AP44 Proposed Rule: Our Comments

On May 25, 2016, the Department of Veteran Affairs announced their AP44-Proposed Rule to amend its medical regulations that will permit full practice authority to all advanced practice registered nurses (APRN) acting within their scope of practice during their VA employment.

According to the American Association of Nurse Practitioners, APRNs have full practice authority within 21 states and the District of Columbia. The proposed amendment would allow VA APRNs to practice with full practice authority within all 50 states by exercising the federal preemption of state nursing licensure laws to the extent such state laws conflict with the full practice authority granted to VA APRNs while acting within the scope of their VA employment.

According to the chapters 73 and 74 of title 38 of the U.S.C., The Department of Veteran Affairs Secretary Robert McDonald can make this change given the “granted express statutory authority to establish the qualifications for VA’s healthcare practitioners, determine the hours and conditions of employment, take disciplinary action against employees, and otherwise regulate the professional activities of those individuals.” Given the recent publicized controversy of long wait times for veterans to receive medical care at VA medical centers, Secretary McDonald and the VA Under Secretary of health, David Shulkin, believe that APRNs can be the answer to “increasing 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 do this, the VA intends to allow APRNs to practice to the “full extent” of their education, training and certification.

The VA administration has requested commentary on the proposed amendment to the medical regulation of APRN’s full practice authority, and the following points are the viewpoints of the Policy Prescriptions® Collaborative.

1. We expect a major shift in the hiring of more APRNs compared to primary care physicians secondary to financial concerns over the federal budget.

According to the United States Department of Labor Bureau of Labor Statistics, the median salary for APRNs is $98,190 compared to Family Medicine physicians’ median salary at $184,390. Given the significant difference in salaries, there is a concern that the Department of Veteran Affairs would find hiring APRNs financially advantageous compared to hiring new primary care physicians.

2. The Department of Veteran Affairs fails to adequately address the Future of Nursing committee recommendation on extended training for APRNs beyond completing their advanced degree.

In the AP44-Proposed Rule, the 2010 Institute of Medicine report on The Future of Nursing: Leading Change Advancing Health is referenced for its recommendation that APRNs should be able to practice to the full extent of their education and training. However, within the same report, there was also a recommendation that by 2020, all APRNs should also obtain a doctorate of nursing practice and complete at least a one-to-three year postgraduate training program. The new proposed rule does not directly address this recommendation and only requires that APRNs must complete an accredited graduate-level program and pass the national certification examination. If these qualification are met this would ensure that “VA APRNs possess and maintain the education, knowledge, national certification and State licensure necessary for VA employment in one of the four recognized APRN roles. APRNs who meet these qualifications would be granted full practice authority within VA in one of the four recognized APRN roles.”

Our concern would be that if the VA would like their APRNs to have full practice rights within its facilities based on the IOM’s Future of Nursing committee recommendations then the VA should follow all the recommendations set forth by the said committee, including the recommendation for postgraduate training prior to independent practice.

3. We recommend promotion of interdisciplinary medical teams to address the complex medical needs of veteran patients

We believe that APRNs should be used to their full practice ability. Several have shown that APRNs produce outcomes comparable to those of physicians and that the care they provide encompasses 80 to 90 percent of the services provided by physicians (Lenz et al., 2004)[i]. Also, there was no increase in claims registered in the Healthcare Integrity and Protection Data Bank in states where APRNs have full authority to practice and prescribe independently (Pearson, 2010)[ii]. However, we also believe that as APRNs move forward in their role within the VA, the other members of the interdisciplinary medical team including physicians remain a vital part to successfully treating the complex patient.

Our Concluding Recommendation

In order to improve access to care for veterans at VA Medical Centers, we support the AP-44 proposed rule to allow APRNs to practice to the full extent of their education, provided that APRNs doing so follow the IOM Future of Nursing recommendation for supervised postgraduate training and that the VA maintain access to an interdisciplinary medical team including physicians for the most complex patients.

[i] Lenz, et. al.  Primary Care Outcomes in Patients treated by Nurse Practitioners or Physicians: Two-Year Follow-Up Med Care Res Rev September 2004 61: 332-351.

[ii] Pearson, L. 2009. The Pearson Report. The American Journal for Nurse Practitioners 13(6).