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In My Opinion

The Respiratory Licensure Mess

Published April 13, 2010 11:38 AM by Jimmy Thacker

I read a story about the Oregon Health Licensing Agency turning 10 recently. It brought to mind all the licenses I have had over the years and the huge amount of money and time I have spent to get them. Almost any licensing agency claims to be working on "streamlining" the process and providing oversight to respiratory therapists.

One state, Alaska, doesn't require a respiratory license. The other 49 all have different requirements and varying timelines in getting a license to work. I am always amazed that after years of licensure, we still have an archaic system that discriminates against good therapists trying to help out in other states.

There's no difference between the therapy you do in New Hampshire and the therapy you do in Arizona, but you must have a license in each state in order to work. We need a central agency to monitor us and to provide us with licenses to work and temporary licenses so we can start working somewhere new when we want. The current system doesn't work, doesn't provide any oversight for therapists to speak of, and is too expensive to make it worth any college student's while to consider going into respiratory therapy. Especially if you have dreams of traveling for a living, it just costs too much and there are too many rules and regulations, unique to each state, to keep up with.

If I can have national credentials, I should have a national license. At the very least, states should work with each other and acknowledge licenses from other states. When I worked for a travel company, the biggest hold up for me going to my next assignment was waiting on the new state to grant me a license, even though I had licenses in several other states. According to the AARC, states charge from $75 to $270 for licenses. California's system is so complicated it cannot even tell you how much you'll spend, just that you have to contact them to find out.

At the very minimum, let's put a cap on what states can charge for licensure. Let's make a standard of how many CEUs are needed and the costs of licenses within the U.S. and additional licenses for those who work across state lines or travel. This seems sensible and long overdue in the field of respiratory therapy. There's no need to go broke just because you like to travel and no need to be confused about licensure requirements just because you want to work more than one place.

That's just my opinion,
Jim Thacker, BS, CRT, AE-C

35 comments

I understand what you mean by working in smaller hospitals yet I have enjoyed the larger facilites. I heard a non medical person state it was because they could not handle the stress of larger facilities I disagreed.

Irissh, Registered Respiratory Therapist November 29, 2014 3:21 PM
Sryacuse NY

Thanks for that Jim Thacker, BS, CRT, AE-C  I agree with you when it comes to the practice of respiratory therapy.

Irissh, Registered Respiratory Therapist November 29, 2014 3:17 PM
Syracuse NY

If having a license guaranteed an excellent & qualified person, and if licensure guaranteed the best outcomes  why do we have so many drunk drivers all with a license.  Government licensing never has worked and never will work.

Patrick RRT#17116, clinical - RRT, St. Mary's October 30, 2014 3:27 PM
Livonia MI

It's all about money!

Paula, Respiratory - respiratory therapist, PRN Staffing April 15, 2013 1:21 PM
Houston TX

"IT'S A MONEY THANG" EACH STATE WANTS TO GET PAID! Each state figure they can keep draining the dollars from Respiratory Therapist. That's the way to go!

Lee .A, CRT,CPFT,BS September 14, 2011 4:15 AM
Fayetteville NC

We really need a Union or we are going to keep getting screwed over. National Union, National License and National standards.

Kristopher Manes, Health Care - Respiratory Therapist, Unknown May 10, 2011 12:29 AM
Phoenix AZ

Hello! I am fresh out of school and currently working in Indiana with my RRT, however, in 3 or 4 months I am relocating to Florida.  

I don't know exactly how to transfer/apply for my license in FL and was looking for any helpful advide??

Thanks,

Lilly

Lilly , Respiratory Therapist January 23, 2011 11:43 AM
Indianapolis IN

I couldn't agree more with the OP.  There truly needs to be some sort of national license or at least a reciprocal agreement (much the same way many nursing boards operate) from state to state.  For one to have to constantly apply and pay for applications, background checks, and letters of reference from each state where he or she has worked is just, well, plain stupid.  

If money is each state's obvious motivating factor, perhaps there is a way that they can still collect their (sometimes exorbitant) fees, all while obtaining the necessary information about an applicant from a NATIONAL database.  Alas, this would be too easy and it just makes too much sense.

