Pennsylvania NP regulations are up for legislative review. Letters are encouraged to be sent to the board of nursing by 12/8/08. I wrote one personally that you can read below, and I got several physicians, dentists, NPs, other colleagues, patients, and even representatives to send letters. Please show your support! If you are an NP from another state that is already independent, please write, showing that NP independence is really safe and affordable, and the quality of care provided is equal to our colleagues.
Send your letters to Ann Steffanic, Board Administrator, Pennsylvania State Board Of Nursing, P.O. Box 2649, Harrisburg, PA 17105-2649.
Here's my letter:
November 16, 2008
Dear Ann,
My name is Joseph Marra Jr. and I am a CRNP that owns and operates the "Urgent Care Center" in central PA. I have been independent now since opening my practice February 14, 2006. I would like to take time to write in my perspective, just a few limitations that are imposed to CRNP's by the current regulations. First, many NP's have a limitation in prescriptive authority. Second is the limitation with collaboration with physicians. Third is the inability to prescribe home health and hospice due to certain language or interpretation within the regulations. Fourth is the limitation of admitting privileges into hospitals, just to name a few.
The current prescription authority limits us as well as our pt.'s. Many pt.'s must return every month even when they are stable within a disease process and medication regime, due to the inability to write for refills. This is not only an inconvenience for the pt. but increases healthcare dollars as well. Also several of my pt.s that have chronic pain from histories such as MVA, work r/t injuries, vertebral compression fractures etc. require monthly prescriptions for chronic pain medications, and we are limited to only 72 hours of medication administration. Many pt.'s come in as new pt.'s whose physician has retired or moved out of the area and had already been prescribed pain medications for years for chronic pain, and Adderall for ADHD, and I have to send them away due to my limitation. Another issue with prescription authority is the limitation with writing for suboxone. I work for Pyramid Healthcare, in addition to my own practice and have discussed with the DEA the rationale behind why we as CRNP's cannot write for a Schedule III drug? They responded; "The limitation is from the State Board of Nursing not us". I would be glad to go to the classes required for this extra education in prescriptive authority, but cannot with the current regulations. So many individuals would benefit from being on a maintenance dose of suboxone and ad to their community, as well as re-enter into the work force. This is such an under rated program, that it is disheartening to me. As a profession we compete for jobs and since we have limitations, we are often times looked over due to another individual with full prescriptive authority, even though we may be just as qualified and work for less money. Limiting our prescription ability simply limits access to quality care.
The second limitation that I would like to address would be the access to collaborating physicians. First of all I don't personally feel that this should be a requirement any longer. CRNP's have proven themselves time and time again, as safe and effective practitioners, with study after study. It has also worked in many other states, so why not in this state. Also it is difficult to obtain a physicians collaboration. They usually fear litigation on someone that they have never even seen. Also, if you must collaborate with the physician, and they tell you, you must address the situation a certain way that you don't feel safe or necessary, the pt., as well as the CRNP's license are at risk. Then there is the matter of paying the physician for their collaboration. This increases healthcare dollars as well. In my own family practice I have been not only trusted to make independent decisions but have been consulted by my physician peers for certain things. We as a profession know our strengths as well as our limitations. If the pt. needs something above what we were trained to do, we simply refer to the ER or a specialist, depending on the severity of the condition.
Third, I have had several pt.s that see me for family medicine due to the inability to get in with a PCP, from living in an underserved area. I offer the lowest prices in town, with a basic visit at only $40 per visit, and I use the $4 prescription plan at the local pharmacies as well as giving out free samples. But when NP's are limited to such things as home health, especially when pt.'s really require debilitating in home care, there is no where else to send them. I find it almost inhumane the way medicine is right now. I can provide the service to the pt., however am unable due to a regulation, and therefore a reimbursement issue. I of course don't turn these pt.'s away, but they get to a point where they can no longer make it to the office, and left with lack of proper care in the homes. Family members are left taking care of these pt.s that have a very high acuity. I implore you to take a serious look at our current regulations for our citizen's sake.
The fourth and last point that I will address in this letter, is that of the inability to admit to hospitals. When you think of total access to care, you must also think of continuity of care. When you have seen a pt. for years and know what meds. they have been taking for certain ailments and aware of the illnesses that have developed, but they have to be admitted under another practitioner, the quality of care is less in my opinion. Although hospitalists are worth their weight in gold, some family medicine practitioners continue to see their own pt.'s. My pt.'s continually express a dislike in this matter. I of course have no option but to reply; "My hands are tied". I understand that some hospitals allow for admitting privileges under other physicians. However, the pt. must be seen by that physician within a certain time frame. The decision made by the physician, may not be considered wrong, but not always the exact choice that HCP or pt. would choose.
In Summary, with limited access to primary care well documented, and less and less physicians going into this specialty, it stands to reason that someone must take over this responsibility. NP's are quite capable of taking care of this population. We are well trained, and several studies have shown that at the end of the study, NP's provide equal care to that of physicians and sometimes even better. I can forward you these studies if you would like. NP's make solid decisions and know their limitations as well. After practicing for over five years and being independent for almost three, I can tell you that this office functions quite efficiently with little to no complaints. In fact I will have some of my pt.'s send you their interpretation of the care that I, and my colleagues provide. I will offer my Urgent Care Center as a model if you would like. Take a day and actually come to my office, see how it runs, and ask the pt.'s what there perception of the quality of care is that they receive. I commend Governor Rendell, for his part in making changes that benefit this profession and ultimately our communities.
Thank you for your consideration in this matter, and should you have any questions, please don't hesitate to contact me at the above number. I would be honored to answer any questions you or the board would have, in the possible revisions to our regulations.
Sincerely,
Joseph F. Marra CRNP