APRNs and Collaborative Practice Agreements

Health Law Talk Presented by Chehardy Sherman Williams

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Rory Bellina (00:17):
Hello everyone, and welcome to Health Law Talk presented by Chehardy Sherman Williams. Before we get started, please be sure to subscribe to our podcast and follow us on Facebook, Twitter, LinkedIn, and YouTube – links in the description below. We hope you enjoy this episode.

Conrad Meyer (00:36):
good morning everyone. So today you have Conrad Meyer and Rory Bellina, and we’re going to be talking about a very interesting topic regarding advanced practice registered nurses, APRNs, or in, in, in some of the industry terms, mid-level providers, and specifically a, a bill that was introduced in the Louisiana legislature in the 2021 session that was going to change how APRNs were going to be able to practice in the state of Louisiana. I mean, pretty, pretty interesting stuff. one of the the critical issues with respect to APRNs is that they have to, currently, as it stands right now in the law, the APRNs have to work with a physician under a collaborative practice agreement, which means this physician oversees them. So there’s a new law, a new bill that was introduced to change that. Rory, what do you, what did you, what do you know about that?

Rory Bellina (01:33):
Yeah, so as currently, like you mentioned, the collaborative practice agreement for APRNs has been around as far back as I know, and, and it’s, it’s been put in place to kind of act as a protection and an oversight for APRNs because a lot of APRNs tend to practice or have, or have clinics in either rural areas or areas where there’s not as much access to MD or do physicians. And so the collaborative practice agreement has seemed to work well, but there’s been some barriers for it, and there’s barriers for APRNs and there’s barriers for the, the physicians that ultimately have to agree to be the collaborating physician with the APRNs. So this bill was gonna change things, and it, some, some people, most likely the APRNs thought it was gonna be for the better and would allow them to practice more freely. And then some people thought that it wouldn’t, that that APRNs still need to be under the supervision of a physician.

So it, like, like you said, it was brought up and it made it through the house. It made it through the Senate. It went to the Senate for a final vote, and they ran out of time. It never got called for a final, final vote. And it, it ended there and the legislative session ended this week. So that’s where things stand now. but, but I think we should talk a little bit about what is the collaborative practice agreement, why we think it’s good, why we think it’s bad, and, and let’s talk about this bill because we both don’t think that this is going to go away, that it’s gonna get brought up. Right. If we have a special session or the next regular session.

Conrad Meyer (03:04):
Correct. I, I don’t think it’s going away. I mean, you and I might, I think interestingly enough, you and I are on kind of opposite sides of the fence on, on this, on this particular issue. Right. and, and, and really it goes back to it very interesting. What is it? Why, why was it necessary? So when, originally when the, the, the dawn right of, of the birth of APRNs in addition to physician assistants, this sort of the mid-level providers, if you will it was, it was thought that, well, we’re gonna go ahead and introduce this, and in order to practice and give an expanded scope of practice, that those APRNs or physician assistants would have to work directly with a physician to be able to, to practice, you know, medicine. Right. In terms of the expanding their scope. So currently, as it stands right now, nurses as they stand, usually have to follow the orders of a, of a physician, Correct. I mean, facilities have policies with respect to things that nurses can and can’t do, but normally the nurses do what the doctors tell them to do. And so the APRNs were sort of expanding that scope to address some of the shortfalls with primary care and access to care. And so that was the purpose.

Rory Bellina (04:18):
Correct. And they, and they had, I think that right to do so because APRNs are an advanced level of a nurse. They go to additional schooling, additional training, testing it. It’s a higher level of a nurse, and it, it’s, it’s, it’s close, you know, their abilities are very close to that of a physician with some, with some limitations. So, you know, rightfully so, I think that it, the, the collaborative practice, it had good intent, but I think it restricted APRNs in some ways. And this was a push to kind of break the chains of those restrictions. And, and I think we should discuss, you know, the, the pros and cons of a collaborative practice agreement and, you know, where we think this went wrong and, and how it can come back up.

