The latest salvo in the federal government’s war on physicians

The latest salvo in the federal government’s war on physicians comes to us courtesy of the Veterans Health Administration (VHA), which is proposing drastic policy changes to expand nursing scope of practice in all veterans’ hospitals.

A new draft VHA Nursing Handbook would eradicate all existing VHA policies concerning physician supervision, and would designate all advanced practice registered nurses (APRNs), including nurse anesthetists, as licensed independent practitioners (LIPs).  This means that they would be able to practice on their own without any requirement for physician oversight or support.  In 2011, the Office of General Counsel upheld the VA’s claim of the right to authorize APRNs to function as independent practitioners “regardless of the scope of practice defined by their licensure.”

And if a nurse practitioner or a nurse anesthetist would rather practice in a care team with a physician, that’s too bad.  The new policy wouldn’t be optional.  As the Office of Nursing Services bluntly (if ungrammatically) stated in an explanatory document, “If the APRN does not want to attain independent status they would not be able to practice as an APRN in the VHA.”

The new VA policy would supersede any state law or individual hospital policy requiring physician supervision or defining limitations to nursing scope of practice.  ”A local policy that restricts APRN privileges is not appropriate,” the ONS document asserts, noting that APRNs are to function “at the top of their license” and that current medical staff bylaws in many VA hospitals “will most likely need to be revised.”

The long-standing VHA Anesthesia Service Handbook would be supplanted by the new rules.  It supports team-based care combining the different skills of physicians and nurses, and specifies that “care needs to be approached in a team fashion taking into account the education, training, and licensure of all practitioners.”  It also provides flexibility to individual VA Chiefs of Anesthesiology to set their own department’s policies.  These concepts, apparently, are now out of favor.

The California Society of Anesthesiologists (CSA) and the American Society of Anesthesiologists (ASA) strongly oppose the new proposed policies.  They note that patients in veterans’ hospitals are 14.7 times more likely to have poor health status than the general population, and 14 times more likely to have 5 or more medical problems, according to a study in JAMA Internal Medicine.  Veterans are more likely to have complications during a surgical procedure, and they deserve physician-level expertise on their anesthesia care teams.  CSA leaders Peter Sybert MD and Mark Zakowski MD were instrumental in obtaining the co-signatures of California Representatives Julia Brownley, Paul Cook, and Raul Ruiz MD on a letter to the Secretary of Veterans Affairs, urging the retention of the team care concept and the current policy directives in the VHA Anesthesia Service Handbook.

What can we do as individuals to speak up against the VHA’s proposed mandate for APRN independent practice? Contact our U.S. Representatives and Senators by phone or email.  For anesthesiologists, the ASA Grassroots Network  has drafted an email appropriate to send to lawmakers on the proposed VHA nursing policy changes, and will send it for you with your signature.  Or call your senators and U.S. representative at their offices and speak to their healthcare legislative aides.   The new policy handbook is nearing its final version, so timing is critical.  Our veterans deserve better.

Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center.  She blogs at A Penned Point.

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  • EmilyAnon

    Do you think the gov’t is test driving these new initiatives with the VA because their medical malpractice claims follow different rules than claims against private hospitals. Such as grievances aren’t heard in front of a jury and claims are time specific to 2 years.

    • EE Smith

      Plus, the VA has kind of a captive audience. It’s not like they have to worry about customer satisfaction. What are they going to say if a Vet objects to being treated by a nurse rather than a doctor? “Take it or leave it”.

      Government healthcare at its finest.

      • NPPCP

        Generally, they don’t. I have many vets come to my clinic and pay cash because they don’t want to drive to the VA. When they must sign understanding there are only Family Nurse Practitioners in the clinic, they usually say, “an NP takes care of me at the VA too.” So, NPs are already caring for our vets. I think they are just matching paper to current practice, in my opinion. Thank you.

        • Suzi Q 38

          You are probably right.

