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ACNM Policy Update - 3/3/2015

State Issues

1.  California Full Practice Authority (CNM-Only) Bill Introduced! 
2.  Pennsylvania Medical Society Video: “Opposing Independent Practice for Non-Physician Providers”
3.  Louisiana Board of Medical Examiners Withdraws Restrictive Rules Proposal
4.  South Carolina APRN Bill Media Coverage (With Poll!)
5.  A Complicated Dance -- West Virginia Introduces, Defends, and then Opposes APRN Compromise Bill
6.  Other Selected State Developments:  AK, CO, GA, MO, MT, OH, VA, WA, WV
  

Federal Issues

1.  Legislation to Identify Maternity Provider Shortage Areas Introduced in House and Senate
2.  Supreme Court Decision with Implications for APRN Regulation
3.  Leapfrog Group Releases Report on Hospital Maternity Care Performance in 2014.
4.  CMS Issues Final Regulation and Letter to Issuers for Health Insurance Marketplace Plans
5.  CMS to Hold March 25 Webinar on Perinatal Payment Strategies
6.  NHSC Site Application Process Open
7.  Choose ACNM's Next President:  Elections Closing this Sunday


Don't Forget to Forward this Note to CNMs/CMs who are not ACNM Members
 


State Issues


Note:  Current status of state legislation of interest to ACNM members can be obtained through ACNM's Legislative Tracking Tool.


1.  California Full Practice Authority (CNM-Only) Bill Introduced!

Congratulations to the California affiliate on the successful introduction of A.1306, a bill that removes the requirement for physician supervision of nurse-midwifery practice, creates the Nurse-Midwifery Advisory Council, updates scope of practice, and deletes the requirement that drugs and devices must be furnished in accordance with standardized procedures and protocols, among other things.


2.  Pennsylvania Medical Society Video: “Opposing Independent Practice for Non-Physician Providers”

The Pennsylvania Medical Society has released a video explaining the rationale for its general objections to full practice authority. Nurse-midwifery is not a specific topic of consideration, but the video might have broad appeal to ACNM members working toward autonomous practice. The arguments presented are used by medical societies across the country. 


3.  Louisiana Board of Medical Examiners Withdraws Restrictive Rules Proposal

In 2014 the Louisiana Board of Medical Examiners proposed rules related to the physician-APRN collaborative relationship that would have increased practice barriers by requiring a secondary back-up physician, requiring at least quarterly site visits, and physician review of at least 10 percent of patient charts, among other things. The Board of Nursing and other stakeholders, including ACNM, expressed grave concerns with the proposal. The Board has decided to withdraw the rules and instead work collaboratively with the Board of Nursing to “develop joint guidelines that will be instructive to both physicians and advanced practice nurses alike.” 


4.  South Carolina APRN Bill Media Coverage (With Poll!)

The Post and Courier has published an article on the APRN bill hearing from several weeks ago that gives a basic overview of the current debate surrounding efforts to obtain full practice authority. The article also has a link to a poll asking readers whether “nurse practitioners and other nurses with advanced degrees [should] be able to practice independently without physician supervision?”  At the time of this writing, 80% of respondents had answered yes. 


5.  A Complicated Dance -- West Virginia Introduces, Defends, and then Opposes APRN Compromise Bill

West Virginia S.516 in its introduced form began to remove some of the regulatory barriers to full practice authority. The bill created a new board – the West Virginia Board of Examiners for Advanced Practice Registered Nurses – with physician and APRN representation, including a designated CNM position. The bill removed the requirement for an overall collaborative plan and also created a pathway to independent prescriptive practice after five years of collaborative practice. However, the proposal limited autonomous APRN practice to rural areas.  While the bill was not representative of an APRN “dream bill,” it was seen by many as a critical first step in efforts to modernize West Virginia’s regulation of advanced practice nurses in a state where efforts to achieve full practice authority have been ongoing for nearly a decade. S.516 was introduced after the original APRN bill, S.21, failed to advance.

