ACNM Policy Update - 3/3/2015

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.

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. 

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." 

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. 

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.

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.

 

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 Post, NPR, and the Wall Street Journal.

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. 

 

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.

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.