Mike, Respiratory Therapy - Respiratory Therapist December 23, 2010 2:29 PM
Los Angeles CA

Good information, Paul. Thanks for your comments. You're correct, there are only 48 states with licensure, however, Hawaii is pushing SB2600 to require licensing in that state, too. It passed the senate on March 3, 2010. It is now going to the House. I think the point here is that some sort of standardization is needed. The AARC and NBRC have not provided much leadership in the past, although the current regime seems a little more in tune with the needs of therapists. The questions seesm to be that if nurses take a national exam, why don't we? Why is there such a difference between licensing fees from state to state? The point of this blog was to discuss ways to improve our standards without sacrficing the quality care I know RTs around the country provide to their communities. You made several excellent points. I appreciate you sharing your thoughts with us.

Regards,

Jim Thacker, BS, CRT, AE-C

Jim Thacker, RT - BS, CRT, AE-C May 6, 2010 11:22 PM
Lexington MO

1st let’s set the record straight.  Only 48 states are licensed. Alaska and Hawaii are not licensed. However, the District of Columbia and Puerto Rico are licensed. Secondly, there is a national standard for licensure (in those states and territories and DC who have licensure laws – it is the passing of the CRT exam). Be aware though that the passing score for licensure may vary by state.  Thirdly there is no national licensure for RNs, Physicians or any other health profession, except perhaps Radiation Physicists under the authority of the body governing nuclear power plants and other facilities (I can’t recall its name right now). Nurses take a national exam NCLEX but licensure is conferred by the states just like drivers licenses.

Licensure is a “states rights” issue. The US Constitution states that all rights not expressly cited in the constitution defer to the states. This means that the Federal Government is not empowered to legislate these rights.  

The cost of licensure is related to the cost of government bureaucracy (One of my graduate school professors said “Bureaucrapathic behavior is dysfunctional “).  As other writers to this blog have stated the costs are sometimes outrageous.  Some states do put onerous requirements that seem to impede applicants ability to enter the system. California seem to have both the most costs and the most stringent application process. (But has it done its protective job or has it gone overboard? Only California residents have the power to change the cost and rules.) Similar questions may be asked in other states and locales.)

The RT laws were originally designed to be fairly priced and to be used nationwide to protect the citizen and the profession. To provide for future expansion of the scope of practice while allowing other professionals to do things that we also do in the “good” practice of health care. The Model Respiratory Care Act provided language that allows us to administer drugs while not imposing iron clad limits as to types of drugs or methods/routes of deliver. {Respiratory Care Practitioners may administer drugs which affect the cardiopulmonary system}.  This practice act was crafted after a long and detailed process was undertaken to assure that public and profession was protected. How do I know that – because I was one of the three people who crafted both that document and the guidelines to the Model Act.

Paul Mathews, Resp Care Education - Associate Professor, Univ. of KS May 3, 2010 6:35 PM
Kansas City KS

Jim, I understand where you are coming from but there are standards for Respiratory Schools. To sit for the NBRC exams you must be a graduate of a CoARC approved program. I think we (us old-timers who remember the good old days) are part of the problem. We can’t just stand around saying “I don’t understand these new kids” and ” why won’t they stay off of my front lawn?” we have to be active in mentoring them, if as a director, a program is not turning out quality people that I can use then I have to go to the director of the program and explain why. If that doesn’t work then I have to go to CoARC and lodge a complaint.  Most importantly I have to get my point across the best way I can, don’t hire those people. If a program can’t get people placed they won’t be around for long.

Joe, Welcome to the field. I think you will find that as long as you are willing to put in the effort Respiratory Care can be both a spiritually and financially rewarding career.  The truly good therapists that I have had the pleasure of working with look at it as a profession not a job.

Bill, you hit the nail on the head, change has to come from within, at the state level.  For that to happen people have to become involved. It is interesting to note the most people forget that the function of a licensure board is not to protect the rights of the people they govern but to protect the public from the people they govern.

