One Voice 6th Annual NP Alliance of Alabama Conference

November 29, 2012

Proposal Prescriptive Authority for NPs who practice in Alabama

Background

• Since 2006 there have been multiple attempts to pass legislation to improve the scope of practice for NPs in the state.

• Several bills have been introduced but never made it out of committee to be considered for a vote.

• The bills ranged from dissolution of collaborative practice to controlled substances.

2011 NPAA ConferenceAugust

• New Legislative Chairs- Terry Watkins and Amy Wybenga unveiled a plan to proceed with introducing bills to include prescriptive authority for Schedules III-V and to build a coalition of strong supporters for the advancement of NPs in Alabama.

• After months of work and multiple efforts two bills were introduced: 1)By the Alabama Primary Healthcare Association (on behalf of NPAA), and 2) By the Alabama Board of Medical Examiners and Medical Association of Alabama.

2012 Legislative Outcomes

• Both bills that were introduced had some language in them that the Executive Committee and Steering Committee of NPAA felt uncomfortable with.

• Mr. Dixon (BME) and Ms. Finch (APHCA) were both notified that changes were needed.

• Eventually both bills failed to progress and the legislative session ended.

Planning for 2013

• Throughout the 2012 calendar year, there have been monthly meetings of the Steering Committee via conference call. One item of interest on the monthly agenda focused on the establishment of guidelines for how to proceed with plans for legislation to be introduced in the 2013 Legislative Session that will begin February 5th, 2013.

• A Leadership Summit was planned for the Steering Committee to begin planning for the 2013 session.

Leadership SummitOctober 11, 2012

• Five of the six regional groups sent representatives to this event and leaders from the Alabama Action Coalition, ABN and Schools of Nursing in Alabama were invited to participate.

• The Board of Medical Examiners and the Alabama Board of Nursing were invited to present plans for how NPAA might begin the process of seeking approval for prescribing Scheduled Medications -Controlled Substances.

PLEASE SEE MINUTES FROM THE October 11 SUMMITFOUND ON THE ENP NPAA

WEBSITE FOR COMPLETE DETAILS OF THIS EVENT

Recommendations From the Summit

• All attendees at the Summit voted to extend an invitation to Board of Medical Examiners and Alabama Board of Nursing to present the same information at the NPAA 6th Annual Conference that they presented at the Leadership Summit.

• Invitations were extended to both groups and both agreed to attend and present.

PRESENTATIONS

The following slides provide a “snapshot” in bullet form of:1. The Alabama Board of Medical Examiners

presentation by Mr. Larry Dixon, Executive Director of the Alabama Board of Medical Examiners (ABME) and Dr. Paul Nagrodzki of the Joint Committee and the ABME.

2. The Alabama Board of Nursing presentation by Ms. Genell Lee, Executive Director for the Alabama Board of Nursing (ABN).

Presentation by ABMELarry Dixon and Paul Nagrodzki

• LD: “BME wants NPs to have prescriptive authority in order to provide care for patients to the fullest extent.”

• LD: “my fault that the legislation that was submitted last year was incorrect. I copied the PA legislation which included that BME would discipline NPs. We do not want to discipline NPs. The discipline for NPs will be through the ABN”.

BME – Larry Dixon

• LD: “diversion is a major issue in prescribing with physicians; must take action and that action will begin with providing oversight of MDs in prescribing narcotics” (looking to oversee schedule II drugs for MDs – perhaps a second license for scheduled II)

• Governor Bentley is appointing a task force to review schedule II prescriptive authority for physicians.

BME (continued)• ABN is not in position to provide DEA certification.• Multiple layers of laws and rules would have to change for

ABN to have the authority. BME and MASA would fight against ABN getting the authority because BME already has a proven plan to educate NPs on how to prescribe controlled substances.

• The BME already has all the mechanisms in place and as soon as the bill is passed and rules are written and accepted, NPs and CNMs would be able to begin the process of applying for and getting a DEA number and begin prescribing.

Dr. Paul Nagrodzki comments:

1. Stated he is very encouraged by the progress made to include NPs as providers of telemedicine. This occurred as a result of NPs who were invited to be on a task force along with PAs and physicians to write the rules for telemedicine in Alabama.

2. Believes the timing is right, the BME is favorable to working with NPs to improve the scope of practice for CRNPs in Alabama.

Process If BME Proposal is Accepted

• Legislation will be developed by BME and NPAA

• Legislation will be presented to the House and Senate in February-Session begins Feb 5th.

• If passed then the work on the rules and regulations would begin – a task force will be appointed with representation from NPAA and BME to write the rules.

Concerns/Issues Voiced by Attendees

1. Attendees pointed out that PAs can only write for 14 days of meds followed by an appointment with the prescribing physician before the patient may receiving more prescriptions.

2. NPs need Schedule II prescriptive authority for controlled substances.

3. Not all CRNPs will seek to obtain the DEA certification.

4. NPs must have a voice in the rule making process.

If Legislation is Passed Mr. Dixon reported

• If proposed bill passes the BME would conduct pharm workshop; has agreed to have offerings via the NPAA annual conference and other times throughout the year to accommodate need.

• Prescriptive Authority will NOT be required for each individual NP-it will be an individual choice.

• If legislation is approved the rules and regulations will be established by a task force with NPs and physicians.

ABN PresentationGenell Lee, Executive Officer of ABN

Genell Lee reported in her presentation:1. The role of the Alabama Board of Nursing is to

protect public health, safety and welfare of citizens in Alabama. The BON’s role is not to be an advocate for the NPs or any nursing group since that is the role of the professional groups.

2. The legislature does not like professional groups bringing issues to come before them when they cannot not agree (nursing and medicine).

