Nurses trained in Advanced Practice are quality providers

"...value-based models that emphasize getting treatment in the right place and at the right time. That tends to mean care is given upfront in a primary care setting where nurses are on the front lines."

This Forbes article (below) describes an unfortunately dicey situation between Advanced Practice Nurses (APRNs) and the American Medical Association.  This unnecessary and unproductive difference of professional opinion risks eroding decades of progress made between physicians and nurses about how to implement best practices for quality patient care and positive health outcomes.

Nurses Say AMA Launching 'Turf War' Over Direct Patient Access ~ Forbes article by Bruce Japsen

Nurses across the U.S. are upset at new American Medical Association policy opposing efforts to allow advanced practice registered nurses to practice independently of a physician’s supervision.

The AMA opposes "the continual, nationwide efforts to grant independent practice . . . to non-physician practitioners” including advanced practice registered nurses (APRNs), the nation's largest doctor group voted at last week's AMA policy-making House of Delegates interim meeting. The move is designed to intensify the AMA’s lobbying agenda through model legislation in Washington and state capitals “to initiate creation of a consistent national strategy.”

The development of a new AMA national lobbying strategy comes as APRNs are seeing states and branches of the federal government allow more direct access to patients without a physician’s supervision. A year ago, for example, the Department of Veterans Affairs grantedveterans access to advanced practice registered nurses in a landmark decision.
The American Nurses Association accused the AMA of perpetuating “the dangerous and erroneous narrative that APRNs are trying to ‘act’ as physicians and are unqualified to provide timely, effective and efficient care.” There are four APRN roles: 

• nurse practitioner
• clinical nurse specialist
• certified registered nurse anesthetist and 
• certified nurse midwife

“(APRNs) practice advanced nursing, not medicine, in which they regularly consult, collaborate and refer as necessary to ensure that the patient receives appropriate diagnosis and treatment,” ANA President Pamela Cipriano said in a statement. 

“For AMA to imply that APRNs are incapable of providing excellent care or that their care puts the patient at risk is blatantly dishonest. The future of health care calls on all health care professionals to work together as a team to meet the growing demand for health care services.”

Increasingly, states are easing restrictions to allow patients direct access to APRNs such as nurse practitioners as a way to get patients low-cost primary care, particularly in areas of the country that lack providers of medical care. South Dakota earlier this year became the 22nd state to allow nurse practitioners to practice independently, no longer requiring supervision by a physician as momentum builds to give NPs full practice authority.

Several nurse groups including the ANA and American Association of Nurse Practitioners (AANP) say the new state and federal laws allowing direct access are often efforts to speed care to patients that is slowed by bureaucratic red tape and not an effort to take business away from physicians. Rather, increased access to APRNs is in keeping with the U.S. health system’s move to value-based care models.

Government and private insurers including Aetna, Anthem, UnitedHealth Group and Blue Cross Blue Shield plans are moving away from fee-for-service medicine to value-based models that emphasize getting treatment in the right place and at the right time. That tends to mean care is given upfront in a primary care setting where nurses are on the front lines.

Veterans Health Care- provide dedicated reimbursement through Federally Qualified Clinics

As a Registered Nurse (RN), I don't understand why there isn't more dedicated revenue offered to Federally Qualified Health Clinics (FQHCs) to help pay for Advanced Practice Nurses (APRNs) who are qualified by education and experience to expedite quality primary care? Moreover, Nurse Anesthetists are completely qualified to administer anaesthesia and should be encourage to enter the field as independent practitioners. I've worked in surgery and, frankly, can see no difference between the practice of the CRNA (nurse anesthetist) and an anesthesiologist in the clinical setting.

Nurse Anesthetists(CRNAs) are qualfied by training and experience to be experts in the field of administering anesthesia, in my opinion.

Although I'm not an APRN, my experience with advanced practice nurses assures me that these qualified clinicians have the compassion and experience to expedite access to care for Veterans who are having to wait for a long time to receive treatments, especially when surgical procedures are required and a nursse anesthist can expedite the schedule.  

Of course, APRNs already work at many clinics where Veterans receive care, including at Veterans Medical Centers, but there is not a dedicated revenue stream provided to compensate for this level of clinicians' care. It's not about reimbursement for the APRN. In fact, APRNs including CRNAs are employees of their facilities. 

Rather, there should be a dedicated billing code for the clinic or hospital to implement that would be specific for primary care or surgry provided by APRNs to veterans. Without a doubt, having this kind of a special billing code available for primary care or surgical procedures, that's provided to veterans by APRNs, would expedite their access to the care they need, at the time it's needed, rather than to have them wait too long before being seen at all.

In fact, Veterans support the APRNs independent practice. Indeed, APRN care is essential to improving access to primary care for veterans, especially because physician shortages are causing long wait times to access care.

Medscape Nurses Reports: Medscape Medical News
Nurses, Veterans Back Independent Practice for Advanced RNs
A group of professional nursing associations and military organizations held a news briefing yesterday to throw their support behind a proposed rule by the Department of Veterans Affairs (VA) that would permit advanced practice registered nurses (APRNs) employed by the VA to practice "to the full extent of their education, training, and certification, without the clinical supervision of physicians," according to a statement in the federal register. 

(In my opinion, this rule should extend to FQHCs as well when Veterans are being cared for in the clinics.)

The proposed rule was published on the federal register on May 25. The VA has made the proposal available for comment in an effort to increase veterans' access to care.

To date, more than 44,000 people have submitted comments, more than six times the total number of comments submitted for previous rules, according to a release from the American Association of Nurse Anesthetists (AANA).

Although organized medicine has voiced strong opposition to the rule, the nursing and veterans' groups at the briefing were ardently behind the plan.

"Healthcare is one of the things our veterans were promised when they raised their right hands to serve their country," CMSGT Robert L. Frank, USAF (ret), chief executive officer of the Air Force Sergeants Association, said at the news briefing. "More than 80% of those who served in the military were enlisted, and many rely on VA healthcare to take care of them. The waiting is unacceptable. We're excited about this rule to allow the 6000 APRNs currently employed by the VHA [Veterans Health Administration] to be used to their full potential. Let them serve our veterans."

The AANA, the American Association of Nurse Practitioners (AANP), the American Nurses Association (ANA), the American Association of Colleges of Nursing (AACN), the Military Officers Association of America, and the Air Force Sergeants Association participated in the news briefing.

Anesthesia Provision by Nurse Anesthetists is Not New

Nurse anesthetists cared for wounded soldiers on the battlefields during the American Civil War and have been the primary anesthesia care providers "on the front lines of every US military conflict since World War I," according to the AANA.

"Our veterans are waiting too long to get the healthcare they have earned and they deserve. For years now, it's been clear to all of us that the VA healthcare system has tried, and despite all their efforts, we still need access to services for our veterans ― we're just not getting it," Juan Quintana, DNP, MHS, CRNA, president, AANA, who also served in the Air Force Reserves, said at the news briefing. "

In anesthesia...an independent VA assessment indicated that anesthesia services and access to those services was one of the limiting factors...for veterans getting surgical care, sometimes waiting for months to get those services.
"In terms of access, CRNAs have been administering anesthesia for 150 years. We provide services in underserved areas, in ruralities, [and] in some VAs without anesthesiologist involvement, [and] in addition to that, in the forward surgical teams that provide services to our soldiers who are in harm's way," Dr Quintana said.

In my nursing opinion, a dedicated revenue code for APRN and CRNA care would help to improve the independent practice needed to expedite care for our nation's veterans.