Art April 29, 2010 2:15 PM

In Ohio, the original intent of the licensure act was to protect the public as I'm sure was the case in other states.  The final version ended up being a shell of the original proposal as a result of the compromises that were made during the legislative process.  The give and take is probably the reason there are so many differences between the states.  I'm not sure there is a mechanism to create a national license and I'm pretty sure the states would not be anxious to give up a revenue stream (no matter how small).  I think we should urge our respective state boards to work towards reciprosity.  Perhaps an additional category for therapists could be added to include travelers and military personnel.  The fees could be prorated to the amount of time the therapist spends in that state.  I hope this adds to the discussion.

Bill April 29, 2010 12:25 PM
Dayton OH

Art, I'm not suggesting that the federal government take over RT. The feds have enough problems of their own. I think an organization who is actually in charge of licensing respiratory therapists is not a new idea, nor is it too far out to think about. Standards should be set about what is taught in respiratory schools. I recently had a discussion with a department manager about how different schools produce drastically different students, who are the future of our field. There is no standard. Even the organizations who regulate what must be taught only address a very basic core syllabus. Institutions decide on what else is needed. Students today are your coworkers tomorrow. On the surface, in my opinion, they seem apathetic to the changing role of the respiratory therapist, uninvolved in organizations such as the NBRC and the AARC, and do not have a "feel" for the changing climate of health care. They provide good care, but are not seeking change that will be needed to provide great care as you and I are now with this discussion. I wish them all well, but think they could benefit by one set of standards to live by, to get CEUs by, and to work under to ensure they are set up for success. I appreciate your comment, sir. I wish you well!

Jim Thacker, RT - BS, CRT, AE-C April 29, 2010 8:43 AM

Melissa, you bring up a great point that involves the lack of standardization. Do we or do we not intubate? I think the answer lies with the hospital we are in. We are trained to do it. Go to any ACLS class and you'll be expected to do it in the Mega Code. Yet hospitals hesitate to let us because of liability. If we mess up, they are in trouble. Rather than making sure our skills stay, they would rather ignore our training and have us not do it. Rather than have a backup plan for when the doctor misses, they won't allow us to do surgery rotations or get tubes during codes so that we can maintain our proficiency. This is the kind of mess licensure has put us in. Having set standards for all therapists would solve this problem. Thanks for your comment.

Jim Thacker April 29, 2010 8:35 AM

Joe, the article simply states the facts: rather than paying for state licenses in each state you decide to work in, it would be more beneficial to become a nurse, so you can avoid all those added costs. Respiratory therapy isn't a glamorous field to begin with. We suffer from low self-esteem, lack of respect and are burdened with costs more than any other discipline in the hospital. Ask any therapist who has been working for a while, especially those who travel for a living, and they will tell you that the costs, while usually reimbursed by travel companies, are high. Lack of standardization results in keeping up with different amounts of CEUs needed for each state. If you only keep one license, it's not an issue. If you keep more, such as the 11 I had at one time when I traveled, it's a big deal. It's confusing and any intelligent person must ask why it's so different just because you have crossed a state line. Working at McDonalds is your choice. You won't get paid as much, you won't get the satisfaction of helping people like you do in a hospital environment, however, you wouldn't have to pay for a state license based on the NBRC and state licensure boards quest to suck all the money they can from you, even though they are crying out for help because of therapist shortages. No one has ruled out the job of a respiratory therapist. Many just feel there are better ways to manage it. As you begin your career, perhaps you'll feel some of the frustration other seasoned therapists have felt for years and develop some empathy for those of us who are dedicated to positive changes in our chosen field of work. Once you have 10 or 20 years under your belt, you may find that you have better ways, too. The fact is that turnover is respiratory care is high, shortages are everywhere, and that many enter the field with high hopes but get confused and distracted by the many regulations we must follow from "voluntary" credentialing agencies who set the tone for the field of respiratory care. I wish you the best of luck, my friend. Who knows? Perhaps you'll be the one to get this mess fixed. Thanks for your comment.

