Letter Opposing APNs Practicing Independently in Veteran’s System

October 10, 2013 

Robert Petzel, MD
Undersecretary for Health
Department of Veteran Affairs
801 Vermont Avenue, NW
Washington, DC  20420 

Re:  Veterans Health Affairs Nursing Handbook 1180.03

Dear Dr. Petzel: 

As organizations representing the majority of the nation’s physicians, we write to express our strong concerns regarding the draft Veterans Health Affairs (VHA) Handbook 1180.03:  VHA Nursing Handbook ,which would mandate that all advanced practice nurses (APRNs) within the VHA be designated as independent providers, without regard to state practice acts.  We are concerned that some of the changes proposed may significantly undermine the delivery of care within the VHA while disregarding the states’ role in regulating the health and safety of their residents in the delivery of health care services.

The draft VHA Nursing Handbook effectively eliminates physician-led, team-based care within the VHA system.  In lieu of team-based care, the draft handbook requires APRNs to attain independent practice and penalizes those who do not wish to attain this status by prohibiting such APRNs from practicing as APRNs within the VHA.  Similarly, local facilities that wish to continue to provide physician-led, team-based care will be prohibited from doing so. 

Our country faces a growing health care workforce problem, as we experience shortages of both physicians and nurses.  At the same time, there is increasing demand for primary care.  Some have argued that APRNs should be granted authority to practice independently from physicians as a means to address primary care needs.  These arguments come at a time when health care delivery and payment models are heading in the opposite direction.  New models of care delivery, including Accountable Care Organizations and Patient-Centered Medical Homes, require integration and teamwork among providers to improve health care outcomes and reduce health care costs.  A growing number of policy experts recommend these team-based approaches. 

These two approaches—independent practice and team-based care—take health policy in two very different directions.  One approach would further compartmentalize and fragment health care delivery; the other would foster integration and coordination.   

The undersigned organizations support the use of patient-centered, team-based patient care.  We believe that increased use of physician-led teams of multidisciplinary health care professionals can have a positive impact on the nation’s primary care needs.  A team-based approach would include physicians and other health professionals working together, sharing decisions and information, for the benefit of the patient.  Physicians, APRNs, physician assistants, nurses and other professionals would work together, drawing on the specific strengths of each member. 

Health care leaders like Geisinger Health System, Intermountain Healthcare, the Mayo Clinic and Kaiser Permanente are successfully using physician-led teams to achieve improved care, improved patient health and reduced costs.  Preliminary data released by a physician-led medical home that is partnering with Blue Cross Blue Shield of Michigan showed $310 million in savings since 2008, including $155 million saved in 2012 alone.  The undersigned organizations look to these physician-led systems as evidence that team-based models of care—not independent models—are the future of health care.

Yet health care teams require leadership, just as teams do in business, government, sports and schools.  Physicians bring to the team the highest level of training and preparation and as such are the best suited to guide the other members of the team.  APRNs are indispensable, but they cannot take the place of a fully-trained physician.  Physicians are trained to provide complex differential diagnoses, develop a treatment plan that addresses multiple organ systems and order and interpret tests within the context of a patient’s overall health condition.  The training and education of APRNs is appropriate for dealing with patients who need basic, preventative care or treatment of straightforward acute illnesses and previously diagnosed, uncomplicated chronic conditions.  APRNs and physicians have skills, knowledge and abilities that are not equivalent, but instead are complementary.  The most effective way to maximize the talents of the complementary skill sets of both professionals is to work as a team.

We believe greater coordination through the use of more flexible collaborative practice agreements and protocols between VHA and physicians and APRNs, taking a team-based approach to care, can address much of the primary care demand within the VHA.  At the same time, the undersigned organizations look forward to working with the VHA on implementing longer-term solutions to increase the overall physician and nursing workforce.

We appreciate the opportunity to provide our views on these critical issues.  Based on all of the above, we strongly urge that revisions be made to the draft VHA Nursing Handbook to ensure that current 

VHA policies in support of physician-led health care teams and state-based licensure and regulation remain unchanged. 


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