The state medical society indicated within days of S.516’s introduction that they would not support the bill, however, and the APRNs began to brace for an amendment to move their regulation under the Board of Medicine. The APRN community was understandably outraged by this failure to stand behind the compromise language. West Virginia Nurses’ Association President Evelyn Martin said, “Even though nurses have complied with every legislative request for eight years and have overwhelming research evidence to support removing these outdated restrictions, we continue to be subjected to abuse and lies about the safety of our practice by organized medicine. The worst part is they are defending turf they don’t even want where nurses are trying to meet the need – rural settings and Medicaid patients.” 

Following a tumultuous week, a substitute bill emerged from committee that incorporated numerous amendments, including placing prescriptive authority under the Board of Medicine and Board of Osteopathy (with the addition of one APRN member on the Boards) and reinstating the collaborative requirements for CNMs. This version of the bill successfully passed out of the Health and Human Resources Committee and was referred to the Finance Committee. The bill must pass out of the committee and be heard on the Senate floor this week in order to advance; at the time of this writing, the bill has yet to be considered by the Finance committee.


6.  Other Selected State Developments:  AK, CO, GA, MO, MT, OH, VA, WA, WV

Alaska S.53 proposes to implement the APRN credential. CNMs are currently licensed as a category of advanced nurse practitioners.

Colorado H.1111 creates the Colorado Maternal Mortality Review Committee for the purpose of reviewing maternal mortality cases that occur in Colorado, identifying the causes of maternal mortality, and developing recommendations to prevent further maternal mortalities.

Georgia H.416, the Consumer Information and Awareness Act, is a truth in advertising bill that would require CNMs and other health care providers to “conspicuously post and affirmatively communicate the practitioner's specific licensure to all current and prospective patients” via name tags and signs in the reception area. 

Missouri S.479 proposes deemed licensure for midwives authorized to provide midwifery services due to current ministerial or tocological certification by an organization accredited by the National Organization for Competency Assurance (NOCA).  Licensure would be effective in August 2015, with rules regarding licensure requirements and scope of practice to be promulgated within 180 days. 

Montana S.81 proposes to increase the number of positions on the Board of Nursing from four to five registered professional nurses, among other amendments. Of these, at least one must have had at least 5 years in administrative, teaching, or supervisory experience in one or more schools of nursing, at least one must be an advanced practice registered nurse, at least one must be engaged in nursing practice in a rural health care facility, and at least one must be currently engaged in the administration, supervision, or provision of direct client care. The bill has been transmitted to the Governor. 

Ohio S.66 proposes to establish Health Care Professional Loan Repayment Program. CNMs would be eligible to participate.

Virginia H.1515 requires nurse-midwives to give all maternity patients information about safe sleep environments for infants that is consistent with current information available from the American Academy of Pediatrics. The bill has passed both Chambers.

Washington H.1339 would allow the Secretary of Health to intercede and stay any decision by a disciplinary (regulatory) board that is determined to expand scope of practice via rule making, interpretive statement, policy statement, declarative order, practice guideline, decision in a formal disciplinary action, or other declaration. The bill has passed the House. A similar bill in Montana, H.438, has been tabled in committee.

West Virginia H.2776 proposes to allow APRNs to prescribe hydrocodone combination drugs for a duration of no more than three days per patient. The bill has passed the House.


 
Federal Issues

 
1.  Legislation to Identify Maternity Provider Shortage Areas Introduced in House and Senate  

Earlier today, the “Improving Access to Maternity Care Act of 2015,” (S. 628/H.R. 1209) was introduced, on a bi-partisan basis in both the House and Senate.  This important bill is the same as legislation ACNM supported in the last Congress which was only introduced on the House side.

The bill, sponsored by Senators Mark Kirk (R-IL) and Tammy Baldwin (D-WI) and by Representative Michael Burgess (R-TX) and Representative Lois Capps (D-CA) would establish a health professional shortage area designation for maternity care services, similar to shortage designations that exist for primary care, dental and mental health services. Specifically, it would require identification of areas in the US experiencing a significant shortage of full scope maternity care professionals, including certified nurse-midwives (CNMs) and certified midwives (CMs).  The designation would also identify areas experiencing shortages of hospital or birth center labor and delivery units.  This designation would set the foundation for ensuring that resources are appropriately directed to address these shortages.