        • EE Smith

          It’s nice that some vets have *chosen* to see a nurse rather than a doctor, but that shouldn’t be imposed on them. Maybe a majority of them, if given the *choice*, would choose to have their medical care provided by nurses rather than doctors. But I don’t think it’s fair to impose that on them.

        • NPPCP

          I couldn’t agree with you more. It seems this is sort of a “creeping incrementalism” where, as said above, policy follows practice. I feel everyone should have a choice concerning the type of healthcare provider they wish to see. They do in the public realm; it should be the same at the VHA. I would hope if a vet wants to wait to see a physician (no matter how long the wait time), they should be able to do that – be it an intern, resident, or attending. If this is not the case, it is not right. This does not change my views on my ability to comprehensively care for a vet. It’s not about me – it’s about a person’s freedom to choose the type of caregiver they want.

          • EE Smith

            “I feel everyone should have a choice concerning the type of healthcare provider they wish to see.”

            100% agreement from here. If we had a freer market in health care, entrepreneurial NPs and PAs would be allowed to open independent practices and citizens would be allowed to choose where they wanted to be treated. There are pros and cons to choosing an NP, a PA, and an MD, but weighing them up and making an individual choice should be a citizen’s right. “One Size Fits All” anything, usually doesn’t.

      • Suzi Q 38

        Not just government healthcare…
        At the teaching hospital I was being treated at, I was seen by 2 or 3 NP’s. They did not make errors. They questioned whether or not I should have my hysterectomy, given I did not have additional diagnostic tests first.
        I wish I had been assigned an Np or a PA for my overall care. I was sent to the gyn/oncologist surgeon first thing.
        Four to five months later (after my hysto), I was finally sent to a neurologist for nerve sensations and weakness in my legs. If I had an NP or PA, I may have gotten to a specialist sooner…Not sure.

        My point is that the specialist didn’t know much about my secondary complaints after my hysto.
        Maybe a PCP or an NP would have taken charge of my overall care more.

        The hospital was obviously cutting corners and not wanting to assign me a PCP. I don’t know that they had any on staff.

    • Noni

      I think you’re right on the $$. I think the fact that they can’t sue and have no other real options (as other posters have pointed out) make it the prime area to practice cost cutting measures like those discussed in the article. And, if there are a high incidence of complications or adverse events these can be blamed on the patients or filed away in government storehouses never to be seen or heard about again.

      I can see why physician organizations are complaining on principle, but I’ve yet to meet a single physician who has clamored to work in a VA.

  • NPPCP

    I have attached a study concerning PAs and NPs increasing liability. They don’t; especially NPs. Perhaps studies like this are why they are test driving these new initiatives?

    http://www.paexperts.com/Nicholson%20-%20Hooker%20Article.pdf

    • Mengles

      Yes, nothing says unbiased like a website PA Experts Network:

      The PHYSICIAN ASSISTANT EXPERTS NETWORK is a resource for attorneys seeking expert medical opinions on the standard of care provided by Physician Assistants(PAs) and Advanced Practice Nurses (NPs), “mid-level” medical practitioners.

      Yup, completely no agenda there.

      • NPPCP

        Hi Mengles,
        So if one’s profession performs a study about one’s profession, it is always biased and invalid? Just getting that clear before that can of worms is opened. That is the website where I found it. The comment you made addresses nothing about the study and results; just a quick brush off. If an MD/DO funded study stated I was a danger to society and only physicians should lead teams, would it be worthless as well?

        • EE Smith

          “So if one’s profession performs a study about one’s profession, it is always biased and invalid?”

          No, no. I always go straight to AstraZenica’s web site when I’m looking for studies proving the off-label safety of various pharmaceuticals, and to ExxonMobile’s web site when I’m looking for studies showing how quickly nature bounces back after an oil spill.

          • NPPCP

            Wow. Okay. You guys are right. No since in even going forward. Just mocking. No mention of the study. Please continue mocking. Please don’t engage in an honest conversation. This is unbelievable. But expected.