Conrad Meyer (05:00):
Right. So, well, let’s, in my view, let’s talk about the pros. Sure. So the pros, you, you have in my mind, you have an individual, you have a an advanced practice registered nurse, right? Who, who is stepping out right on their own in a different world, doing more scope or increasing their scope of practice,

Rory Bellina (05:23):
And likely in a rural area or an underserved area.

Conrad Meyer (05:25):
Well, I don’t know if I would agree with that. I think you see APRNs in various settings. So I wouldn’t, I mean, I would agree that, that in a rural area or in a medically underserved area, Moosa, for example, I would, I would expect to see that. but, but they’re stepping out for the first time and they don’t have the same training, knowledge, training and experience that a physician would have, for example. I agree with that. You know, so for example, a physician’s gonna go to the four years of, of medical school, and then another four to six years of additional residency and training before they’re, they’re in their respective field. Whereas APRNs have to work a certain number of years in critical care, go to, and then from there, go to a school that I think, you know, obviously it’s a lot less time and there’s suddenly thrust, they’re thrust into practice, and you’re dealing with patients on a whole new level.

Right? It is, you’re, you’re the one making the decision. So no longer is the physician, you know, a, a analyzing, doing the differential diagnosis, coming up with a treatment plan, that mid-level that APRN is now making those calls. Mm-hmm. . So in, in my opinion, I think that the, the, the lack of that training, the lack of that knowledge, the lack of that experience could be a hindrance and possibly affect medical decision making for patients simply because they just don’t know. Right. And so to have that physician oversight of my mind was critical to be able to, you know, for me, for me is a patient safety issue. you know, I’m, I’m not, Look, I love APRNs, I’m not, you know, I’m not bagging on ’em. Right, Of course. I mean, but I’m looking at it from a patient safety issue and Right. And, and so that’s why I thought they were

Rory Bellina (07:09):
Important. And I think it’s important for our listeners to, for us to just briefly discuss what is the collaborative practice agreement and what typically is what’s required in it and what is typically done. So what, and, and the basics of it, right? Are that you have a physician and the physicians are restricted to how many APRNs they can act as the collaborating physician for, Right. But essentially they are the a monitor per se of that aprn, and they’re required to check

Conrad Meyer (07:37):
In. Well, I wouldn’t just say a monitor. I think they’re also someone that’s a sounding board too, and oversight. I mean, to say monitor, it sounds like they’re just watching the, watching the show. Right? But are they, are they, do they have oversight? I mean, aren’t, I mean, they do, they’re involved in the decision making as well.

Rory Bellina (07:51):
They do. They do. And they are, like you said, they, the, from the monitoring standpoint, it’s checking. They have to check a certain amount of patient records. Mm-hmm. , they have to check in with the aprn, you know, certain thresholds. And and, and to go to your point, it is a sounding go. Because if a patient comes in, the APRN doesn’t know how to handle that patient or just needs some advice, they have that collaborating physician to go to that can help them get that information. So I, I do agree with you. I think it’s, it’s excellent for that. It’s an excellent model. And, and it, I think depending on the setting, the physical setting of the aprn, you can make an argument on why this bill should have passed. And you could also make an argument on why the system’s not broken right now. Let’s keep it going as it is.

Conrad Meyer (08:37):
So to your counterpoint, why, why would you say, you know, that’s my pro, you know, what’s the con of having a collaborative agreement? Where, where do you see the, the, the, the ru where the rubber meets the road? What’s the problem?

Rory Bellina (08:50):
I think the, the, the problem from what I’ve heard from my APR and clients is getting that collaborating physician and getting them to stay on, you know, they’re having to check in with a physician to say, Did you check my notes? Did you check these records? We need to schedule our meeting. It becomes more of a administrative burden for them. I can see that. And, and sometimes an APRN wants to, you know, they go through their training that you discuss, and they want to go back to their, their hometown or to a rural setting, and they, they really struggle to get a collaborating physician to sign up to do this because it’s, I don’t wanna say it’s a burden for the physician, but it’s, it’s extra work for a physician to be a collaborating physician for the APRNs. And, and physicians are busier than anyone.