ACNM and ACOG closely cooperated in the work of securing reintroduction this session and we are gratified to see an excellent outcome to those efforts.  ACNM will be preparing advocacy materials and a grassroots Action Alert that will be sent to our membership in the next few days that will facilitate your advocacy efforts in support of the bill.

 

2.  Supreme Court Decision with Implications for APRN Regulation


The Supreme Court’s decision in North Carolina Board of Dental Examiners v. Federal Trade Commission has implications for efforts to locate APRN practice regulation under the auspices of state medical boards. One of the key questions of the case was whether the board thwarted competition by engaging in anticompetitive conduct to prevent non-dentists, including those offering lower prices, from providing teeth whitening services.  Interested members can view a more thorough analysis of the case and its key questions in this October 2014 ACNM summary.

As our colleagues at AANA and authors of an amicus brief to the Court point out, the 6-3 ruling affirms that unsupervised state regulatory boards comprised mostly of practicing professionals have the potential of acting in their own economic self-interest by protecting their competitive position in ways not intended or authorized by the state, thus warranting oversight. The FTC similarly commented that “the Supreme Court affirmed the Federal Trade Commission’s position in recognizing that a state may not give private market participants unsupervised authority to suppress competition even if they act through a formally designated ‘state agency’…We are pleased with the Supreme Court’s recognition that the antitrust laws limit the ability of market incumbents to suppress competition through state professional boards.  We will remain vigilant through our enforcement initiatives and advocacy to safeguard competition and ensure that American consumers benefit from entrepreneurial initiative.”  

For additional analysis of the Court’s ruling and its likely implications for the regulation of health care providers in the states, refer to these articles from Modern Healthcare, TheWashington PostNPR, and the Wall Street Journal.


3.  Leapfrog Group Releases Report on Hospital Maternity Care Performance in 2014

Every year, The Leapfrog Group, an organization of employers and other organizations that purchase health insurance coverage for dependents and their families, as well as business coalitions on health, ask every adult general acute care and free-standing pediatric hospital in the U.S. to voluntarily complete their hospital survey.  Leapfrog uses the survey data to publicly report on issues that matter to healthcare purchasers and consumers, including maternity care.  Measures included on the Leapfrog Hospital Survey are endorsed by the National Quality Forum and/or aligned with those of other significant data collection entities, including the Center for Medicare Services (CMS) and the Joint Commission.   

Leapfrog has just recently released its 2014 maternity care report.  Among the measures reported by participating hospitals are those related to early elective delivery, episiotomy and ensuring that high risk births occur in appropriate facilities.   


4.  CMS Issues Final Regulation and Letter to Issuers for Health Insurance Marketplace Plans

On February 20, the Centers for Medicare and Medicaid Services (CMS) released its final2016 Letter to Issuers in the federally facilitated marketplaces.  On February 27, CMS published a final regulation related to benefits and payments in the marketplaces.  Together these documents provide significant guidance for insurers on how to structure the products they offer through this coverage mechanism. 

ACNM commented on draft versions of both of these documents, focusing our comments on issues related to network adequacy and the accuracy of plan provider network directories.

CMS notes that many people newly enrolling in a plan are undergoing care for an existing condition with providers who may not participate with their new plan.  Although the agency does not adopt a specific requirement, it encourages insurers to adopt a policy allowing people in this situation to continue treatment with their existing providers for a specified transition period, giving them time to select new providers who participate with the plan.

CMS finalized a proposal supported by ACNM that will require plans to provide a link to their provider network directories that will be easily available through the marketplace websites. The directories must be up-to-date, accurate and complete, including information on which providers are accepting new patients, provider location, contact information, specialty, medical group, and institutional affiliations.  The directories must be updated at least monthly.  The data must be available to anyone, regardless of whether they are enrolled in the plan.  Data will also be available in a machine-readable format so researchers can more easily analyze it. 

