONER FACULTIES, Nurse Practitioner Core Competencies,
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecompetenciesfinal2012.pdf, (April 2011, Amended
2012).
7
AMERICAN NURSES ASSOCIATION, Code of Ethics for Nurses, http://www.nursingworld.org/codeofethics.
The Nurse Practitioner Association of Maryland, Inc.
P.O. Box 540, Ellicott City, MD 21041
Toll Free: 888-405-6726 Fax: 410-772-7915
www.npamonline.org NPAM@npedu.com
standards. Furthermore, Maryland state statute has always included the requirement for nurse practitioners to practice in
accordance with national standards (Health Occupations §8-302(5)(2) and see also HB 999, Page 3, Lines 14-17).
In 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 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. Nurse practitioners have assumed an increasing role as primary care
providers in Maryland.
For those reasons stated above, we ask the committee for a favorable vote on HB 999.
The Nurse Practitioner Association of Maryland is committed to improving the health of Maryland citizens through
professional representation and legislative advocacy for nurse practitioners across the state. If we can be of any further
assistance, or if you have any questions, please do not hesitate to contact the NPAM Executive Director, Beverly Lang, at
410-404-1747 or NPAMExDir@npedu.com.
Sincerely,
Andrea Schram
Sandra Nettina
Andrea Schram, DNP, CRNP
President, NPAM
Sandra Nettina, MSN, CRNP
Chair, Legislative Committee
CC:
The Honorable Bonnie Cullison, House Sponsor
Julia Pitcher Worcester, NPAM Legislative Consultant
The Nurse Practitioner Association of Maryland, Inc.
P.O. Box 540, Ellicott City, MD 21041
Toll Free: 888-405-6726 Fax: 410-772-7915
www.npamonline.org NPAM@npedu.com