Jim Thacker April 29, 2010 8:32 AM

  I was rather alarmed when I read the lead to this article. It said " The current system doesn't work, doesn't provide any oversight for therapists to speak of, and is too expensive to make it worth any college student's while to consider going into respiratory therapy."

 As a RT student, I find the above quote to be rather pessimistic. Its well worth it for me to spend up to $270 for licensing for a job that pays as well as RT. I was expecting the license fees to be much higher based on the lead to the story.

  If I follow your logic it would be better for me to work at McDonalds because I would not have to pay a licensing fee or buy an expensive text book for school.

 I can understand your frustration about licensing, but to rule out the profession because of the red tape is a little extreme.

Joe April 28, 2010 1:34 PM

I traveled for 5 years and found the practice for RT to be very different from state to state. In some states your were inserting arterial lines and in others you were not allowed to touch a line for an ABG having to rely on the nursing staff to obtain your sample. Same was true for intubating, balloon pumps…etc. My travel years were some time ago when a few states did not have licensure and OJTs were still a primary source of the RT team. However, even the licensed states had different practice criteria for RTs. I always hoped this would change but a recent look at the Department of Health’s websites for various states, to assist with criteria for Sleep Techs scope of practice, revealed  this still remains to be true.  If a national license were to be created a great deal of work would need to be applied to the scope of practice to assure an RT did not loose their ability to practice the care they have grown accustom to providing.

.

Melissa Sasser, DME - BS RRT/RPSGT, Performance Home Medical April 28, 2010 8:54 AM
Olympia WA

I so agree! I think it is great to have a licensed profession, but as it is right now nothing is standard, some states want proof of high school graduation(really!). The NBRC checks your education before allowing the exams. State verifications can be done on line, yet each state wants a letter from the previous state-I could go on. The AARC and/or the NBRC needs to set a standard

LS April 28, 2010 12:05 AM
SD

Duh, that should be societies and their. Thats what happens when I try to type fast and dont use smell check.

Art April 27, 2010 8:17 PM

This is a rather complex matter.  

First a few points. The AARC is a voluntary national organization setup to in their own words:

“ … continue to be the leading national and international professional association for respiratory care. The AARC will encourage and promote professional excellence, advance the science and practice of respiratory care, and serve as an advocate for patients, their families, the public, the profession and the respiratory therapist.”

They have no legal standing in any state or for that matter nationally. They do not accredit or regulate any respiratory therapists. They are akin to a fraternal organization like the Shiners or VFW that allows likeminded people to band together for a common cause.

In their mission statement the NBRC states:

The primary purposes of the NBRC and its 31-member Board of Trustees are to provide high quality voluntary credentialing examinations for practitioners of respiratory therapy and pulmonary function technology; establish standards to credential practitioners to work under medical direction; issue certificates to and prepare a directory of credentialed individuals; advance medicine by promoting use of respiratory care in treating human ailments; support ethical and educational standards of respiratory care; and, cooperate with accrediting agencies to support respiratory care education. Since its inception, the NBRC has issued over 341,000 professional credentials to more than 204,000 individuals, and currently tests nearly 40,000 candidates annually. One of the respiratory therapy examinations is the standard for licensure in the 48 states that regulate the profession.

Again a voluntary agency that states have chosen to use rather than develop their own standardized exams.

I am an active member in both the AARC and the NBRC and feel that they both serve vital functions in our profession but recognize that licensure is not included in either of their roles.

As far as a national license no other medical profession I can think of has a true national board. Do you really think that the federal government is the best group of people to do this? Remember the AARC has been fighting an uphill battle simply to get recognition for Respiratory Care in regards to reimbursement from CMS for over a decade.

Reciprocity would be nice but as long as different states have different standards, defined by state law, this is problematic. State societys can suggest changes to boards but again have no legal standing to make any changes on thier own.  Being from one of the last states to require a license, Nevada, I know firsthand what type of people we had coming to our state after they were no longer able to practice in their home states.

Individual state licensure is not the best solution but is the most practical and beats what came before it.  

