VA Plan for Independent Advanced Practice RNs Riles Physicians

May 25, 2016

In a move decried by organized medicine, the Department of Veterans Affairs (VA) formally proposed to let its advanced practice registered nurses (APRNs) work independently without physician supervision in its far-flung healthcare network, the largest in the nation.

The VA said that by maximizing the abilities of APRNs it would increase veterans' access to care and shorten their notoriously long wait times for appointments.

The American Medical Association, however, said it was disappointed by the plan because it runs counter to physician-led, team-based care, which it called the best approach to improving quality. And the American Society of Anesthesiologists (ASA), alarmed that certified registered nurse anesthetists (CRNAs) would replace its members in the operating room, has started an opposition campaign with a battle cry of "Protect our Veterans."

The VA's Veterans Health Administration (VHA), which encompasses some 150 hospitals and nearly 1400 other facilities, has entertained the notion of emancipating APRNs from physician supervision for several years. The plan would cover nurse practitioners (NPs), clinical nurse specialists, and certified nurse-midwives, in addition to CRNAs.

The VA that said allowing APRNs to practice without physician supervision in VHA facilities would create nationwide consistency in what is now a patchwork of state regulation. NPs, for example, can practice independently in only 21 states and Washington, DC. CRNAs have that authority in 17 states, according to the VA. The proposed regulations would override state laws that require physician oversight of APRNs.

CRNAs Say They're Already Doing It on the Battlefield

The American Association of Nurse Anesthetists said in a news release that the VA plan mirrors medical care on the battlefield, where nurse anesthetists have been the main providers of anesthesia in the United States military since World War I. Calling APRNs "underutilized," the association said the VA is taking its cue from the National Academy of Medicine (formerly the Institute of Medicine), which recommended that APRNs be able to practice to the full extent of their education and training.

For its part, the society representing anesthesiologists said that independent practice for CRNAs in the VHA would lower the standard of care.

"The policy change is based on a shortage of some types of physicians in the VA," the ASA said in a news release. "However, there is noshortage of physician anesthesiologists and the change is not needed to improve access to anesthesia care in surgery. The policy would abandon a proven model of care where physician anesthesiologists and nurse anesthetists work together as a team to provide veterans high-quality and safe anesthesia."

The VA is accepting comments on the proposed regulations through July 25. The proposal contains instructions on how to submit comments.

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