Debate Continues As APRN Practice Bill Picks Up Changes

Gongwer News Service
NOVEMBER 19, 2019

A long-running and contentious effort to provide independent practice for advanced practice registered nurses picked up another change before a House panel Tuesday.

The House Health Committee accepted a round of changes to the measure (HB 177), which was initially designed to eliminate the standard care arrangement or collaborative agreement that APRNs are required to have with a physician. The new version instead would allow nurses who have completed 2,000 clinical hours of work under a collaborative agreement to practice without one. It would also allow an APRN to instead have an agreement with another APRN who has completed the 2,000-hour requirement. (Comp Doc)

Despite the change, physician groups continued to oppose the measure.

Proponents, meanwhile, said patients would receive better access to care under the new proposal.

Joscelyn Greaves, president of the Ohio Association of Advanced Practice Nurses, said feedback from committee members led to the creation of a transition period for newly graduated APRNs can practice independently.

"We thought it made sense to keep the standard care arrangement in current law until they had completed about 2,000 hours," he said.

APRNs who practice outside of their scope of practice would lose their licenses, she said. Insurance companies could also do chart reviews and place other checks on APRNs if there are concerns about safety.

She told Rep. Manning that some members pay for collaborative agreements and she provided the committee with examples. On average, APRNs were paying collaborating physicians $1,000 per month.

Michele Pirc, an advanced practice nurse, said she went back to school to get a psychiatric specialty but struggled for a year to find a psychiatrist to sign a collaborative agreement. When she found a collaborator, the agreement restricted her to hospital settings, whereas she wanted to practice in long-term care settings. That was changed after several months.

"Until the current standard care arrangement regulation is retired, this unnecessary mandate will continue to be a major obstacle that prevents our patients from getting the care they deserve, the care that can help them lead healthier and happier lives," she said.

Dr. Paige Gutheil Henderson, representing the Ohio Osteopathic Association, urged the committee to oppose the measure, saying the best care model is led by a physician. She compared the years of post-graduate training for physicians to the requirements for nurse practitioners, which she said can be as little as 500 hours of online training.

"Clearly, the differences in education and training between a physician and nurse practitioner are stark," she said. "Quite simply, if a provider hopes to be fully equipped to issue a patient diagnosis, that person should graduate from medical school and receive years of hands-on training in patient care. There is no replacing the combination of education and training physicians must undergo."

Rep. Jim Butler (R-Oakwood) said one major concern is that providers often don't reach out to others for additional expertise.

"Are you confident that they know what they don't know enough to reach out to a collaborating provider?" he asked.

Dr. Henderson said knowing what you don't know is the "key skill" for health care providers.

"It takes on the job training for them to reach a level of comfort to reach out to me," she said. "I don't see any other way to help them than to have that collaboration agreement."

Rep. Don Manning (R-New Middletown) asked why the only opposition to the measure is just from physician groups.

Dr. Henderson said health care systems likely have more confidence that they can have robust processes and quality assurances in place above and beyond the legislation, but the legislation does not guarantee that APRNs would work for a responsible health care system.

The latest version of the bill, which allows APRNs with 2,000 hours of practice under an agreement to practice independently, does not compare to a residency for physicians.

"For all I know those 2,000 hours could be bad clinical care," she said.

Monica Hueckel, senior director of government relations for the Ohio State Medical Association, also voiced opposition, saying the proposal wouldn't encourage more APRNs to practice in rural areas because nothing keeps them from doing so now.

Collaboration agreements often include specific language about how often nurses should consult with physicians, she said. That flexibility allows for doctors and nurses and figure out what is appropriate.

"From my perspective and the perspective of physicians in the state of Ohio, a standard care arrangement does mean something," she said.

She also said she did not believe it was appropriate for physicians to charge for collaboration agreements. The OSMA and other groups have surveyed physicians and have not found one that is charging a nurse to sign a collaboration agreement.

She told Rep. Manning there could be business relationships that are designed to compensate physicians for the time they spend consulting, but she has not seen any instances in which doctors have required a fee to sign an agreement.

Rep. Beth Liston (D-Dublin) asked about changes in the bill related to the 2,000-hour independent practice standards.

"It doesn't say what clinical practice actually means, so I am unclear what those 2,000 hours actually equate to," Ms. Hueckel said.

Those 2,000 hours can be under the collaboration of another APRN, she said.

"We continue to have a lot of concerns," she said. "This bill at its essence is still an independent practice bill."

Margaret Clark Graham, a nurse practitioner for 42 years and educator for 26 years, detailed education standards for advanced practice nurses. Online programs include hands-on activities, video conferences and significant oversight, she said.

"It is very important to remember that advanced practice nursing has over a 50-year history with outstanding outcomes for improving population health and well-being and there are many checks and balance," she said.

"The Standard Care Arrangement is a barrier to practice for Ohio APRNs," she added. "And, there is no evidence that indicates the need for this barrier."

Other groups, including the Ohio Chapter of the American College of Emergency Physicians, the Academy of Medicine of Cleveland and Northern Ohio, the Ohio Dermatological Association and the Ohio Psychiatric Physicians Association, submitted written testimony in opposition. Mercy Health submitted testimony in support.