Last Thursday, May 17, the Committee of the Joint Boards of Nursing and Medicine convened to discuss draft regulations for HB 793. At the beginning of the meeting, representatives from VCNP and organized medicine testified, with each side given just fifteen minutes to make its case. VCNP’s strong presence included attendance and testimonies from VCNP leadership and members, as well as esteemed guests from schools of nursing throughout Virginia. Thank you to everyone who took the time out of their busy schedule to participate!
 
The committee reviewed the draft regulations and each of the proposed updates to the Virginia Administrative Code, discussing and voting upon each revision. Important highlights of the draft regulations include:

• 18VAC90-30-20: Fees – An autonomous practice attestation application will be a one-time cost of $100. Please keep in mind that the prescriptive authority fee of $75 and $35 for renewal will soon be eliminated.
• 18VAC90-30-86-A-1: Autonomous practice (for nurse practitioners other than certified nurse midwives or certified registered nurse anesthetists) – The Transition to Practice period must include the “completion of the equivalent of five years of full-time clinical experience as a nurse practitioner”. Five years of full-time experience will be defined as a minimum of 1,600 hours/year, for a total of 8,000 hours. This is an average of 32 hours/week, minimum.
• 18VAC90-30-86-C: “The nurse practitioner may submit attestations for more than one patient care team physician with whom he practiced during the equivalent of five years of practice, but all attestations shall be submitted to the boards at the same time.”
• 18VAC90-30-86-D: “If a nurse practitioner is licensed and certified in more than one category, as specified in 18VAC-90-30-70, a separate fee and attestation that meets the requirements of subsection B shall be submitted for each category. If the hours of practice are applicable to the patient population and in practice areas included within each of the categories of licensure and certification, those hours may be counted towards a second attestation.”
• 18VAC90-30-86-E: If an NP’s physician is unwilling to sign the attestation, “The burden shall be on the nurse practitioner to provide sufficient evidence to support the NP’s inability to attain an attestation”. The NP may then provide other evidence that shows they have met the qualifications for attestation.
• Much to the benefit of NPs, the draft regulations did NOT include any mention of establishing “core competencies,” as proposed by organized medicine’s original commentary. As we know, NP education and licensing already establishes competency and maintains strong, nationally-recognized standards. Further, the draft regulations ensure that the attestation will be an attestation of TIME, not “quality”.

 
An annotated copy of the draft regulations is available HERE. They are also posted on the Virginia Regulatory Town Hall site on the General Notices page. The regulations for HB 793 are considered “emergency regulations,” which ensures that they must be finalized by the middle of December at the very latest. The regulations will become effective the day they are published.
 
Board of Nursing Executive Director Jay Douglas has assured us that she and her team will develop a “robust communication plan” to ensure that all NP licensees receive notice of the regulations’ progress; and we will continue to keep all VCNP members apprised of the latest developments.
 
WHAT’S NEXT?
 
Given that the Committee of the Joint Boards was able to effectively work through the draft regulations on Thursday, another Committee meeting is not required. However, the regulations still must pass the Board of Nursing, as well as the Board of Medicine. Should they pass both Boards, they will move on to the Attorney General and Governor for final review. Jay Douglas and her team will handle the implementation phase, which will include developing online resources, crafting the attestation form, and creating a special license format that will distinguish NPs who have attained autonomous practice.
 
A second 30-day Town Hall Forum comment period is scheduled to soon begin. Our goal is now to ensure that the Board of Nursing passes the regulations as they stand. We will send an email with more details about the comment period as soon as the forum is made available.
 
Timeline

• 7/17/18 – Board of Nursing meeting to adopt the emergency regulations
• 8/3/18 – Board of Medicine meeting to adopt the emergency regulations
• Regulations will undergo review by the Attorney General and Governor.
• Mid-December – Regulations must be complete.

The regulations will become effective the day they are published.
 
HB 793 is ultimately not about an independent practice model – it’s about a NP’s ability to utilize their knowledge, skills, and judgment to provide care without mandated supervision or collaboration from a physician. This will lower barriers to practice, expand access to care. We are excited to continue to work on behalf of NPs throughout the Commonwealth and are thrilled to see the legislation come to fruition!

On Thursday, May 17 at 9:00 a.m., the Committee of the Joint Boards of Nursing and Medicine will be convening in Henrico to promulgate regulations pertaining to HB 793. VCNP leadership and the GR committee, in conjunction with our legal council and lobbyist, have worked fastidiously to compile and submit comments to the Committee of the Joint Boards, in an effort to ensure that the regulations passed will suit the best interests of NPs.
 
Please plan to join us at the May 17th meeting, to be held at 9:00 a.m. at the Perimeter Center, 9960 Mayland Drive, Suite 201, Board Room 2 in Henrico. Just as with the General Assembly Subcommittee and Committee meetings, VISIBILITY is key. During the meeting, the Committee will receive public comment, consider draft regulations, and make recommendations. They may address the issue again at their next meeting in June, as to finalize their recommendations to the Board of Nursing in July and the Board of Medicine in August. Additional information is available on the Virginia Regulatory Town Hall site.
 
A substantial NP presence at the meeting will help demonstrate our dedication to the legislation and belief in its positive impact – which can only be achieved without oppressive regulations.
 