So a lot of times it’s, it’s more of an administrative issue from what I’ve heard from my apr. And clients getting that, that collaborating physician and, and staying on top of him or her to get them to review the chart, to get them to the review the records. And they’re having to send in, you know, attestations that this was done to the, to the various boards in the state. And if that doesn’t happen, it’s on the aprn. So that’s the burden that I hear. it, is it detrimental to their practice? No, but it, it, it makes it more difficult for them. Now if they’re not in a rural setting, if they’re in a, a big city or, or big parish, I don’t think it’s as big of a burden because they likely have a physician that will be that, and they’re probably close in proximity. But, but otherwise, that’s the position or the biggest con that I hear. Right. And I think why the APRNs were, the big reason why I hear they were pushing to be free is that they went through additional training

Conrad Meyer (10:31):
Free. And whether we locking ’em up, I mean, I I, I don’t know if I would say free, you know, to, to, to break the change that behind them. I mean, the collaborative is not, I don’t think it’s as dead weight. I can see the administrative burden, what you’re saying about, I don’t know if it’s as dead weight, it’s that, I mean, I don’t know. In other words, the physician has liability too. I mean, remember that they do. So that, so that collaborative position, when they’re not, when they’re not reviewing or they’re taking their time to review charts, they could be running into some bylaw issues. Correct. On trial timeliness, they could be running into some exposure payer issues in terms of Tommy’s submission of claims, other liability issues. So they’re on the hook too. Correct. So, but I can, I can understand the doc who is sort of, Oh, I gotta look at this again. this, you know, I can totally, I can see that problem.

Rory Bellina (11:20):
Right? Right. And, and that, that’s, that’s what I hear. So I think let’s discuss, you know, where this bill was and what it intended to do, and, you know, possibly why we think it, it, it maybe didn’t make it out of a full Senate vote and, and that we, you know, it comes back up and how it could be changed, or, or if they bring it up as is, do we think it’ll make it,

Conrad Meyer (11:43):
So we’re talking about House Bill 4 95, is that right?

Rory Bellina (11:45):
Yes. House Bill, four 90 fives introduced in the 2021 regular session. And it was, it was co-authored by numerous representatives out of the House. House.

Conrad Meyer (11:53):
Well, what, And so, wait, so, so let’s, for the listeners, what is the normal, you know, the process, right? It went to some committee first, Is that right? Correct. And then, and then they go through committee and they do some revisions on the bill, right? Correct. And then after that, if it le if it passes the committee, what happens next?

Rory Bellina (12:13):
Then it goes, as you said, it’s, it’s authored by, this one’s authored by about 10 or 12 different house members. So it starts there. It typically gets sent to a committee, committee reviews. It makes revisions, it leaves committee, it goes to the full house for a vote. Once it passes the full house, then it goes to the Senate. The Senate typically sends it to committee, The committees make revisions, then it goes to the full Senate for a vote. This bill made it to the full Senate for a vote, but they never took a final vote on this. And that, that, that is common. That’s not an uncommon thing on why did they not take a vote on it? Did they, Was there something wrong with it? Typically, what we hear, or what we hear from people in Baton Rouge is that if final vote is not made on a house bill or a Senate bill, it’s typically because they know that it’s not going to pass. And so it, you know, for lack of a better word, instead of them being embarrassed or, you know, disappointing the people that they told it would pass, or that we’re encouraging them to, to push it to get passed, they say, We’re not even gonna put this to a vote, because we don’t want that stigma of it failing and then us having to bring it up again. They would rather just let it silently go and bring it up again in the next session.

