State Level RxP Successes: May was a very significant month for those interested in the prescriptive authority (RxP) agenda. Hawaii was successful in having their legislation pass both the House and Senate; and subsequently the House-Senate conference, although it never made it to the Governor's desk. Iowa's initial bill passed their Senate by a vote of 28 to 22; the House by 72-22; with the revised bill passing the Senate by a final vote of 33-16. On May 27, Governor Terry Branstad signed the bill into public law. This is the fourth state to have enacted RxP legislation with Guam (1998) still in the implementation process. With the Department of Defense (DoD) and USPHS successfully utilizing the services of prescribing psychologists, those interested in the RxP agenda have been focusing their efforts primarily at the state level, and to some extent within the Department of Veterans Affairs (VA). The underlying policy issue remains: Should health care practitioners of all disciplines be able to practice to the fullest extent of their training and clinical expertise, as recommended by the Institute of Medicine (IOM) in its landmark 2010 report The Future of Nursing: Leading Change, Advancing Health? With telehealth/telepsychology increasingly being utilized, why should geographical boundaries continue to play a significant role in defining "quality care"?
An Exciting Vision for the Future: Historically, health care "scope of practice" acts have been established and overseen at the state level. Nevertheless, the federal system (relying upon the constitutional concept of "federal supremacy") has functioned in whatever manner best fulfills its underlying mission. For example, DoD established the concept of military Medics, made famous by the television show MASH in the early 1970s. This May, the VA published in the Federal Registerproposed rules for nursing's scope of practice which would essentially override restrictive state barriers which are not in the best interest of clinical and patient care. During his tenure this effort had the support of former Obama Administration VA Secretary Eric Shinseki (2009-2014).
"The Department of Veterans Affairs (VA) is proposing to amend its medical regulations to permit full practice authority of all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment. This rulemaking would increase veterans' access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services to the full extent of their education, training, and certification, without the clinical supervision of physicians…. VA intends that the services to be provided by an APRN… would be consistent with the nursing profession's standards of practice…."
"By permitting APRNs throughout the VHA system a way to achieve full practice authority in order to provide advanced nursing services to the full extent of their professional competence, VHA would further its statutory mandate to provide quality health care to our nation's veterans…. Standardization of APRN full practice authority, without regard for individual State practice regulations, would help to ensure a consistent continuum of health care across VHA by decreasing the variability in APRN practice that currently exists across VHA as a result of disparate State practice regulations. As of March 7, 2016 CRNAs have full practice authority in 17 states, while CNPs have full practice authority in almost 50% of the nation, which includes 21 states and the District of Columbia…. This proposed rule is consistent with the recommendations of the Institute of Medicine (IOM) of the National Academy of Sciences to remove scope-of-practice barriers. Specifically, the 2010 IOM report, 'The Future of Nursing: Leading Change, Advancing Health'…."
In this rulemaking, VA is proposing to exercise Federal preemption of State nursing licensure laws to the extent such State laws conflict with the full practice authority granted, except for applicable State restrictions on the authority to prescribe and administer controlled substances. The VA remains the largest employer of nursing and psychology and, as such, does have a major impact upon the expectations and aspirations of the professions. Former VA senior official Robert Zeiss reflects: "During my tenure at OAA (2005-2013) and continuing today under the leadership of Kenneth Jones (Director of Associated Health Education), the number of funded psychology postdoctoral training positions increased from 52 to 402. Phase III of the five year Mental Health Expansion Initiative will increase those numbers even more for the 2015-16 academic year."
A Historical Perspective: As indicated, former VA Secretary Eric Shinseki supported this effort. The key VA architect beyond this evolution was Cathy Rick, former Chief Nursing Officer (2000-2014) and now Senior Advisor for Nursing Leadership at the Jonas Center for Nursing Excellence. "We began the journey of crafting policy/proposed legislation for APRN full practice in early 2011 with consideration for the following: * Reduce variability in clinical practice across the entire VA Health Care System. * Decision for standardization of practice based on solid published evidence/outcomes. * Consistent with Institute of Medicine recommendations (IOM, 2010). *Transformation of National Healthcare System. * Cost-Effective Care. * Team Based Care/Medical Home/PACT. And, * Access to Care." Over the years I have come to appreciate that fundamental change takes time. Therefore, Cathy's vision, passion, and persistence were absolutely necessary for success.
Significant Change is Coming: Also this May, * on a bipartisan vote of 23-3, the Senate Armed Services Committee recommended the enactment of the National Defense Authorization Act for Fiscal Year 2017 which would require, not later than one year after the date of enactment, the commencement of a pilot program to assess the feasibility and advisability of training and utilizing physician assistants (PAs) specializing in psychiatric medication at military medical facilities in order to meet the increasing demand for mental health care by establishing a psychiatric fellowship program for physician assistants. The pilot program would consist of two rounds with each round taking a maximum of two years to complete. The Secretary is to select at least five individuals for each round. And, * at a recent HRSA (Health Resources and Services Administration) Advisory Committee on Interdisciplinary, Community-Based Linkages, Acting Administrator Jim Macrae reported that 30% of new hires in the past two years by federally Qualified Community Health Centers were veterans. Health centers are our nation's safety net, especially for rural veterans. One in three people living at or below the poverty level rely upon these centers for their primary medical care.
In Memory: Prior to his most unfortunate and totally unexpected passing, former Division 42 President Steve Walfish shared with us the impressive publication by Jeff Zimmerman and Diane Libby Financial Management for your Mental Health Practice: Key Concepts Made Simple. Throughout his professional career, Steve strove to educate our mental health colleagues on the financial aspects of being a healthcare professional – a critical skill which most of us never learned in graduate school. Jeff and Diane do a wonderful job of walking their readers through such fundamental concepts as carefully reading official rental agreements and determining appropriate payment rates for practice colleagues. Who knew that there is so much more to consider in being "an excellent therapist" after those long years of training? Aloha,
Pat DeLeon, former APA President -- Division 18 – June, 2016
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