We are collecting the names and contact information of those who plan to attend, as to ascertain how many members and colleagues we may anticipate. Please RSVP by MONDAY, MAY 14 via this form. Be sure to indicate on the form if you are interested in providing testimony at the meeting; we will be in touch with further details about what information, statistics, and personal experience we recommend highlighting.
 
You may view a copy of our comments by clicking here. Organized medicine’s oppositional comments are also available here. See “Concerns with VAFP and MSV’s Comments” below for our reaction to their remarks. The meeting agenda package also includes comments from other organizations and interest groups, including VHHA, ER physicians, and pediatricians.
 
DOWNLOAD THE MEETING AGENDA
 
Concerns with Organized Medicine’s Comments
 
There are numerous issues with the regulations suggested by the Virginia Academy of Family Physicians (VAFP) and the Medical Society of Virginia (MSV):

• The addition of “quality” metrics is NOT a reflection of the legislation – it should be removed. The HB 793 legislation is ONLY concerned with the duration of experience.
• The notion of Core Competencies over and above NP certification is not in the statute – and imposition of such a concept is inappropriate. The 5 year requirement is not a structured training program overseen by an MD; it is simply professional job experience gained by an already licensed NP.
• In regards to the requirements for an attestation: the law does not contain any notion of a physician “approving” an NP or judging quality – the physicians are simply meant to attest to the relationship. The Joint Boards are the only people intending to assure competence and pass judgement on the safety of practitioners.
• Organized medicine appears to fear being designated as an NP’s emergency management plan; but in reality, there is no statutory requirement for a specific physician to be designated or documented. It is the sole responsibility of the NP to have a general plan for referrals and emergencies, should they choose to open their own independent practice.

HB 793 has passed the General Assembly, but the joint Boards of Nursing and Medicine are now seeking public comment on the enactment of regulations to implement the bill until 11:59 p.m. on May 4, 2018. HB 793 is legislation to authorize nurse practitioners who meet certain qualifications to practice without a practice agreement with a patient care team physician.
 
We have the opportunity to provide input on how regulations should be written. In order for the regulations to be implemented in the best favor of NPs, we need you to write a comment today. Topics that need to be commented on for consideration in adoption of regulations will be:
 

• Equivalence of at least five years of full-time clinical experience
• Routine practice in a practice area included within the category for which the NP was certified and licensed
• Requirement of an attestation of practice
• Fee associated with submission of attestation and issuance of autonomous designation
• Acceptance of “other evidence” demonstrating that the applicant met the requirements
• Endorsement of experience in other states
• Unprofessional conduct – falsification of attestation

Note that the Boards are seeking public comment on the topics above. HB 793 has been signed into law – therefore, the Boards are NOT seeking public comment on changes to the legislation itself.
 
CLICK HERE to post a comment on the Virginia Regulatory Town Hall site. You may also email Ms. Elaine Yeatts directly: elaine.yeatts@dhp.virginia.gov. Please comment if you haven’t already and reach out to your colleagues asking them to do the same. Contact your region’s GR chair with questions.
 
TEMPLATE FOR PUBLIC COMMENTARY POST
 
Thank you for the opportunity to provide public comment. I have been a nurse practitioner (NP) for ___ years practicing in ________ setting in ________ county/city. Completion of graduate education and national board certification deem that I am a competent clinician. Please keep this in mind as rules are being promulgated.
 
Use any of the recommended talking points below to add to the template. NOTE: it is important that you personalize the talking points using your own words.

• The five-year equivalent requirement creates a costly bottleneck to building provider workforce and equitable distribution in primary care delivery for underserved and vulnerable populations. Unduly burdensome regulations on top of this requirement will result in additional bottlenecks compromising access to care.
• NPs already pay fees associated with RN, NP, and prescribing licenses. Any additional fees associated with submission of attestation and issuance of autonomous designation should not create a financial barrier for qualified NPs to practice.
• Acceptance of “other evidence” demonstrating that the applicant has met the requirements must be broadly interpreted. We ask that the Joint boards issue a guidance document listing examples of supporting evidence that they would take into consideration. Office administrators, health system administrators, and credentialing documents should all be accepted as evidence that an applicant has met the necessary requirements.
• The Boards should credit applicants by endorsement for all of their time employed and licensed in other states towards calculating their clinical experience requirement for practicing without a practice agreement.
• NPs in any state or working for U.S. Armed Forces, U.S. Veterans Administration or the Public Health Service should be able to submit evidence that the five-year full-time equivalent collaborative requirements have been met with signature from employer, physician, practice administrator, etc.
• There is no demonstrated need for additional requirements on the attestation in order to protect the public beyond what is listed in HB 793. The attestation should be used to document clinical experience under a sworn statement that this information is accurate and meets the requirements of the law.
• Most, if not all, states requiring attestation of transitional clinical hours are not overly prescriptive in what they require in their regulations or on their attestation forms. Therefore, in Virginia it should not be necessary to further define what is meant by “the patient care team physician routinely practiced with a patient population and in a practice area included within the category for which the nurse practitioner was certified and licensed.”
• Both the NP and the patient care team physician should be held to disciplinary standards for providing falsified documentation to the Boards.