Genell Lee presentation continued 3. The Board of Nursing statement:The Alabama Board of Nursing believes expanding the scope of

practice of certified registered nurse practitioners (CRNPs) and certified nurse midwives (CNM) to include prescriptive authority for certain controlled substances will improve access to and quality of care for Alabama’s patients. The Board has reservations regarding any proposal that would require one profession to answer to multiple regulatory boards.

4. The Nurse Practice Act states that “CRNPs and CNMs are not allowed to prescribe controlled substances” therefore regardless of who certifies a NP or CNM to have a DEA # the nurse practice act would have to be changed.

5. NPs are split on this issue and until they come together as a group to reach consensus, they will continue to have difficulty getting anything passed.

Questions to Genell Lee

Question: Who were the responders at the public hearings?GL: The responders at the public hearings were a few RNs, but the majority were NPs and certified nurse midwives.

Question: Was a roster taken to identify how many were NPs?GL: No

Question: Did anyone attend more than one meeting?GL: Maybe a few. Not many.

Question: What other states have joint scheduled drug authority? Answered from the audience: 18 states

Questions to Genell Lee (continued)Question: How long would it take the ABN to obtain the authority to issue

DEA #s for Scheduled Drugs?GL: There will be a delay if you go through the ABN. The Board of Nursing does not issue DEA #’s. The process if changing legislation would have to occur.

Question: What will it take for the ABN to develop a bill: GL: Legislation will have to be developed. Sponsors will have to be found. That may be hard due to the division between nurses themselves.

Question: If dentistry regulates their own scheduled drugs why can’t the ABN regulate? GL: Alabama Public Health law must be changed so that ABN would be able to issue the qualifying certificate to prescribe controlled substances. GL: ASNA supports prescriptive authority , but not by other regulating body (ASNA supports ABN).

Final Comments by Genell Lee

The ABN statistics were provided and demonstrated that there are 2099 CRNPs in Alabama in collaborative practice and yet the numbers for those who answered the NPAA survey and attended the public hearings do not even approach half of that number. I don’t understand why there are so few attending or participating in forums and voicing their opinion.

VOTING• Using hand held clickers to vote the group was first asked to

answer 5 practice questions.• Following the practice session, instructions were given to

the group for how to complete the survey.• There were 220 registrants:• At the time of the vote, approximately 170 remained to vote

anonymously by clicker. The following slides represent the results of the voting.

• Others who voted by ballot (n=13) are noted below the clicker votes. They had to ID their ballot with name and license number to be counted and are on file.

Are you a Certified Registered Nurse Practitioner practicing as a NP in Alabama?

A. Yes = (n=150) B. No =(n-16)

BALLOT:C. Yes = (n=10)D. No = (n=3)

Are you a student in a nurse practitioner program?

A. Yes = (n=6)B. No = (n=163)BALLOTC. Yes = (n=3)D. No = (n=10)

Do you work in a primary care setting?A. Yes = (n= 89)B. No = (n=80)

BALLOTA. Yes = (n=10)B. No = (n=3)

Do you work in an acute care setting?

A. Yes = (n=40)B. No = (n=129)

BALLOTC. Yes (n=3)D. No = (n=10)

Do you work in a rural area?A. Yes = (n= 76)B. No = (n=91)BALLOTA. Yes = (n= 7)B. No = (n=6)

Do you work in a Federally Designated Rural Health Clinic?A. Yes = (n= 28)B. No = (n= 142)BALLOT C. Yes = (n=2)D. No = (n=10)E. No Answer = 1

Do you work in a hospital? A. Yes = (n= 32)

B. No = (n= 132)BALLOTC. Yes = (n= 4)D. No = (n= 9)

Do you support nurse practitioners having prescriptive authority for schedule III-V with the Board of Medical Examiners as the certifying body with the provision that all discipline will remain under the Board of Nursing?

A. Yes = (n=158)B. No = (n=16)BALLOTC. Yes = (n=11)D. No = (n=1)E. No Answer=1

Are you opposed to ANY plan that has the BME as the certifying agency for Prescriptive Authority for Scheduled

Controlled Drugs? A. Yes = (n=21)

B. No = (n= 151)BALLOTC. Yes = (n=1)D. No = (n= 11)E. No Answer= 1

I understand that the plan for prescriptive authority for III-V as presented by the Board of Medicine will move forward with proposed legislation in 2013. A. Yes = (n=173)

B. No = (n= 0)BALLOTC. Yes = (n=12)D. No = (n= 0)E. No Answer = 1

I understand that any plan for the ABN to be the certifying agency for Schedule III-5 will require multiple laws and regulations to be changed and may not be feasible in the near future.

A. Yes = (n=164)B. No = (n=3)BALLOT C. Yes = (n=13)D. No = (n=0)

While I believe that all NPs should be governed by the Board of Nursing, I support incremental changes (such as Prescriptive Authority for Controlled Substances) in collaboration with other health professional disciplines to advance the scope of practice for nurse practitioners in Alabama?

A. Yes = (n=161)B. No = (n=8)BALLOTC. Yes = (n=12)D. No = (n=0)E. Want to see proposed leg=1

35. As a nurse practitioner in Alabama, the most important issue to me that would advance the scope of practice for all NPs in Alabama is:

a. Approval of Prescriptive Authority for Controlled Substances Schedules II-V (n=2)

b. Approval of Prescriptive Authority for Controlled Substances Schedules III-V (n=5)

c. Elimination of the Collaborative Agreement and Joint Committee (n=1)

d. Elimination of the review of 10% of my charts by my collaborative physician (n=3)

e. Improvement in reimbursement by insurance companies in Alabama (n=8)

THIS ITEM WAS ONLY ANSWERED BY BALLOT-some voted more than once