Conrad Meyer (13:27):
So, so to my point earlier about the knowledge training and experience, when I, when you look at the bill a and you look at the changes, it, it, it has some pretty stark changes to it in terms of, of the requirements now. So when you look at it, and you kinda get into the weeds, now, APRNs will have to have 6,000 hours of PR of, of under their belt. Right, Right. In a particular specialty. So in other words, if they’re gonna go to, you know, ortho, cardio, neuro primary care, they’re gonna have to have 6,000 hours in their specialty. Right. To be able to get that aprn without the collaborative agreement that was in the bill. And then, but prior to that, prior to that, the, the, the, as an rn, they needed to have 4,000 hours clinical hours, Right? Right. I mean, that is a tremendous amount of

Rory Bellina (14:17):
Time. It’s, it’s a lot of, it’s a lot of work. And from what I hear from APRNs, they feel that the amount of time, work, energy that they’ve put in, that they, that they should not have. Again, I’ll bring up the, the administrative burdens that they have with these collaborative practice agreements that they should be allowed to practice with inside their scope. I don’t think they’re asking to do anything that they’re not allowed to do by their license. I think it’s more of a personal, I don’t, I don’t know if it’s really an issue, but it’s more of a, of a personal, you know, struggle that APRNs have, that we went, we got the hours, we went to the schooling, the training, the testing, we’re licensed and certified, and, but then we still have to have someone who, who isn’t even an APR and their physician. I mean, no, that’s obviously a step above as far as training goes, but, but not even someone in our specialty kind of checking our work. And I think for them it becomes, that’s more of a, of a personal thing, because you don’t see that in a lot of other non healthcare related industries. And I think it’s a, from the ones that I’ve spoken with, that’s their struggle is that in no other industry do you really see someone that’s, you know, not directly as you kind of checking your work and system.

Conrad Meyer (15:30):
I don’t, I don’t know if I agree with that. Let me, let me flip the tables on you here for a second. What about paralegals and law? What if suddenly the Louisiana Paralegal Association said, Well, we’re gonna give paralegals a license, They gotta take, you know, 2000 hours of, of, of, of, of training, and suddenly we’re gonna allow paralegals to go file pleadings. We’re gonna let them put their name and signatures on pleadings in court and allow them to do that. How, how would we respond? I mean, would we have the same arguments? Like, for example, the arguments I’m making saying, Well, you know, hey, they really don’t have the knowledge training and experience as a lawyer. They never went to three years of law school. They never did X, Y, and Z. You know, So I don’t, I don’t know if I would buy that, that hook line and sinker.

but, but, you know, cause I can see that happening. I can see suddenly we’re opening Pandora’s box. Mm-hmm. . But to your point I don’t know if I would agree back to the hours, you know, is, is 6,000 hours enough, Right? Right. Is that enough? I mean, I don’t know. I mean, if I’m a physician, for example, I’ve gone through four years of school, two of those four years right? Are on rotation, then I’m getting matched into a residency program. That’s only after I pass my, my, my board. I have my two year boards, then I have my, my four year, and then now I’m in a residency program after I’ve matched and I have another four to six years of additional training. Sometimes I go to a fellowship even after that. So, so does that, you know, does that 6,000 hours of hours, you know, that was in the bill, right? Mm-hmm. , is that gonna s I mean, is that enough? I mean, who’s to

Rory Bellina (17:08):
Say I don’t, I don’t think anyone knows. I think the six, that’s the point. That it could be an arbitrary number that we don’t know. Is that

Conrad Meyer (17:14):
Enough? We don’t know. And the thing is, is will the patients care?

Rory Bellina (17:19):

Conrad Meyer (17:20):
So, and that, that’s a real point.

Rory Bellina (17:22):
I mean, Right. So Conrad, is your kind of position on this, that the system really isn’t broken right now? Why change it?

Conrad Meyer (17:30):
No, I don’t think that’s the, I, I think, I think that’s a, that’s a tough question, really, honestly, because I do believe, I understand the desire to break away from the contract, but maybe there’s a way to meet in the middle. Okay. Maybe there’s a way that you can allow APRNs to have, have the freedom and scope of practice, their desire while giving patients greater access to care, but still having sort of that oversight of a, of a physician and, and, and, and, and I don’t know the solution. I mean, I, I mean, I can’t, I’m, I’m gonna let us, but I’m, I’m just thinking out loud here. Maybe there’s a way to thread the needle, right? To cover both

Rory Bellina (18:11):
Ends, Right. And really find out what the position of the APRNs are. You know, is it that they’re, is there not enough? Do they,

Conrad Meyer (18:18):
Oh, wait. Well, interestingly, I wanna tell you this. Did you know that federally qualified healthcare centers on the federal law, APRNs already don’t need a collaborative agreement? I

Rory Bellina (18:27):
Did not

Conrad Meyer (18:28):
Know that. They don’t need it. So if you wanna go work for an FQHC as a aprn mm-hmm. , you don’t need it.

