2 days ago
Regulatory Challenges for NPs, PAs — How to Keep Up
A roadside rest stop isn't the typical place to meet up with your patient. But it worked for Johnny L. Rollins, MSN, APRN, ANP-C, a nurse practitioner (NP) and associate director of the Advanced Practice Provider Programs — survivorship at the University of Texas MD Anderson Cancer Center, Houston — and his patient who lived in Louisiana.
As a licensed provider in Texas, he can't practice medicine in another state unless licensed there as well. Rollins said his patient needed a telemedicine visit.
'A telemedicine visit is technically a billable clinic visit,' Rollins told Medscape Medical News, 'and compliance with state and federal telemedicine law is required.'
As a result, he said, this patient and some others from Louisiana, have driven across the Louisiana-Texas state line, parked at a welcome area rest stop, and then started the video clinic visit to meet compliance requirements.
Rollins' story illustrated how keeping up with regulations is necessary — but also a challenge, not only for physicians but also for the 280,140 NPs and the 152,103 physician assistants/associates (PAs) practicing in the US.
Changes regulating both NP and PA practices, some said, have increased in recent years, sometimes spurred by COVID-related changes. Staying up to date is crucial, as not paying attention could jeopardize a healthcare worker's practice. Despite the challenge, many sources of information can help NPs and PAs stay up to date.
Who Regulates?
Beyond federal and state legislation regulating how NPs and PAs practice, healthcare organizations may have additional policies, so it's crucial to be aware of all of them, experts said.
For PAs, while there is some variation in state law, 'the majority of states have abandoned the concept that a medical board or other regulatory agency should make decisions about scope of practice details for individual PAs,' according to the American Academy of Physician Associates, Alexandria, Virginia. Rather, most states allow the scope of practice details to be decided at the practice level.
For NPs, the American Association of Nurse Practitioners, Austin, Texas, offered state-by-state practice information, with information on the regulatory structure (full practice, restricted, and reduced), regulatory agency, continuing education hours needed for licensure, signature authority, and other requirements.
Changes, Fast and Varied
Staying up to date on regulatory changes and requirements is more difficult these days, said Susan S. VanBeuge, DNP, APRN, FNP-BC, a professor in residence at the University of Nevada, Reno, and a practicing NP. She cited more changes in requirements on both the state and national level in recent years than in the past.
Deborah Busch, DNP, RN, CRNP, CPNP-PC, IBCLC, CNE, FAANP
'One of the biggest challenges for NPs is the variation in state law,' said Deborah Busch, DNP, RN, CRNP, CPNP-PC, IBCLC, CNE, FAANP, an NP and associate professor at Johns Hopkins School of Nursing, Baltimore. The regulatory environment has been 'more of a moving target the last 5 years or so,' she said. She cited COVID-19 as one reason, explaining it was accompanied by the expansion of some services, but now, as some are going away, close attention is needed to know what stays and what goes.
'The rapid pace of regulatory change in the current environment can be complex,' agreed Todd Pickard, DMSc, PA-C, a PA at the MD Anderson Cancer Center, who cares for patients and also serves as executive director of Advanced Practice at the Cancer Center.
As complex as these regulatory shifts can be, Jennifer Orozco-Kolb, DMSc, PA-C, chief medical officer at the American Acad emy of Physician Associates, pointed out that one of the core competencies for every PA is staying informed about evolving laws and regulations.
'The volume of regulatory changes impacts the entire healthcare team,' she said. So, a change in, for instance, a fee schedule will affect all providers who offer that care, she said.
Primary Issues
What regulatory issues most concern NPs and PAs?
'The primary issues concern reimbursement, patient eligibility, and care modalities, as well as assisting patients in navigating their coverage,' Pickard said.
Regulatory compliance in telehealth was important, as Rollins, the NP who has had rest area telehealth visits, knew. In most cases, he said, other communication with the patient can be handled by HER platform messaging; it's the telehealth visit with an out-of-state resident that's the logistical challenge.
Susan S. VanBeuge, DNP, APRN, FNP-BC
Continuing education requirements could also change, as VanBuege knew. In Nevada, for instance, the state nursing board requirements for continuing education in cultural competency changed recently. 'It went from 2 hours at regular intervals to now 4 hours of continuing education [in cultural competency],' VanBeuge said.
A delay in license renewal might occur if an NP applied for renewal without those required 4 hours included in the continuing education, she said.
That's why it's so important to keep an eye on the legislative proceedings in the state that an NP or PA practices in, she said. 'Our legislature meets every 2 years,' she said of Nevada. 'During that time, anything can happen within those 2 years.' Changes often do occur that affect healthcare providers, she said.
Changes in guidelines for the COVID vaccine, issued in late May, are another example of the need to stay current on policy changes, Orozco-Kolb said. Those changes are dramatic, going from recommending everyone 6 months or older get vaccinated to limiting access to those older than 65 years or younger people with a risk factor for severe COVID.
It's important to know the policy of a hospital network, Busch said. For instance, 'a state board of nursing may allow [NPs] to do a certain procedure, but a hospital network may have an internal policy restricting it.' The limitation isn't always about ability, she added. Rather, a hospital may already have a team in place that provides that procedure, she said.
Sources of Help
Policy courses are part of the education, said George Zangaro, PhD, RN, associate director of the DNP Executive Track at the Johns Hopkins School of Nursing. So, he said, simulations of regulatory cases are to prepare for the real world. 'We put a heavy emphasis on clinical, ethical, and legal responsibilities that NPs have in practice.'
How to keep current on regulations in the most efficient way?
'I turn to my practice leadership, financial teams, my colleagues, and, in many cases, professional associations such as the American Society of Clinical Oncology (ASCO),' Pickard said. He acknowledged how time-consuming it is, taking time away from other responsibilities, but also noted how critical it is to both his patients and his practice.
Likewise, Rollins said, he turns to colleagues and consults the legal and compliance teams at the MD Anderson Cancer Center.
George Zangaro, PhD, RN
'Once out of school, to keep up, continuing education is important,' Zangaro said, beyond the required hours. He encourages graduates to attend conferences regularly. 'Most conferences have a regulatory session included in them, depending on the current hot issues.' Membership in the NP and PA organizations has built-in tools to help, the organizers pointed out.
The American Association of Nurse Practitioners offers information on frequently asked questions about government policy, additional information on policy tracking, and a government affairs update newsletter that is for members only.
The American Academy of Physician Associates offers insight on requirements, certification, state licensing, and maintaining certification. (While the organization, the American Academy of Physician Associates, uses only 'associates,' not 'assistants,' Oregon is so far the only state to adopt the title change to associate, effective June 6, 2024.)
Turn to 'trusted sources,' Zangaro said, such as the National Council of State Boards of Nursing, the Centers for Medicare & Medicaid Services, and national associations such as the American Nurses Association.
While many sources of help are available for staying current with regulations, VanBeuge emphasized that the responsibility is on the shoulders of the healthcare practitioner.
'It's on you as the license holder to be responsible to know what is happening, and not the regulatory body's responsibility to tell you.'
