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! You may view a draft version of the official minutes for the meeting by clicking here.
 
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”.

 
A copy of the draft regulations is available HERE. They are also posted on the Virginia Regulatory Town Hall site. 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.

We are delighted to announce that Governor Northam signed HB 793 yesterday evening, without any additional amendments!
 
THANK YOU to everyone who has dedicated themselves to advocating for the legislation by sending letters, placing phone calls, and being present at subcommittee hearings and other legislative events. Countless hours from VCNP leadership and membership – as well as the tenacious efforts of our patron, lobbyist, lawyer, and PR firm – have led to this spectacular moment!
 
Please take a moment to write and thank Governor Northam, as well as our bill patron Del. Roxann Robinson! We have created a VoterVoice thank you letter for the Governor Northam and have linked to Del. Robinson’s email, below. We will announce next steps for the legislation soon.
 
Click here to thank Governor Northam
Click here to thank Del. Roxann Robinson

Our political opponents are trying to convince the Governor to amend HB 793 for their personal benefit.
 
The Medical Society of Virginia (MSV) has pushed an amendment to the Governor’s office that would convolute the Transition to Practice period as proposed by our version of HB 793. This amendment:

• undermines the existing scope of practice of NPs
• deteriorates the practice team model articulated in existing practice law
• protects physician turf and limits consumer choice
• circumvents the legislative process and substantively changes the legislation passed by the Virginia General Assembly

VCNP does not support the MSV amendment. In spite of repeated efforts to negotiate with MSV, their envoys have refused to see eye-to-eye with us. They remain determined to protect their turf, at the expense of Virginians’ access to care.
 
Without this amendment, the Department of Health Professions (DHP) has determined that nearly 50% of NPs currently practicing in Virginia would be immediately eligible for the attestation process, as they have already completed the equivalent of five or more years of practice. Once an NP completed the attestation process, they would be permitted to practice independently, without an agreement with a physician.
 
The MSV amendment would change the nature of the Transition to Practice period and severely decrease the percentage of eligible NPs, undermining the very intent of the bill. Our aim is to expand access to care by allowing NPs to practice to the full extent of their education and training. HB 793, without further amendment, would significantly bolster the workforce of individuals ready and able to provide quality care to patients across the Commonwealth.
 
By Monday, April 9th at the latest, the Governor must decide whether to sign, amend, or veto HB 793. There is no time to lose. We need you to MOBILIZE your colleagues, peers, and clients in support of HB 793, unamended.
 

Here’s what you can do:

• Request that your PATIENTS send a letter using our VoterVoice campaign or call the gubernatorial office at 804-786-2211. See “How to Call the Governor’s Office” below for a sample phone script.
• Ask your collaborating PHYSICIAN to contact the Governor, if they are supportive of our cause.
• Lead by example! Continue to write and call the Governor’s office, while engaging your fellow NPs and encouraging them to do the same.
• Distribute the HB 793 Frequently Asked Questions document to anyone with inquiries about the impact of the bill and how it will be implemented.
• Share the videos from the VCNP Facebook page! New testimonies about the importance of HB 793 are being posted regularly. Sharing the videos on your personal profile raises awareness for our cause by tapping into your network of friends.

Writing the Governor’s office is simple using our Voter Voice software! Visit the TAKE ACTION page of CareforVA.com to get started – it takes just a few minutes of your time.
 

Dial 804-786-2211.
 
A representative of the Governor’s office will answer the phone. You may wish to incorporate elements of your practice or personal story into this suggested phone script:
 
“Hello. My name is _____, and I am a [NP/physician/patient] calling in support of HB 793, a bill which would allow Nurse Practitioners to practice independent of a collaborative agreement, after completing a Transition to Practice period of five years and an attestation process.
 
HB 793, as it stands, would increase access to healthcare by expanding the workforce of healthcare professionals ready and willing to provide quality care throughout the Commonwealth, including underserved regions. The bill in its current form is widely supported by legislators, having passed the House 97-2 and the Senate 40-0.
 
Amendments to the bill are not necessary, as such alterations would make regulations unduly cumbersome and hinder access to care in Virginia. I respectfully request that the Governor sign HB 793, without further amendments.
 
Thank you for your time. Please let me know if you have any questions.”

VCNP respectfully requests that Governor Northam sign HB 793 without further amendment, as it passed the Virginia Senate 40-0 and the House of Delegates 97-2. To voice your support for HB 793 unamended, please send a letter to the Governor by utilizing our VoterVoice platform.
 

HB 793 passed in the General Assembly and was signed by Governor Northam!

We have composed a Frequently Asked Questions document to address inquiries we have received from both members and non-members. The document explains how the legislation will take effect, clarifies what attestation entails, and describes how experienced NPs can be “grandfathered” in. The document may be found below:

The next steps involve the Department of Health Professions (including the Boards of Nursing and Medicine) promulgating the regulations for how this bill will be implemented. As this process unfolds, you may have questions about what this bill might mean for you and your practice. Let us know your questions! Click Here to ask a question about HB793.

Today, the Virginia Council of Nurse Practitioners – along with Del. Roxann Robinson, the patron of HB 793 – generated a huge legislative win that will move nurse practitioners in Virginia closer to obtaining Full Practice Authority.

During the Virginia Senate Education and Health Committee’s reading of HB 793, Del. Robinson introduced a new “substitute” bill that removed many of the overbearing restrictions in the original bill that opponents had wanted to impose on NPs. The substitute was unanimously approved by the committee in a 15-0 vote.

The new substitute bill goes a long way to reduce the restrictions that would have been imposed by the original House subcommittee substitute of HB 793, but it does retain the five-year transition to practice requirement. With this being a top concern for members, VCNP’s Executive Committee, all Regional Presidents, and regional Government Relations chairs, held an emergency conference call Wednesday night to discuss the new substitute bill and to vote on if they wanted Del. Robinson to move forward with it. Nine members of the Executive Committee and 12 Regional Presidents all voted unanimously to move forward with the substitute.

Mark Coles of the Tidewater region noted before the vote: “Virginia is a state where legislative progress is only made incrementally. We might be an outlier with a five-year transition to practice, but there are more than 20 other states around the country that would love to be in the place where we are right now. Full practice authority is within reach.”

It is important for all members to understand that, with the new substitute bill, more than 50 percent of NPs in Virginia have already met the five-year transition to practice requirement. Once the substitute bill is approved by the entire Senate, it will return to the House floor for another vote. Should it pass again and be signed by the Governor, rules will be promulgated by January 1, 2019 and NPs will be eligible to move forward with authority to practice without requirement of a collaborative agreement.

VCNP President Chris Daley noted to everyone on last night’s call that we are pledged to transparency throughout this process. If you have questions or concerns, please contact your Regional President or Government Relations chair. It is the goal of the VCNP Board to ensure that everyone is comfortable with this process.

HB 793 will be voted on by the full Senate in the upcoming days. Please stay tuned for additional details on our progress.