VA: APRNs may practice without oversight

January 17, 2017

In the wake of heated criticism about lengthy wait times for veterans’ care at Veterans Health Administration hospitals, the U.S. Department of Veterans Affairs has moved to allow advanced-practice registered nurses to practice to their full authority without physician oversight and regardless of individual state law in VA facilities.

Bob GattyIn the wake of heated criticism about lengthy wait times for veterans’ care at Veterans Health Administration hospitals, the U.S. Department of Veterans Affairs has moved to allow advanced-practice registered nurses (APRNs) to practice to their full authority without physician oversight and regardless of individual state law in VA facilities. Among the critics: President Donald Trump, who discussed the issue during his election campaign.

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The proposal, which drew 223,296 comments during the consideration process, excludes certified registered nurse anesthetists and is intended to make it easier for veterans to be seen by medical professionals, thus reducing the time they must wait to be seen for treatment. The final rule took effect Jan. 14.

“This preemptive rule increases access to care and reduces the wait times for VA appointments utilizing the current workforce already in place,” the VA said in its final rule implementing the policy, adding that the new policy will be especially beneficial in medically underserved areas.

The rule was strongly opposed by groups representing physicians, including the American Medical Association and the AUA.

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Last July, the AUA joined more than 100 state and federal medical societies on a letter initiated by the AMA opposing the draft rule and urging the VA to consider alternatives that focus on a team-based model of care rather than independent nursing practice.

“This is consistent with the AUA’s position and consensus statement on advanced practice providers being a part of a physician-led team,” the AUA said in a Policy and Advocacy Brief article posted online in early January. “The statement, in particular, was developed in conjunction with representatives from the Urological Association of Physician Assistants and the Society of Urologic Nurses and Associates,” the article noted.

The AUA will continue to work closely with the AMA to monitor the rule’s implementation, and that the AUA’s standing VA Workgroup is currently “dissecting the decision and formulating a response that can be shared with appropriate government officials,” the article said.

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In the brief, the AUA pointed out that urologists are critical to providing care to veterans.

“It is imperative the AUA also begins to hear from its members in the field on how this rule may be impacting patient care,” the AUA noted, asking urologists to contact the AUA’s Government Relations & Advocacy Department at GovernmentRelations@AUAnet.org or 202-403-8500.

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The new rule permits three roles of APRNs to practice to the full extent of their education, training, and certification without the clinical supervision or mandatory collaboration of physicians. They are Certified Nurse Practitioner, Clinical Nurse Specialist, and Certified Nurse-Midwife.

“Standardization of APRN full practice authority, without regard for individual state practice regulations, helps to ensure a consistent delivery of health care” across the Veterans Health Administration by decreasing the variability in APRN practice that results from varying state practice regulations, the VA said in the rule. About half the states have their own scope-of-practice laws for nurse practitioners.

In addition, the new policy also helps make the most efficient use of APRN staff capabilities at its facilities, the VA said, thus increasing its capacity “to provide timely, efficient, and effective primary care services, as well as other services.”

The VA said it did not address the team-based care argument in its rule “because we consider it to be an integral part in addressing all of a veteran’s health care needs. Establishing full practice authority to VA APRNs, including CRNAs, would not eliminate any well-established team-based care.”

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“This part of the VA’s final rule will rewind the clock to an outdated model of care delivery that is not consistent with the current direction of the healthcare system,” said AMA President Andrew Gurman, MD, who also said state laws should be followed.

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Trump deeply critical of VA

In January 2016, during a campaign news conference, President Trump slammed the long wait times that many veterans have experienced at VA hospitals, helping to raise the level of debate about the issue.

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“I’m entirely in favor of fixing the VA health care,” Trump said at the time. “The VA is one of the great catastrophes in this country. People are waiting five days, six days, seven days on line. They’re dying while they wait on line. And I am in favor of, if they can’t get a doctor within a reasonable period of time, they’re going to go see a doctor and the country’s going to pay for it.

“They’re going to a private doctor, or a public hospital, or a public doctor but someplace that can take care [of them] immediately. We’re losing thousands of people waiting on line.”

A Sept. 2, 2015 report from the VA Office of Inspector General said that an effort to confirm reports that 47,000 veterans died while their health care applications were pending was unsuccessful because VA records were insufficient.

In December, Trump reportedly was considering a plan to allow veterans to opt out of VA hospital care and instead see private doctors of their choosing, following through on that campaign statement made nearly a year ago.

“We’re working on something to make it great for veterans,” Trump told reporters later. “People are dying. We’re going to fix it properly.”

While many Obama administration policy rules are expected to be rolled back by the Trump administration, this new rule expanding the rule of APRNs may well dovetail with its views about making VA health care more accessible to veterans.

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