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CRNP Independent Practice (SB 25/HB 100)

CRNP Independent Practice (SB 25/HB 100)

The Issue:  These bills would allow an “advanced practice registered nurse-certified nurse practitioner” (APRN-CNP) to practice independently in Pennsylvania, providing full medical care without a collaborative agreement or supervision under certain conditions.

What YOU can do:  Reach out to your State Representative today, especially if s/he is a member of the PA House Professional Licensure Committee, and ask them to support Chairman David Hickernell’s amendment to HB 100.  Explain that all Pennsylvanians, including those in rural and other underserved areas, deserve equally high-quality medical care.  This limited pilot project, as proposed, would give certain qualified primary care nurse practitioners six years to demonstrate that they could truly enhance access to quality care and improve health outcomes in the state’s primary care Health Professional Shortage Areas.

After five years, the impacts of the pilot project would be assessed before any further legislative consideration of independent practice. (Research has demonstrated that granting nurse practitioners license to practice medicine independently has not significantly increased care access in states where this has occurred, as they claim it will in PA (see below).

For more information or ways you can help, please contact Amy Davis (AmyDavisDO@aol.com), PA ACP Health & Public Policy Committee Chair, or Mr. John Nikoloff (John@pa-erg.com), PA=ACP Policy and Government Relations Consultant/Lobbyist.

History: The state’s 13,700 certified nurse practitioners have been seeking independent practice for 20 years but did not have significant legislative support until 2017, when the Hospital and Health System Alliance of Pennsylvania changed its policy to endorse this action.  The Coalition of Nurse Practitioners cites their roles in Federally Qualified Health Centers and the Veteran’s Administration as examples of why this would be helpful.  They claim their independent practice would not only expand access to combat the shortage of primary care physicians but also expand care in rural and underserved areas, all with care cost savings, too.

The State Senate has passed legislation the last three sessions that would give CRNPs independent practice without a collaborative arrangement, but with PA-ACPs efforts,  the bills have been held back from consideration by the House of Representatives.

SB 25 (Prime Sponsor Sen. Camera Bartolotta) Text:    https://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=HTM&sessYr=2019&sessInd=0&billBody=S&billTyp=B&billNbr=0025&pn=0507

HB 100 (Prime Sponsor Rep. Jesse Topper) Original Text: https://www.legis.state.pa.us/cfdocs/billinfo/billinfo.cfm?syear=2019&sind=0&body=H&type=B&BN=0100

HB 100 Amendment: Chairman Hickernell’s amendment to HB 100 would establish a pilot program that allows a licensed primary care CRNP meeting all qualifications to practice independently in a Health Professional Shortage Area for six years, with a research study conducted after five years to assess the efficacy of CRNPs in practice without collaborative agreements.

Qualifications would include licensing, continuing education, three years and a minimum of 3,600 hours of working under a collaborative agreement within the past five years, and certification of ability by a physician under whom the CRNP worked with a collaborative agreement for temporary certification in the pilot program.  This would permit the CRNP to practice independently only within the geographic areas of the state’s primary care Health Professional Shortage Areas. 

The project would be overseen by a Subcommittee of the Board of Nursing headed by the Secretary of Health or Physician General, and including three physicians and three nurse practitioners.  Program participants would continue to have their own CME requirements for two year relicensing, to complete educational programs mandated for primary care practitioners or certain patient services, and an additional ten hours of patient safety and risk management training.

After five years of the pilot project, the Joint State Government Commission will conduct a research study to determine whether the project demonstrates improvements in access, outcomes, quality health care, movement of NPs to underserved areas, and other factors such as ER use and referrals, diagnostic tests ordered, primary care referrals, etc.

Nurse practitioners have promoted their ability to expand access and improve outcomes for more than a decade.  Following the study, legislation would be required to allow independent practice after the six year period expires.

SB 25/HB 100 Summary:  SB 25 and HB 100 as introduced would allow an APRN-CNP license be issued to any CRNP working under a collaborative agreement for a year following graduation from an accredited master’s, post-master’s, or doctoral nursing program in primary care fields or mental health, or if the CRNP worked for three years and at least 3,600 hours under a collaborative agreement.  The proposed APRN-CNP license would be renewable every 2 years, requiring 30 credits of Continuing Education (16 of them in pharmacology if prescribing) and maintenance of certification in one of the above fields.

APRN-CNPs would also be permitted to form professional corporations with other licensed healthcare clinicians, including RNs.  Scope of practice would be limited to the nurse’s licensed field.  The APRN-CNP would be required to maintain liability insurance in his/her name but would not be eligible to participate in the MCARE fund.

One of the most often cited reasons in favor of APRN-CNP independent practice is the PA physician shortage, especially in rural areas and for patients having lower incomes.  Recent studies (e.g. Health Affairs, Jun-2018) have demonstrated those populations have experienced increased clinician access in states where Advanced Practice Nurses (APNs) were allowed independent practice.  However, analysis demonstrates these increases were not statistically significant.  The vast majority of newly independent nurses choose to practice in areas already well-served by physicians, presumably for economic reasons.

What Is PA-ACP Doing?
PA-ACP has been leading the Primary Care Physicians' coalition and opposing the immediate independent practice of CRNPs for well over a decade.  CRNPs are an integral component of team-based care, adding a valuable perspective to patient care.  However, their training focus, breadth, and duration do not sufficiently prepare them for independent medical practice.  Mr. John Nikoloff and ERG Partners have been working closely with those in the PA General Assembly (PA House and Senate) on our behalf.  As expected, the State Senate passed SB 25 in a 44-6 vote in June of 2019.  Since then, PA-ACP has been working closely with the PA House leadership, and Professional Licensure Chairman David Hickernell to ensure all patients get the best possible care.

This summer, PA-ACP, with other primary care physician organizations, worked with Chairman Hickernell to develop conditions for a pilot project over a six year period with an evidence based study of results after five years to weigh the relative effectiveness of the certification, continuing education and implementation of the pilot program.

National ACP Policy on NP Independent Practice: ACP advocates strongly for team-based care models and values highly the contributions of nursing as an important part of a quality healthcare model.  However, ACP is opposed to the independent practice of nurses.