Response to AAP

Setting the Record Straight

In its February issue of AAP News, the American Academy of Pediatrics (AAP) published an article titled “How to manage liability risks when supervising mid-level providers” written by James P. Scibilia, M.D., FAAP, a member of the AAP Committee on Medical Liability and Risk Management. For an association courting a favorable relationship with the National Association of Pediatric Nurse Practitioners (NAPNAP) and its members, the article’s language, tone and content were unfortunate.

Throughout the article, the author repeatedly used the outdated and offensive “mid-level provider” terminology. Along with confusing and misleading patients, this term incorrectly implies that pediatric-focused advanced-practice registered nurses (APRNs), including pediatric nurse practitioners (PNPs), are not fully capable to provide a wide-range of pediatric care and  always require supervision. Nothing could be further from the truth. The term “mid-level provider” calls into question the legitimacy of NPs to function as independently licensed practitioners, according to their established scopes of practice,” according to a position statement by American Association of Nurse Practitioners (AANP). The archaic term “…implies that the care rendered by NPs is somehow ‘less than’ some other (unstated) higher standard. In fact, the standard of care for patients treated by an NP is the same as that provided by a physician or other healthcare provider, in the same type of setting,” says AANP. NAPNAP agrees with these statements and appeals to all healthcare stakeholders to refrain from using “mid-level provider” terminology immediately.

Dr. Scibilia falsely claims that “In some states, the NP does not have an additional scope of practice beyond the usual registered nurse (RN) scope and must rely on standardized procedures for authorization to perform medical functions that overlap with those of physicians.” The truth is nurse practitioners in every state have a scope of practice that is expanded well beyond that of registered nurses. Those with the Pediatric Nurse Practitioner (PNP) certification graduate from either a master’s or clinical doctorate program from an accredited university. The PNP must then pass a national board certification exam focused on acute or primary care practice before being licensed as a pediatric-focused APRN. Pediatric-focused APRNs are first educated, licensed and employed as registered nurses and therefore, have thousands of hours of professional practice caring of children. To suggest that pediatric nurse practitioners have “far fewer hours of formal clinical training” is inaccurate and misleading.

The article notes “Mid-levels care for less complex patients…” and “When delegating authority to provide care, pediatricians should determine the proper means of oversight.”  Again this is misleading. In 21 states and the District of Columbia, nurse practitioners are able to practice independently per statute. And the number of states passing full practice authority legislation is increasing with each legislative session. The federal government is poised to propose rules allowing nurse practitioners practicing in almost 2,000 Veteran’s Administration medical centers and clinics spread across every state to practice to the full extent of their education and training without physician supervision.

The main focus of the article is about physician risk when collaborating with nurse practitioners (and physician assistants). While it’s understandable that legal liability is of concern in our litigious society, the overall tone of the article insinuates that nurse practitioners are risky healthcare providers requiring physician oversight to protect pediatric patients. The data cited in incomplete and one-sided. According to Nurses Service Organization (NSO), one of the largest professional liability insurance companies for APRNs and RNs, in a five-year closed claims analysis, the average total incurred for malpractice closed claims for nurse practitioners is $290,935. That’s a far cry from $431,974 cited by the author.

Regardless of the manipulated figures, NAPNAP encourages all pediatric nurse practitioners to carry professional liability insurance. NAPNAP’s position statement on malpractice notes “NPs have a responsibility to ensure that the malpractice insurance coverage applicable to their provision of professional health care services is sufficient to protect themselves and the individuals they care for.”

Attorney Carolyn Buppert authored a 2012 article in the Journal for Nurse Practitioners that states, “Generally, the malpractice liability and insurance premium of a physician does not increase because the physician has a collaborative relationship with an NP. Actuarial data have shown that the incidence of lawsuits against NPs is lower than the incidence of lawsuits against physicians.”

In summary, pediatric-focused APRNs are knowledgeable, trained and capable of providing high-quality care to their patients and their families. As the U.S. healthcare system turns to team-based and patient-centered care, inaccurate and paternalistic articles such as this only serve to perpetuate misinformation and outdated thinking. It’s time to move  into this century and realize that different providers have different—not inferior—skill sets. 

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In the ever-changing world of Advanced Practice Nursing, we will post news events pertinent to Nurse Practitioners who have dediated their career to Pediatrics.

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Nebraska Age Guidelines
Nebraska APRN board guidelines for age.pdf

Nurse Practitioners Salute Nebraska for New Health Care Law

AANP Commemorates 20th State to Grant Patients Full and Direct Access to Nurse Practitioners

AUSTIN, TX (March 5, 2015) – The American Association of Nurse Practitioners (AANP) today commends Governor Ricketts and the Nebraska Senate for passing Legislative Bill 107, which grants full-practice authority to Nebraska's nurse practitioner workforce. By adopting the law, Nebraska becomes the twentieth state to authorize nurse practitioners to provide the full scope of services they're educated and clinically trained to deliver, significantly expanding patient access to high-quality health care.

According to AANP, the move makes right last year's turn of events, in which the former Nebraska governor vetoed a similar nurse practitioner bill. He did so on the last day of the 2014 legislative session, thus preventing Nebraska lawmakers from overriding the veto after they unanimously voted to adopt the legislation.

"After a year's delay, Nebraskans will now benefit from a 21st century health care delivery model that has been shown to improve access, reduce wait times and control costs, particularly in rural and underserved communities," said AANP president Ken Miller, PhD, RN, CFNP, FAAN, FAANP. "We urge lawmakers in states considering similar legislation to follow Nebraska's example and move into closer alignment with national recommendations that prioritize the health care needs of patients."

Signed into law on March 5, the new Nebraska measure retires the requirement that nurse practitioners maintain career-long "collaborative agreements" with physicians as a condition of nurse practitioner practice, a mandate that had created obstacles and delayed patient care.

Leading policy groups like the Institute of Medicine have long recommended that states adopt such legislation to improve health care access. They cite extensive data showing nurse practitioners, including those with full-practice authority, have outcomes that are equivalent to those of physicians, and also offer patients a much-needed approach that is highly focused on health promotion and disease prevention.

Independent research further shows nurse practitioners are more likely to live and work where they can serve patients with full-practice authority, a significant issue as the U.S. contends with rising demand for health services nationwide. This has prompted some lawmakers to launch campaigns recruiting nurse practitioners from neighboring states that have yet to eliminate collaborative agreements, a trend that has enormous public health implications as competition grows for high-quality health providers.

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The Senate passed legislation April 14 to reform Medicare fee-for-service payment and extend federal funding for the Children’s Health Insurance Program.  The “Medicare Access and CHIP Reauthorization Act” (H.R. 2) cleared the Senate on an overwhelming bipartisan vote of 92 to 8, after being approved by the House March 26 on a 392 to 37 vote.  

In addition to permanently replacing the dysfunctional “sustainable growth rate” (SGR) system for updating Medicare fee-for-service payments with stable updates and a merit-based incentive payment system, H.R. 2 also includes a two-year reauthorization of funding for the Children’s Health Insurance Program (CHIP) including all provisions of the current law such as increased federal matching assistance percentage (FMAP) payments and maintenance of state eligibility and enrollment efforts.  Senators rejected an amendment to extend CHIP funding an additional two years.

The bill also includes provisions enabling nurse practitioners to document face-to-face evaluations for durable medical equipment orders and extends a number of expiring Medicare and Medicaid policies, including a two-year reauthorization of funding for the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program.