APN bill killed in committee, but APNs not defeated.

Colorado, like the rest of the nation, is facing a crisis within the current healthcare system. Soaring costs and barriers to access are not unique to our state. The number of rural and underserved communities in Colorado further magnifies these problems.

HB 1023 would have enhanced the public access to skilled nursing and health care services of Advanced Practice Registered Nurses (APNs). Through these updated provisions, administrative and bureaucratic barriers that patients, practices, and providers encounter when providing care to the residents of Colorado would have been eliminated.

The Colorado Nurses Association (CNA) worked with the insurance groups and the Colorado Medical Society to gain agreement on wording in parts of the bill. The Bill passed the House by a vote of 63-1, but was killed in the Senate Health and Human Services, partially due to negative information by physician specialty groups.

The Colorado Nurses Association will be convening APNs over the summer to strategize how best to bring the bill back next session. It will be important for APNs to invite their local legislators to come and visit their workplace to really understand what advanced practice nursing is all about. Work will continue with the Medical Society and physician specialty groups. It will be crucial to engage consumers and have them testify about the value and accessibility of APN practice.

What were the specific changes proposed in this bill?

* Current language would have been clarified to decrease confusion and assure that the public has access to all types of Advanced Practice Nurses. This bill used the generic term "advanced practice nurses" to replace any of the individual titles.

* Insurance companies would have been required to allow APNs onto their panels without restriction.

* This bill did NOT require the same reimbursement rate to APNs as is provided to MDs.

* APNs could have signed forms for patients whom they care for-such as jury service, utility company forms, school forms and physicals, CPR directives after they have spent time caring for the patient, etc.

* Under these proposed changes, APNs would have been able to directly authorize parking privileges (handicap sticker) for patients, without the delay of seeking a physician that may not have a relationship to the patient to sign the state form.

Why the proposed amendments?

* These proposed amendments would have expedited care for health care situations and patients in all areas of the state, not just the rural areas.

* Timely and quality access to primary care providers in rural and underserved areas would have been assured.

* By statute, APNs are independent practitioners and do not require physician supervision.

* APNs have the skill, knowledge and experience to provide health and medical care to patients-and have safely been doing so for over three decades. Their full scope of expertise should be readily accessible and reimbursed, especially in rural areas, where there is a shortage of physicians.

* Research has shown that timely healthcare reduces the severity of complications and reduces the cost of care. Increased access to high-quality APN care for those in underserved areas of our state would not only improve resident health, but would help to decrease the cost.

Why these changes would have improved access and care for the citizens of Colorado:

* This legislation would have increased the number of available primary care providers to rural and underserved areas.

* Insurance access is limited in rural areas. These limitations hinder access for patients, and at times can be perceived as a restraint of trade issue.

* Fighting for access onto the panels can become expensive and time consuming.

* Opening insurance panels and Medicaid managed care network panels to Advanced Practice Nurses would encourage APN primary care providers to practice in rural and underserved communities. The federal government already recognizes and reimburses APNs directly for care provided.

* For example, Otero, Bent and Crowley Counties have seen a decline in ten family physicians in the last 20 years. Eight Family Nurse Practitioners have located into the area and are providing primary care that has helped fill the void.

* In 2002, there were 20 counties that ONLY had nurse anesthetists providing anesthesia. In 5 other counties, nurse anesthetists and physicians shared services without supervision. Nationally, 65% of anesthesia is provided by nurse anesthetists.

This legislation would have improved quality of care.

* Current legislation and the Nurse Practice Act recognize APNs as primary care providers. APNs are nurses that have additional education in diagnosis and management. To become an APN, one must obtain a master's degree from a nationally accredited program, and complete clinical rotations in area of specialty. APNs are healthcare providers "that provide high-quality healthcare services similar to those of a physician" (AANP, 2006).

* APNs provide preventative healthcare and education, as well as diagnosis and management of health issues. APNs may prescribe medications, including controlled substances. This requires additional education and hours of clinical experience.

* A collaborative agreement with a physician is required primarily as a referral source.

* There is no malpractice or liability for the collaborating physicians.

* There is no direct oversight, supervision, or signatures required for prescriptions.

* No appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilization or cost. (Cochrane Database of Systematic Review 2006 Issue 4 2006).

* The APNs are fully liable for their independent practice, even when they are an employee. General treatment care protocols, applicable to all providers, may be appropriate if based on the latest evidence-based guidelines.