Rory Bellina (18:36):
That’s interesting.

Conrad Meyer (18:37):
And that’s federal rules. So the feds already have Right, taken the step right to, to, to, to cut the ties. Right? Now it’s, it’s, and this is a battle, and we all know this. I mean, it’s a battle between the docs, right, Exactly. And the nursing board. So we’re watching the, we’re watching the Battle of the Boards. Correct. Right. Because the bill also put together, you notice, interestingly, it, it advocated for this independent practice advisory panel with Louisiana Department of Health. I saw that. And this was gonna put together a, a five voting member panel. Right. And when you look at the, the, the panel makeup, The panel makeup, now, there is you know, one physician from the State Medical Society, one from the Louisiana Medical Association, one from the American Academy the Louisiana Academy of Family Physicians two from the Louisiana Nurse Practitioners Association one from the Louisiana Council and Administrative and Nursing Education, and one from the State Board of Nursing as a non-voting, but interesting, the one board member from the Board of Medical Examiners is a non-voting member. Interesting. So they wanted to pull that out, you see because they don’t want the board to, to, to, I think, I think to weigh in on this issue,

Rory Bellina (19:49):
And I, and I think it’s up for a, it’d be a good conversation to find out where are the barriers, You know, is it that, you know, there’s a restriction on the number of APRNs a physician can collaborate and oversee? Is, does that need to be expanded or does there need to be more of an incentive for physicians to work with the APRNs? You know, do they, do they need to come up with a mandatory program where every phy, every physician out of x amount of years of experience is required to be a collaborating physician for then, then I think you’re gonna run real afoul from the physician side if you’re mandating me to do that. I mean, that, that’s, I don’t, that’s, I think that’s a slippery slope.

I think, I think the, the question or the struggle will be is, like you said, where can they meet in the middle, find out what the real issues are and what their real, what the real barriers are and, and how can this be worked out? So I mean, the, the number one goal is patient care and patient safety and, and knowing, I

Conrad Meyer (20:47):
Think also access to care too, Don, wouldn’t you say? I mean, Yeah, absolutely. So patient safety, access to care, all the things you mentioned.

Rory Bellina (20:53):
Absolutely. And, and, and by getting that, I think everyone, both boards need to continue working together to find out what is the best way to get that to everyone. So

Conrad Meyer (21:01):
Let’s just say this goes forward next year or the year after. Sure. Right. Let’s just say another bill comes up, and this time it’s got, it’s gonna get outta committee, it’s gonna get out on the floor, it’s gonna get called mm-hmm. . Okay. But here’s the, here’s the interesting thing, and I want to kinda leave you with this. What about physician assistants? If APRNs suddenly have the freedom to have no collaborative agreement, what do you think the PAs are gonna say?

Rory Bellina (21:25):
You think they’re gonna look at this and copy this bill and, and propose it for

Conrad Meyer (21:29):
Themselves? I think they’re gonna give it a try, Wouldn’t you? I mean, if I’m a PA and I’m doing a similar scope of practice and suddenly my aprn next to me says, Hey, I don’t need an agreement anymore. See you as I and ara, right? Yeah. They’re gonna come back and say, I’m gonna do it. We wanna do it too.

Rory Bellina (21:44):
And then are we opening it up? Are we opening it up to where we’re gonna have, like you said, the mid-levels just practicing on you?

Conrad Meyer (21:52):
What do you think you think it’s gonna get? You think the Pandoras, if I’m a pa, you know, and I see APRNs get special treatment because they put forth legislation, what do you think I’m gonna do next year?

Rory Bellina (22:02):
It could be, it could very well happen. The, the association could get together and say, we want this as well.

