Federal agencies consider telehealth, scope of practice proposals

In an effort to increase access to health care providers for members of the military and veterans, federal agencies are seeking ways to expand telemedicine and practice authority for advanced practice registered nurses (APRNs).

Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information.

The 2017 defense authorization bill expands telemedicine under the Department of Defense (DoD) TRICARE program, and would shift the definition of “location of care” from where the patient is located to where the doctor is located for purposes of medical licensing, professional liability, and reimbursements. To address lengthy patient wait times, the Department of Veterans Affairs (VA) recently proposed to grant full practice authority to APRNs.

Some members of the medical community have raised concerns that these actions are not only against the best interests of patients, but also could lead to similar changes outside of the DoD and VA. Physicians should take note, because issues of licensing and scope of practice can arise in the most unlikely of places.

In response to the VA’s proposed rule to grant full practice authority to APRNs, the American Medical Association (AMA) submitted a letter with signatories from various medical practice areas, and the AACU commented in a separate letter that raised points that are of particular interest to urologists.

Next: AMA's letter raised multiple issues

The AMA’s letter raised multiple issues, ranging from training differences between physicians and APRNs to questions of federalism. The strongest argument the AMA raised was the fact that the VA itself had recently released a study on the quality of care by APRNs that found that APRNs, while important to the medical team, do not offer the same quality of care as physicians. The AMA explained in its letter:

The authors of this evidence synthesis found “scarce long-term evidence to justify” the position that “a large body of evidence shows that APRNs working independently provide the same quality of care as medical doctors.” The authors conclude that “strong conclusions or policy changes relating to the extension of autonomous APRN practice cannot be based solely on the evidence reviewed [in the brief].” While the VHA cites this brief in supporting documents for the Proposed Rule, the evidence brief’s conclusions do not support the VHA’s proposal.

AACU also looked to the VA’s own reports for evidence against giving full practice authority to APRNs, and highlighted in its letter that the VA Office of Inspector General (OIG) found that the VA lacked the internal controls to properly determine appropriate staffing levels for physicians as well as nurses. AACU commented that “OIG’s reports on staffing shortages within VA consistently indicate a root cause of veterans’ inability to access VA health care: the absence of consistent staffing plans undermines the ability of officials to determine the appropriate number of physicians required to meet patient care needs.”

In an effort to move the VA toward a positive solution that ensures patient safety, AACU also strongly recommended that the VA “increase efforts to ensure it utilizes the full amount of GME positions before adopting this rule change” by filling all of the 1,500 new GME opportunities for which VA received funding in 2014. AACU concluded that “focusing efforts on VA’s GME program will ensure that VA does not substitute the expertise of a physician with that of a lesser-trained APRN.”

Next: Defense bill would expand telemedicine

Defense bill would expand telemedicine

The recent defense authorization bill that expands telemedicine is far from being implemented for TRICARE beneficiaries, and must still go through the congressional conferencing process to iron out differences between the Senate and House versions of the bill. This is expected to happen in the early fall when Congress reconvenes, though congressional staffs are reportedly working on resolving major differences now. Moreover, President Obama’s administration has indicated he would veto either version of the authorization bill if the final bill contained provisions, unrelated to telemedicine, to which the administration has consistently objected.

Have you read: States attempt to limit importance of MOC

Nevertheless, some version of a defense authorization bill usually passes annually and if the telemedicine provisions are left intact in the final version, they would overrule current state laws that define “location of care” in telemedicine for TRICARE members. Section 705 in Senate bill 2943 is designed to enhance telemedicine practice, but the trouble lies in subsection d, which states:

“For purposes of reimbursement, licensure, professional liability, and other purposes relating to the provision of telehealth services under this section, providers of such services shall be considered to be furnishing such services at their location and not at the location of the patient.”

To conclude, physicians should be aware that issues of licensing and scope of practice can arise in the most unlikely of places, and state laws and regulations are no longer the only source for these provisions. Physicians are encouraged to get involved in the political process and contact their senators and representatives.

Also from the AACU:

Single-payer proposals crop up at state, federal level

Competition-stifling facility regulations scrutinized nationwide

Increased use of telehealth prompts heightened legislative activity

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