        • Mengles

          “So if one’s profession performs a study about one’s profession, it is always biased and invalid?”
          It’s called CONFLICT OF INTEREST. Try looking up what that means.

          • NPPCP

            Yes, yes. Okay. You are right. I deserve the condescending attitude and the humiliating spanking for posting a study. Thank you. Thank you so much. What was I thinking? No since in talking about the study or the issue at hand. Gosh Dr. Mengles; if I only had a brain.

      • NPPCP

        Wow Mengles. Strawman. Diversion. No fact facing. What journal was the article published in? Why wouldn’t an article of this nature be on a site like that? It is relevant? Still. Nothing about the data, changing your post, and mocking.

  • buzzkillerjsmith

    I’m not gonna get into the whole MD-NP-PA cage fight, but I think the whole “top of license” stuff is pretty funny in a scary kind of way. Does that have any similarity to “running the engine in the red zone” or “leaving it all out on the field?” Maybe our overlords would like us to sacrifice ourselves for the good of the organization, using rhetoric as our race-dog rabbits.

    I don’t know about you, but the mere thought of working at the top of my license all day every day makes me want to take a nap. Better to stay somewhere between the top and bottom at least some of the time.

    • NPPCP

      Great insight as always.

  • Tiredoc

    Does anyone but me find the idea that VA nurses of any stripe should be given more autonomy strange? Why is the medical organization most plagued by institutional sloth attempting this?

    Knowing the VA, there are two possibilities, neither of which involve the arguments presented above. First, the supervising physicians don’t want to supervise. They’d much rather the N.A.s just do their job and don’t talk to them. Second, the N.A.’s feel that they’re overworked, and want the ability to bypass physicians in the scheduling of operations.

    It’s the VA, people. Always think lazy first.

  • guest

    My concern is about the direction of government policy not about NP’s in medicine. `I suppose I do believe that PCP’s are a necessity in medicine. If policies continue to replace PCP’s, eventually I assume they will become an extinct species. No more posts by our fave buzzkillerjsmith and Tiredoc. All extinct birds.

    • EE Smith

      There will still be doctors, it’s just that only the rich and the well-connected will have access to them.

      • guest

        If they continue to be destructive towards the field with this issue with the VA being the start, it is going to impact everyone eventually. Not sure about the billionaires, but the rich in general still have to use services.

        • Michael Rack

          Won’t impact the rich too much:

          1. Concierge care
          2. Some specialists (I know of some cardiologists who do this) do provide primary care services for patients without a pcp, and hire NP’s to help out with this.
          3. Good primary care will always be available for those able and willing to pay cold, hard cash (unless the gov makes this illegal).

          • NPPCP

            If those cardiologists work in a state where NPs practice on their own license – then it is a “win-win” for everyone. The cardiologist puts out the cash, creates a job, and takes no responsibility for the NPs diagnostic choices. The NP gets a job and practices freely taking full responsibility for every decision they make; a perfect setup.

  • MabelMabel

    With the VA being swamped, with long waiting lists, could this be a move to speed up the “assembly line?” The VA did something similar in the mental health area a few years ago. I’m really glad I don’t work there — it sounds like a nerve-wracking pressure cooker environment. But my heart breaks for the veterans and their loved ones, who deserve properly supervised care.

    • EE Smith

      If the VA is an example of how single-payer government-run healthcare would be provided in this country, it makes me very leery of it.

      • MabelMabel

        I totally agree. Although I want everyone to have equal access to necessary medical care, I am frightened at what the single-payer systems (Medicare/Medicaid) are doing. They keep lowering provider reimbursements, which lures private insurance companies to follow suit. What this has done to mental health providers is remove their ability to make a living — not get rich, mind you, just be able to pay their bills and save a bit toward a house, retirement, kids’ school, etc. I wonder, who will be left to provide medical care if one cannot make a living at it? Of course, one can “sell their soul” and work for the government….!

