The number of states that have granted nurse practitioners (NPs) full practice authority has reached a tipping point at 26 plus the District of Columbia, with New York and Kansas being the most recent wins in 2022. President-elect of the American Association of Nurse Practitioners (AANP) Stephen Ferrara, DNP, FNP-BC, FAAN, FAANP, was a key player in the legislative push in New York. Dr Ferrara shared insights with Clinical Advisor on how to strategically lobby for full practice authority in other states and other legislative issues he is working on such as allowing NPs in New York to treat injured federal employees with workers’ compensation coverage and clear student athletes for return to play postconcussion. At a federal level, he is part of an effort to allow NPs to order diabetic shoes for Medicare patients.

Q: How long did the process take to grant NPs full practice authority in New York?

Dr Ferrara: It was certainly an involved experience. New York had been working on this in some way since 2008, believe it or not. It takes that long for legislation to finally pick up some steam, get recognized by the key leaders in the legislature, and move forward. Being in it for the long haul is key.

Compromise is part of the equation when negotiating policy. Stakeholders must understand this at the outset of the process and be prepared to have a clear line of what is and what isn’t negotiable. 

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In New York, the NP community made a number of attempts at full practice authority over the years. In fact, in 2014, a bill passed called the nurse practitioner modernization act, which said that NPs with at least 3600 hours of practice did not need to maintain a written practice agreement with a physician but did need to maintain a collaborative relationship with a qualified physician.  What needed to be maintained at that point was a collaborative relationship and the state essentially replaced a formalized written agreement with a regulated relationship with a physician as a condition of practice.

What changed in April 2022 is that experienced NPs with 3600 hours of clinical experience no longer need to have a written agreement or any sort of regulated collaborative relationship with a physician or a hospital system. AANP is very proud that NPs in New York State can practice at the top of their license, education, and training and have full practice authority. We believe as NPs that this will increase access to health care for the people of New York State.

Q: Is 3600 hours of clinical experience a common requirement for full practice authority in other states?

Dr Ferrara:  It’s important to know that there is no evidence to support these requirements. In fact, 17 jurisdictions authorize full practice authority without this added regulatory hurdle.

This NY requirement predates the pandemic and is a holdover from the 2014 law. Unfortunately, how New York picked those hours is not very evidence-based and data haven’t proven that transition to practice hours are necessary. Some other states have had similar experiences. When we have different states with different laws, it is hard to understand why this makes sense.

The AANP has always advocated for full practice authority from the point of graduation and successful passage of national certification boards because NPs are fully educated and trained to provide a full scope of services. This degree of variability makes it difficult for NPs who are contemplating moving to another state. And, it makes it difficult for policymakers because there is such wide variation in legislature across the country. 

Q: What legislative issues are you currently working on?

Dr Ferrara: A number of barriers for patients who are seeing NPs in New York State still exist. In the next legislative session, The Nurse Practitioner Association New York State will be looking to tackle the ability of NPs to return students to athletic activities postconcussion. Currently, student athletes with concussions who attend public elementary, middle, and high schools can only return to sports activity with a physician’s letter. New York law does not recognize NPs as providers who can clear student athletes for sports activities in New York State. This is one of those issues that even the full practice authority bill doesn’t touch upon because it is not directly related to the licensure of NPs per se but rather pertains to public health law.

Another issue that seemingly makes no sense in New York State is that the Department of Motor Vehicles allows NPs to sign the medical certification section of the application form for handicap parking only if it applies to permanent disabilities. If a patient has a temporary disability such as a fractured leg and only requires access to handicap parking for a relatively short amount of time, the NP cannot sign that form.

There is growing legislative interest to put patients over paperwork and address these issues. Updating these areas would streamline care and build more efficiency in the health care system.

Q: How much pushback are you getting from physician groups for these changes?

Dr Ferrara: There is significant pushback whenever there are changes to laws and regulations regarding other health care professions. We certainly look at the robust evidence that has been conducted and published to date showing that NPs are providing the same high quality of care as other health care professionals and are cost-effective. I believe as many other health policymakers do that NPs increase health care access to patients, especially those working in underserved and underrepresented communities such as federally qualified health centers where patients rely on those health centers as their primary access to health care.

Q: What issues are you working on at the federal level?

Dr Ferrara: At the federal level, AANP is focused on retiring all barriers to practice for NPs that impede timely patient access to care and prevent NPs from practicing to the full extent of their education and clinical training. This includes certifying our Medicare patients’ need for diabetic shoes. Under current law, only a physician can certify this need, causing delays in access for NPs’ patients. This issue is becoming increasingly acute, as NPs are the fastest growing clinician group within the Medicare program and over one-third of Medicare beneficiaries receive care from NPs. To fix these inefficiencies in our nation’s health care system, Congress and/or federal agencies must take legislative and regulatory action.  

While we have seen progress over time in recognizing the high-quality health care NPs are providing to patients, these inefficiencies cause harm. Similarly, federal employees run into barriers when they are hurt on the job. Instead of continuing to be seen by their NP, they have to see physicians to certify their injury and oversee their treatment while receiving federal workers’ compensation. The first step to retiring this barrier was taken when the US House of Representatives passed HR 6087, with a strong bipartisan vote, which would authorize NPs to certify federal workers’ compensation claims and oversee patient treatment, in accordance with State law. We are hopeful the Senate will act and send this legislation to the President retiring this barrier once and for all.

Q: What should NPs who are dealing with these barriers do?

Dr Ferrara: Health policy is one of the areas that I’m very passionate about. And yes, we are clinicians first. But if we aren’t able to do the work that we’ve been educated to do, and that prevents us from offering our complete selves to our patients, health policy is critically important. Clinicians who can’t see injured federal workers may not necessarily know why and they may not necessarily know that there are efforts to fix that. The advocacy piece is that we need to hear those voices. We need those folks to step up and speak with their legislator, write to their legislator, make legislative visits, and tell their stories about how they were attempting to see patients who came in but were not allowed to because of this antiquated law or regulation that exists.

Those are powerful stories that legislators need to hear. I encourage any clinician who ever encounters these types of barriers to reach out and try to be part of the solution.

Dr Ferrara is president-elect of AANP, a primary care family NP, associate dean of clinical affairs, and associate professor of nursing at Columbia University School of Nursing. He also is the former executive director of The Nurse Practitioner Association New York State.