Art Little, Respiratory - MBA, RRT, CPFT, MountainView Hospital April 27, 2010 4:20 PM
Las Vegas NV

I agree, Jacque, it's a hard battle to win, but if we never talk about it, it will most definitely never happen! That's why I brought it up. Therapists need to start asking their state society folks why it is the way it is. Change must start somewhere. I think this blog is as good of a place as any!

Thanks for your comment,

Jim

Jim Thacker, RT - BS, CRT, AE-C April 27, 2010 2:52 PM
Lexington MO

I was a Travel Respiratory Therapist for close to 8 years.  I finally gave it up for all the above reasons.  AARC, NBRC, and your local respiratory society will provide NO support towards your cries for reciprocity.  Great idea, but a definite no-go for respiratory.

Jacque Wilson, , RRT, AE-C BHS April 27, 2010 2:24 PM
San Antonio TX

Ricket and Ken, I agree with you both. Reciprocity would be good, just like they do with nurses. Being able to have an established organization set some standards so that we're all equal across the board would be even better.

Jim Thacker April 27, 2010 1:39 PM

How about states granting each other reciprocity.  This might require some standardization.  Some states require 10 CEUs per year, Florida requires 24 per two years.

Ricket Sandy, Sleep April 27, 2010 1:21 PM
Orlando FL

My thought would be since NBRC and the AARC are already nationally established that they have some form of orgainizational basis for the national licensing.  I think if CRT's are licensed in any state that they should be included in any nationwide aspects of the RT profession as they are in their respective states. This should be about us trying to establish national licensure, and the only goal. This is a great idea, it would be a win-win for all RT's, just as an idea, each state that you go to practice in will have to have to have some streamlined process, concerning CEU's, disiplinary actions etc. All just ideas now, so brainstorming to find solutions is beneficial to all of us.  Regards

Ken Sands, RRT April 27, 2010 1:11 PM
CA

Lisa, especially for our military and their families, a simpler licensure scheme would benefit many people. Thanks to your family for your commitment to our great nation.

Jim Thacker, RT - BS, CRT, AE-C April 27, 2010 12:30 PM
Lexington MO

A national license at first sounds great, but many factors go into it. First, each state does have "some" way of policeing the practitioners. It follows a report and a displinary action ussasully thru a board. I also know that there are many problems with this. A better choice would be keep it at state level and have the NBRC and the AARC oversight. This way there is a potentional to keep more consistant structure and fee range. It can also allow for a provision that you only need one verifacation and FBI check. Once that is done (and the other processing needed), then the additional states should only charge a transfer/ supplement fee.

The reason for the complexity of each state process lies in the state legislatures that modify bills to meet their needs. Many of the licensee laws were passed on the seat of something else.

Our profession would be very differant than all other professions that all need to go thru each state despite their national credentails- whether that is good or bad- could be both.

If anyhing is to be done, it must come from the NBRC AND the AARC as they would also need to be ready to have the oversight in the process.

Peter Kappler, Respiratory Care - RRT, St Lukes East April 27, 2010 12:29 PM
Lees Smmit MO

I whole heartedly agree with a national license. My husband is active duty and we have been moving around for 12 years. I have had licenses in AZ, TX, FL, and SC. I am now waiting for a position to be funded by the Army at Lundstuhl Regional Medical Center. We have been here almost a year and I keep hearing that it will open up soon. Meanwhile, the position requires a current state license to practice and mine will expire the end of this year. How do I keep a state license current while I am waiting overseas to get a job?!?!

Lisa, RRT April 27, 2010 12:21 PM
Ramstein AB AE

Well, I hope Ken isn't suggesting that this is something that should be exclusive to RRTs, since CRTs make up the bulk of the workforce. Only allowing RRTs to have national licenses would be shooting ourselves in the foot, although I know in his state of California, they detest CRTs. Even if not a national license, have licenses that transfer across state lines. And yes, Ann, it is about the money on both ends. For them, they make money off of us. For us, we're trying to save money. It should be about leadership. This is a subject that the NBRC should be looking in to, that the AARC should be voicing an opinion on. Many hospitals are short on therapists and rely on travelers. We need to help those willing to travel to be able to work as soon as they can. For some, living close to a state line causes headaches. Therapists in Kansas City, for instance, must decide between Kansas or Missouri licenses, or both, so they can keep their optionis open. One license solves it all, as do licenses that transfer across state lines.