In both documents CMS noted that the National Association of Insurance Commissioners (NAIC) is working to develop a model law on insurer network adequacy and indicate that they agency plans on deferring to the outcome of the NAIC’s process as opposed to establishing specific network adequacy criteria on its own.  The agency stated that “This reflects our general position that network adequacy is an area subject to significant State regulation and oversight.”  Such deference to state regulators has been a large motivator for ACNM’s efforts to engage that audience through written and in-person communications.  Many of our affiliate officers have met with their respective state insurance commissioners to discuss inclusion of midwives in plan networks and adequate coverage of the services they provide.  ACNM’s national office has also been in communication with the NAIC on the topic of provider network adequacy both through written and in-person communication. 

 

5.  CMS to Hold March 25 Webinar on Perinatal Payment Strategies

On March 25, 2015 from 12:00 - 1:30 p.m. eastern time, the Centers for Medicare and Medicaid Services (CMS) will hold the third in a series of webinars from the Maternal and Infant Health Initiative. This webinar will focus on alternative payment methods that can encourage the delivery of high quality care to women across the prenatal, postpartum, and intrapartum periods.  During the webinar national experts as well as state and federal officials will discuss promising approaches to perinatal payment reform that are currently being explored.  Click here to register.


6.  NHSC Site Application Process Open

The 2015 National Health Service Corps (NHSC) Site Application cycle opens on Tuesday, March 31 for healthcare sites that have never been approved as an NHSC site.  Currently there are more than 9,200 NHSC clinicians and more than 15,000 NHSC-approved health care sites providing healthcare in urban, rural, and frontier areas located throughout the Country.    

 The benefits of becoming an approved NHSC-site are many including access to NHSC Loan Repayment  and Scholarship Program providers who are currently seeking employment at NHSC-approved sites.  Sites can also utilize the NHSC Jobs Center, where NHSC-approved sites post job openings and site profiles to attract the attention of more than 17,000 unique visitors each month.  In addition, NHSC-approved sites can participate in NHSC Virtual Job Fairs, which provide NHSC-approved sites the opportunity to recruit providers in a cost effective manner since interaction is facilitated online via the internet and phone.    

When the cycle opens on March 31, facilities will submit an NHSC Site Application through the Bureau of Health Workforce Program Portal.   Below are several resources potential NHSC site applicants may find helpful:

2014 NHSC’s Site Reference Guide. The 2015 Site Reference Guide will be made available on March 31.  

NHSC Site Eligibility Requirements  

NHSC Site Applicant Checklist  

All auto-approved sites, including Federally Qualified Health Centers (FQHC), FQHC Look-Alikes, American Indian Health Facilities, and  Federal Prisons, do not need to apply but must contact their regional representatives directly to have their site added to the NHSC system of record.  

 

7.  Choose ACNM's Next President:  Elections Closing this Sunday

Voting in the ACNM 2015 election will close this Sunday, March 8. Offices on the ballot are President-Elect, Secretary, Region II Representative, Region V Representative, and two spots on the Nominating Committee. You will also vote whether to approve the entire Final Draft Bylaws Revision. Check your inbox for electronic voting instructions from the ACNM Election Coordinator. Let your fellow members and colleagues know you’ve participated by downloading and sharing our graphic on your Facebook, Twitter, and Pinterest accounts!  


Don't Forget to Forward this Note to CNMs/CMs who are not ACNM Members

As usual, if you know any CNMs/CMs who are not currently ACNM members, please forward this Policy Update to them.  We want to be sure they know what the association is doing on their behalf and the kinds of activities that their membership would support.



Should you have questions about state issues, please contact Cara Kinzelman, ACNM's Manager of State Government Affairs at [email protected] or 240-485-1841.  

If you have questions regarding federal issues, please contact Jesse Bushman, ACNM’s Director of Advocacy and Government Affairs at [email protected] or 240-485-1843. 



Not an ACNM member?  You can access all of the member benefits, including receipt of every ACNM Policy Update, by joining today.  

Want to take action or get involved?  Contact ACNM's Government Affairs Committee.


Don't have the time or energy to get involved, but still want to contribute?  Support the Midwives-PAC.
 


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