Conrad Meyer (22:09):
Correct. Correct.

Rory Bellina (22:11):
So, and, and then we have, then we have, you know, possible other issues of trying to keep in access to health and patient care

Conrad Meyer (22:17):
Come up. Well, not even addition to the House bill, remember, remember too now the financial side of APRNs Okay. On incident two billing, which we’re not gonna get into here, That’s a whole different topic. Right? Right. But you know, you have that 15% where they’re reimbursed by Medicare at at 85% on their own if they build it on their own. But if they bill it with a physician, then they can bill it under the physician’s NPI as an incident to it. Correct. If they meet requirements. Correct. But they get the hundred percent then, Correct. So there’s a 15% gap. So I guess the question is, is, is that gonna stay? Right, Right. Or is Medicare gonna say, Hey, we’re seeing, we’re seeing the, the tsunami coming. Right, Right. We’re just gonna go ahead and give ’em the a hundred percent outright because we have, you know, numerous states who are now letting APRNs practice on their own. Correct.

Rory Bellina (23:06):
Yeah. And, and, and we don’t know. And, and we need to see how this is happening in other states, you know, with, with Covid and the expansion of telehealth and telemedicine. You know, is it gonna be more of a progressive approach where the goal is to get the most providers and the most access to patients and finding ways to do that?

Conrad Meyer (23:26):
Well, I guess only time will tell. We’ll see. I think so we will see next year, the next legislative session to see if somebody decides to put this forward. I think so. I think, you know what? I don’t know. I think we’ve covered all of our rounds on the house. Bill 4 95. I’m gonna look forward. I’m gonna keep Dr. Who do you who put this, Who was the, the, the legislator that drafted this? Was this,

Rory Bellina (23:46):
It was representatives, Ivy Carter, Cox Green, James, a Numer. Numerous amount of them. But it, it’s something that we should definitely follow and maybe we could reach out to them and find out where they think this Bill did make it at a full Senate. And, and if they plan to bring it again in the next session,

Conrad Meyer (24:01):
I think that would be something great for a follow up. I think so too. Absolutely. Well, great. Well that’s great on this one.

Rory Bellina (24:07):

Conrad Meyer (24:07):
Topic. Absolutely. Absolutely. We’ll look forward to our next episode coming up soon, and I hope everybody continues to listen at the I Dunno, Health Law talks at Chehardy Sherman Williams. Thank you.

Rory Bellina (24:21):
Thanks for listening to this episode of Health Law Talk, presented by Chehardy Sherman Williams. For more information or to contact us, please visit our website, LinkedIn in the description below. Also, please be sure to subscribe to our podcast and follow us on Facebook, Twitter, LinkedIn, and YouTube.

In this week’s episode of Health Law talk, Conrad Meyer and Rory Bellina discuss APP’s or advanced practice providers. In the 1960s and 70s, a family physician was usually in a solo practice with maybe one or two fellow physicians. Supporting that practice read the nurses, aides, lab technicians, or even a spouse who might help with obtaining lab work, blood draws, or other services. In today’s complex healthcare delivery system, mid-level providers, often referred to as advanced practice providers (APP), include advanced practice registered nurses (APRNs), physician assistants (PAs), and clinical nurse specialist (CNS), just to name a few.  These APP’s are continuing to increase in number as well as expand the scope of respective practices. The nuances involving the APP scope of practice along with the needs of an ever demanding population craving healthcare require decisions involving the role that APPs will play alongside physician providers in delivering the healthcare that is desperately needed in today’s marketplace. This episode will delve into these topics and more so please join us for this exciting episode on APP’s with health law talks.

Health Law Talk, presented by Chehardy Sherman Williams, one of the largest full service law firms in the Greater New Orleans area, is a regular podcast focusing on the expansive area of healthcare law. Attorneys Rory Bellina, Conrad Meyer and George Mueller will address various legal issues and current events surrounding healthcare topics. The attorneys are here to answer your legal questions, create a discussion on various healthcare topics, as well as bring in subject matter experts and guests to join the conversation.

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