Jim Thacker April 27, 2010 11:49 AM

DON'T YOU GET IT?  ITS IS AND ALWAYS WILL BE ABOUT THE MONEY!

ann annitti April 27, 2010 11:37 AM

I am in totally agreement also with a National licence. If an RT passes the NBRC exam and obtains their RRT, then there should be a program or waiver to practice nationwide, given you are licensed in at least one state. At this point, seems like the states wont even consider a national license if they are missing out on the money and or control.  I think idea has good merit, and would be a positive move for the RT proffesion if the red tape  was worked out.  Ken RRT CA

Ken , respiratory - RRT, mayers memorial April 27, 2010 11:34 AM
Fall River Mills CA

Autumn, I agree with you that CEUs are an integral part of working in medicine. I've always been a little shocked when coming across supervisors who were not insistent that the staff attend conferences and training events, and that these opportunities were not budgeted. I know you can get almost all of your CEUs, depending on your state, by attending one conference or even an ACLS class (in days gone by), but that's not the point. The point is to stay technically competent and be the most well-read therapist you can be. Supervisors and facilities do us a great injustice by not placing more emphasis on getting CEUs. These days, you can sit at your computer at work and watch webinars from the AARC in a pinch. There is no excuse for not getting your CEUs!

Thanks for your input.

Jim

Jim Thacker, BS, CRT, AE-C April 26, 2010 9:55 PM
Lexington MO

Agree with the universal requirements as long as they compare apples to apples.  An example would be the requirement for our hospital for an example would be quiet different than a teaching facility.  

In our state we must have 10 CEU's a year and $100 can keep you working.  I like the idea of CEU's or some would be satisfied with complacency.  There's no room to sit down .... gotta learn something every day!

Autumn, CARDIOPULMONARY - DIRECTOR, WAYNE GENERAL HOSPITAL April 26, 2010 1:12 PM
Waynesboro MS

Thank you for your comments. I agree with you and felt your frustration when travelling and as a Missourian living close to the Kansas border. I think most would even agree to a higher cost if the license were to be made national, or at least reciprocal. We will see if others want to share their opinions and experiences on this subject, too. In the mean time, I wish you much success in your career!

Jim Thacker, RT - CRT, AE-C April 15, 2010 3:54 PM
Lexington MO

I agree, a national licensing would be beneficial and provide better oversight. I doubt the states are going to be willing to give up the revenue to do this.

I live in Nevada but work in Utah. The Nevada licensing is complicated, not to the degree of California but still complicated. It's a long convoluted application full of contradictions and veiled instructions. I have heard of several people having their application sent back for things like, not listing separately a temp license from the permanant license in another state. The list of reasons for the apps being sent back is long. The agency prides themselves in making the process hard as evidenced by the statement on the home page. They want many things that don't even make sense, including the exact day my diploma from college was issued and a copy of my high school diploma, origonal - not certified copies of birth certificates, to name a few.

If I have credentials from the NBRC I had to prove I graduated from an accredited program, to get into the program you had to prove you had a high school diploma/ged. To top that off this state requires a separate license for blood gases -a process that is difficult to figure out and will cost another 70-80 dollars on top of the 275 you have to send in with the respiratory license application.

Out of curiosity I pulled up a nursing license for the state of NV. That application is half as long, asks for fewer documents, is clear and concise and is half the cost. It lists all cost up front, the fee for the license and the fee for the FBI background check. The Respiratory license just says something about after they recieve the fingerprint card and the fee for the background check.... the fee amount is left as a mystery.

A national license would prevent so many differences between state licensing procedures. I think it would also give therapists a voice in their licensing procedures. Right now we are left to the mercy of whatever state we need a license in with no rhyme or reason to anything.

Jennie , RRT April 13, 2010 1:11 PM
NV

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