MORGANTOWN — Nurse practitioners in West Virginia are seeing benefits from a 2016 bill that lifted some restrictions on their scope of practice. But some challenges remain on the horizon.
Perhaps the most significant aspect of 2016’s HB 4334 was its provision enabling Advance Practice Registered Nurses – APRNs or NPs – who work in private practice and meet certain conditions to write prescriptions without collaborative agreements with physicians.
The collaborative agreement system at the time was rife with flaws and was tying the hands of APRNs who wanted to go into independent practice. Before the bill passed, a number of APRNs who tried to open up shop had to close them.
One of those was Toni DiChiacchio, who is immediate past president of the West Virginia Nurses Association and WVU nursing school’s assistant dean for Faculty Practice and Community Engagement.
She had to close down her Sabraton-based practice of three years because of restrictions in the law as it stood, and lobbied for years to get HB 4334 passed (The Dominion Post first wrote about the bill in 2014, noting it had been stewing idly for years at that point).
Asked recently about how the bill has panned out, she said fewer people who have their own practice are closing. “We’ve kind of stopped that process.” And, in fact, more and more APRNs are opening practices up.
There hasn’t been a huge surge of new practices, she said. Statistically, only about 1 percent of APRNs open their own practice. “So we didn’t expect huge results immediately, but we are seeing incrementally this change.”
HB4334, during all the years it percolated through the legislative system, had support from legislators, including nurses, of both parties, but strong opposition from physicians who controlled key committees and kept it buried.
It finally passed during the second year of the GOP majority, when Delegate Amy Summers, a registered nurse but not an APRN, used her leadership position in the House Health Committee to push it through.
“More nurses are going down the nurse practitioner path and people are having more options for access to care,” said Summers, R-Taylor, now House majority leader. Providing more healthcare practitioners to rural areas had always been part of the goal of the bill.
One downside, Summers said, is they are losing some bedside nurses who are going into the APRN field. They’ve dealt with that legislatively, to some degree, she said, by lifting some code restrictions blocking nursing schools from expanding their enrollment.
Asked if she envisioned pushing any NP-related legislation for the 2020 session, she said no. HB 4334’s main goal was to get NPs out from underneath physician scope and let them practice under their full scope of training. “They’re doing that and they’re setting up practices and it’s exciting and people are having more options for care.”
Former Delegate Denise Campbell, D-Randolph, was the bill’s lead sponsor during the days of the Democrat majority and stayed on as a cosponsor after the GOP took over. She is a registered nurse and vice president of the Nurses Association.
West Virginia has an aging population and a lot of veterans, she said. “That leaves West Virginia really needing to have enough healthcare providers to meet the needs.”
And many of the NPs she knew when she served in the Legislature couldn’t care for their patients anymore when their physician-collaborators retired or moved on. They couldn’t write prescriptions and people don’t want to go to multiple providers.
“It’s helped fill the gap in rural areas,” she said. Emergency department visits have declined in some areas. “It opens up another opportunity for some nurses who want o build on their RN degree. “They can if they want to, work independently, if they want to go back to their hometown or work in an undeserved area. It opens up jobs it opens up business for West Virginia. That’s a good thing.”
Challenges ahead
HB 4334 didn’t grant NPs unrestricted prescriptive power, and there are still some things that could help NPs help their patients in the future, Campbell said.
NPs can’t prescribe Schedule II drugs for short-term pain relief – such as hydrocodone or oxycodone. That means a patient has to see a physician or undertake the time and expense of visiting an emergency room. So it would be useful for NPs to be allowed to prescribe a 72-hour supply for acute conditions (this allowance was in the House version of HB 4334 but stricken by the Senate).
NPs can’ prescribe medications for children with ADHD, Campbell, said, and are limited to what they can prescribe for their patients in hospice care.
They can’t write prescriptions for diabetic shoes, she said, and this is an issue for a state with a large percentage of its population with Type II diabetes. They also can’t refer patients for home health care or hospice. “As the population ages, these are things that are going to be even more important in our state.”
DiChiacchio said there is strong interest in moving a bill to allow NPs to prescribe72 hours of Schedule II drugs for patients in legitimate pain who need a short prescription. But there’s been pushback on that.
Those who watched the debate at the Capitol know that some, particularly physicians, worry that giving NPs this power could worsen the state opioid crisis. Others point out that it was physicians, not NPs, who’ve been writing the prescriptions that led to the crisis.
DiChiacchio said there are sufficient safety features in place under the current opioid-abuse laws. “Nurse practitioners are not going to cause new cases of addiction if they are empowered to prescribe Schedule IIs if they need to.”
On the topic opiod abuse, Summers pointed out that NPs can prescribe Suboxone, but can’t provide counseling in office-based medication-assisted treatment (MAT) programs.
DiChiacchio added that state code requires MAT programs to have physician directors. This limits access for patients who don’t want to go to specialized addiction clinics.
“That’s kind of the movement we’re trying to make,” she said, “to get this into primary care just like any other kind of treatment.”
The insurance snafu
One remaining problem was threatening to close more NP practices. One of those was Phoenix Rising Health Care, operated by Traci Tannehill in office space in Fairmont Regional Medical Center.
The problem was that some insurance companies wouldn’t contract with APRNs for certain Medicare coverage – in particular Aetna/Coventry and UnitedHealthcare. Summers and DiChiacchio had both referenced this problem and said they were working ot correct it. DiChiacchio put The Dominion Post in contact with Tannehill.
Tannehill opened her practice in January, taking on some oncology patients of retiring Dr. John Azar – patients who’d been treated and cured but needed routine screenings or iron treatments and other follow-up and built up the practice from there.
When The Dominion Post first interviewed her in October, she hadn’t received a single Medicare or Medicaid payment, hadn’t taken a paycheck since March, and she and her nurse, Sherri Leuliette, had both taken second jobs, and staying open was an open question.
“I’m just on the cusp,” she said then. “I’ve invested everything I have personally into it. … I think we’re going to make it but it literally is week by week at this point.”
The Dominion Post contacted Aetna and UHC with a list of questions, but both gave short, nonspecific answers.
Aetna said, “We currently contract with nurse practitioners in independent practice for our Commercial and Medicare products if we have a geographic or business need. We recognize the benefits of having these providers in the rural areas of West Virginia, and meet all geo-access requirements as mandated by CMS as well as the NCQA [National Committee for Quality Assurance ] standards.”
UHC said, “Nurse practitioners are an important part of our provider network in states across the country. As UnitedHealthcare expands in West Virginia, we continue to enhance our network across many practice areas to ensure that individuals have appropriate broad access to physicians and other care providers across the state, including nurse practitioners with their own practices. We look forward to working with these care providers as we move forward.”
But last week, we contacted Tannehill again to see if she was still in practice. She was, and had good news. Both companies had changed course and decided to open their networks to NPs.
“It is very good for our practice,” she said. “I think we’re going to be fine now.”
We re-contacted both companies to see what led them to change their minds. UHC said, simply, “We are going to keep with our original statement as we continue to expand our network in the state.”
Aetna said it will start allowing direct contracts with NPs effective the first quarter of 2020. “Our overall goal is to better support providers, especially within rural areas of the state, while meeting all geo-access requirements as mandated by CMS and NCQA standards.”
DiChiacchio remains cautiously optimistic. “It seems like a great thing,” but as far as it really being implemented, “I’m skeptical. Hopefully it works out. That was a huge problem.”
Tweet David Beard @dbeardtdp Email dbeard@dominionpost.com
