NURS 4

Current Issues in Regulation and Licensure: Regulatory Responses

Changes to the Affordable Care Act

The ACA increased access for under-insured and uninsured U.S. residents, who are estimated to number more than 50 million. This law/program also had a significant impact on the estimated 6,400 shortage areas in the United States, including 66 million Americans who have limited access to primary care (ANA, 2011). The need for APRNs to work in a variety of settings, but particularly in primary care, has been enormous, but their usefulness has been dependent on lifting practice restrictions in their state of licensure. The ACA is now in the midst of partisan controversy, and the future of its key provisions is currently uncertain. Key policy issues related to the ACA include regulation of health insurance coverage and costs, potential changes to Medicaid and Medicare, potential changes in reimbursement for prescription drugs and prescribing practices, and handling of reproductive health services (Kaiser Family Foundation, 2016). Both state and federal regulatory agencies will play a part in enacting these changes; regulations governing the health insurance marketplace (HealthCare.gov, 2010) and the Medicaid and Medicare programs (CMS, 2014) will need to reflect any changes made by the U.S. Congress. Programs that rely on state matching funds (e.g., Medicaid) will likely be forced to reevaluate their state’s contribution. Reimbursement Significant breakthroughs have been made in reimbursement policy for APRNs, largely as a result of grassroots lobbying efforts and coalitions of APRN specialty nursing organizations. With the passage of federal legislation in 1997 allowing APRNs to bill Medicare directly for services, consumer access to care provided by APRNs has improved. Managed care markets value efficiency and provider effectiveness. Understanding the concept of market value has motivated APRNs to become more skilled in costing out their services and winning contracts in a competitive market. Scope of Practice The Future of Nursing progress report (IOM, 2016) noted that only minimal change in expansion of nurses’ scopes of practice had been accomplished since 2010. APRNs continue to struggle with these issues, although progress has been made in some states as well as at the federal level. A 2014 report from the Federal Trade Commission (FTC) provided an unbiased analysis of the consequences of continuing to impose restrictions on APRNs’ scopes of practice. The report noted associations between mandatory physician supervision/collaborative practice agreement regulations and restriction of independent APRN practice. The FTC (2014) projected that these environmental factors would likely lead to decreased access to healthcare services, higher costs, and reduced quality of care, leading to minimization of nursing’s ability to innovate in the delivery of health care. The Department of Veterans Affairs (VA) recently finalized a regulation allowing full scope of practice for APRNs with the exception of CRNAs (Dickson, 2016). Boundary disputes within and across the health professions create tension and are counterproductive to efforts to improve nursing’s contributions to care, as those efforts rely on equitable teamwork. It is imperative for APRNs to be cognizant of reports such as that published by the FTC and to keep abreast of inroads such as those made in the VA. Compelling evidence (e.g., the FTC report) and progress in high-level government agencies (e.g., the VA) can serve as leverage when negotiating with lawmakers and other stakeholders at the state level to enact changes in scope of practice laws. Increased Use of Unlicensed Assistive Personnel Unlicensed assistive personnel (UAPs) are individuals who are unregulated in many states, inexpensive, and employed in acute and primary care settings. In many settings, UAPs are used appropriately. However, when employers misunderstand the UAP’s role or expand job descriptions in an effort to provide more care at less cost, there is a risk that UAPs may be asked to function beyond their capacity and in a way that approaches nursing practice. Potential dangers include unsafe patient care and liability for nurses who, because of their employment situations, feel forced to delegate more nursing tasks to UAPs than safe standards of delegation would dictate. Electronic Access to Healthcare Services The impact of technology on the delivery of health care, including telehealth, was mentioned earlier in this chapter in the context of questions about whether the federal government has an interest in interceding in the standardization of state licensing requirements to facilitate interstate commerce. Such action would pre-empt the states’ authority to license health professionals. However, the states maintain their right to protect their citizens. Today, nurses who live in one multistate-regulation state and practice telehealth in another multistate-regulation state have the benefit of multistate regulation (but must affirm licensure in the second state). Where no multistate compact exists between states, however, the nurse must generally seek licensure in the state in which the patient resides. Interstate Mobility and Multistate Regulation Cumbersome licensure processes across geopolitical boundaries make seamless transition difficult or impossible, particularly for APRNs. The Nurse Licensure Compact (NLC) model, adopted by the NCSBN, is nursing’s mutual recognition model of multistate regulation and licensure for RNs. States adopting this model voluntarily enter into an interstate compact, which is a legal agreement between states to recognize the license of another state and to allow for practice between states. This allows the nurse to possess a “home state” license and practice in a remote state without obtaining an additional license. The compact must be passed as law by the state legislature and implemented by the BON in each state (NCSBN, 1998). A number of states moved quickly to enter the compact when it was instituted, but many states remain independent. As of January 2017, 25 states were participating as compact states (NCSBN, 2017b). Until 2015, there was no system for APRN participation in a nursing compact. Consequently, although the compact may apply to a nurse’s RN license, it does not extend to cover advanced practice, and APRNs must apply for licensure in each state of practice. In May 2015, NCSBN approved the APRN Compact model, which would allow APRNs to hold one multistate license and extend privileges to practice in other APRN Compact states (NCSBN, 2017a). To participate in this system, state NPAs would need to be revised to include the Uniform APRN Requirements. Currently, no states have enacted APRN Compact legislation.