Internists offer alternatives to VA’s proposal to allow APRNs to practice independently

ACP submits comment letter for proposed rule on Advanced Practice Registered Nurses

Washington, July 25, 2016 -- The American College of Physicians (ACP) today offered an alternative to the Department of Veterans Affairs’ (VA) proposal to permit full practice authority for Advanced Practice Registered Nurses (APRNs).

The VA’s proposed rule would establish additional professional qualifications an individual must possess to be appointed as an APRN within the VA. It would also establish additional professional qualifications an individual must possess to be appointed as an APRN within the VA and exercise Federal preemption of state nursing licensure laws to the extent such state laws conflict with the full practice authority granted to VA APRNs while acting within the scope of their VHA employment.

“While ACP does not support the VA's proposal to broadly preempt state licensing laws to grant full independent practice authority to APRNs, we propose an alternative that would involve promoting nimble and adaptable clinical care teams, where every clinician on the team works together to ensure the needs of patients are met at each step of the way,” said Nitin Damle, MD, MS, FACP, president of ACP.  Such multidisciplinary clinical care team models match patients with the health care professionals on the team who have the training and skill needed to meet their care needs,  modeled on ACP’s 2013 position paper, “Principles Supporting Dynamic Clinical Care Teams,” published in Annals of Internal Medicine.   

ACP’s letter asserts its support for veterans to have access to a personal physician who accepts clinical responsibilities for care of the “whole person,” consistent with the Patient-Centered Medical Home model.  “While internal medicine physicians have unique training to exercise clinical leadership responsibilities for the team and to care for adults with complex illnesses and diagnostic challenges, patients might appropriately be seen by other members of the clinical care team -- including nurses -- depending on their specific clinical needs and circumstances with physicians being available for referral or consultation as needed," Dr. Damle said.

ACP’s letter observes that because primary care encompasses various activities and responsibilities, it is simplistic to view primary care as a single type of care that is uniformly best provided by a particular health care professional.  To illustrate, the letter notes that an advanced practice registered nurse providing primary care commensurate with his or her training may consult with or make a referral to an internal medicine physician, a family physician, or another physician specialist when presented with a patient with significantly complex medical conditions.

Effective clinical care teams allow each member of the team to practice to the full extent of their training and experience, ACP observed.  While ACP does not support pre-emption of state licensing laws, it strongly encourages states to examine their laws to ensure that all clinicians are able to practice the full extent of their training and skill while practicing within a dynamic clinical care team.”

The College also noted that telemedicine offers a way to create virtual teams in areas experiencing an acute shortage of primary care physicians.

ACP’s letter concludes that, “The specific recommendations in this comment letter offer an alternative to the VA’s well-intended but ultimately fundamentally flawed ‘full practice authority’ pre-emption of state laws that would promote highly functioning, patient-centered dynamic clinical teams that use the talents, skills, training and professionalism of all members of the team to provide the best possible care to VA patients.  Our nation’s veterans deserve nothing less.”


About the American College of Physicians

The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 148,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.