  • Suzi Q 38

    I think they are merely preparing for the Obamacare cuts.

    I can see where NP’s. PA’s, and nurse anesthetists could “fill in” when it gets very busy, but this is a huge step. Their message is loud and clear.
    A more direct message than I ever thought would occur at the advent of a new healthcare system.

    I had always thought that the Va was a very busy and “crazy” place, with all of its needy patients and physicians plus other hospital personnel.
    That being said, my father in law got very good care there after his major strokes.
    I am trying to envision more NP’s instead of physicians. He did not have a PCP. He had two neurologists overseeing his care.

  • Morgan

    There is a difference between oversight and collaboration. All nurse practitioners collaborate when working with a case for which they are inexperienced. It doesn’t have to be written in a legal agreement, it occurs naturally as part of their professional practice. Nurse practitioners are highly educated health care providers. The nursing model of care is similar to the medical model and includes assessment, diagnosis, outcomes identification, planning, implementation, and outcome analysis. The educational preparation of an NP begins at an undergraduate level and continues throughout their educational and professional careers.

    I have posted below the “core courses” in the ACNP curriculum. Not included below is the admissions examinations for undergraduate consideration in basic sciences and math (ATI TEAS or NET), the requirement for all students to achieve a B or better to maintain enrollment in nursing school, the two sets of boards/licensing exams, and the specialty certifications NPs obtain throughout their training. I just wanted to emphasize that, while NPs approach patients from a holistic viewpoint, their education and practice is not entirely different from their MD peers. They have a grounded science foundation which prepares them for the second step of being a student..their experience as a new clinician.

    I do not believe any new graduate NP or MD student is experienced enough to practice autonomously, but I do believe there should be an endpoint to both their proctored/guided experience followed by a supported transition into collaborative (not supervised) practice.

    The Nurse Practitioner Pathway: Adult Acute Care

    1. Prerequisites- BSN Admissions: (GPA must be >3.5 in prerequisites)

    Biology, Chemistry, Organic Chemistry, Biochemistry, Statistics, Nutrition, Psychology, Sociology, Cultural Anthropology, Developmental Psych, Life-Span Human Growth and Development, Human Anatomy & Lab, Human Physiology & Lab.

    2. BSN (4 years):

    Clinical Microbiology & Lab, Genomics, Med/Surg Didactic & Clinical, Health Assessment & Lab, Med/Surg Didactic II & Clinical , Clinical Lab, Human Pathophysiology, Pharmacology, OB Didactic & Clinical, Pediatric Didactic & Clinical, Adult Health/Gero I Didactic & Clinical, Psych/Mental Didactic & Clinical, Research, Adult Health/Gero II Didactic & Clinical, Community Health Didactic & Clinical, Ethics

    3. MSN ANCP Courses: (2-3 years)

    Adult Acute Care Theory I, Strategy & Healthcare, Advanced Pharmacology (P695 & P660), Policy & Healthcare, Graduate Research, Graduate Statistics, Advanced Physiology & Pathophysiology, Advanced Health Assessment Lab/Lab Models, APRN Role/Negotiating, Adult/Gero Acute Care Didactic I & Clinical, Adult/Gero Acute Care Didactic II & Clinical, Adult/Gero Acute Care Didactic III & Clinical, Acute/Critical Care Lab (chest tube placement, central lines, LPs, ECG/Dx imaging interpretation, etc), 699 Thesis Project

    4. DNP Courses: (1-2 years)

    Graduate Statistics (800), Epidemiology (802), Scientific Foundations, Health Informatics, Clinical Leadership, Quality & Safety Improvement, Policy Analysis, Thesis/Capstone Defense, Implementation Science (N900), DNP Residency, DNP Capstone

  • Robert Luedecke

    The VA also keeps track of morbidity and mortality. If you can’t stop it, that is the best way to tackle this problem is to show it hurts people.