Advanced Practice Nursing

Advanced Practice Nursing Interim Study Proposal 2007-238 December 18, 2008 Prepared for Rep. Sandra Prater and Rep. Clark Hall Bureau of Legislative Research Project Number 08-286

Table of Contents About This Study...1 Executive Summary...2 Background...4 Advanced Practice Nurse...4 State Licensing...4 Prescriptive Authority...4 Collaborative Agreements...5 State Laws and Policies...6 Arkansas...6 Alaska...7 Arizona...8 Idaho...9 Iowa...10 Maine...11 Montana...12 New Hampshire...13 New Mexico...14 Oregon...15 Utah...16 Washington State...17 Washington D.C....18 Wyoming...19 Other States...20 Health Care Expenditures...21 Total Health Care Expenditures...21 Expenditures: Hospital Care...22 Expenditures: Physician and Other Professional Services...23 Expenditures: Drugs and Other Medical Nondurables...24 Access to Health Care...25 Population Lacking Primary Care, 2007...25 Population Lacking Primary Care, 1992-2007...26 Rate of Physicians in Primary Care, 2006...27 Rate of Physicians in Primary Care, 1992-2006...28 Rate of Physicians in General/Family Practice, 2006...29 Rate of Physicians in General/Family Practice, 1992-2006...30 Primary Care Doctors as Percent of All Doctors...31 Rate of Advanced Practice Nurses...32 Rate of Nurse Practitioners...33 Arkansas's Medically Underserved Areas...34 Area Health Education Centers...35 Community Health Centers of Arkansas...36 Family and General Practice Physicians per 10,000 Population...37 Nurse Practitioners with Prescriptive Authority per 10,000 Population...38 Adverse Actions for Advanced Practice Nurses...39 Adverse Actions in States That Repealed Collaborative Agreement Requirements...40 Hospital Emergency Room Visits...43 Page i

State Health Indicators...44 State Health Ranking...44 Teen Births...45 Births to Women Receiving Late or No Prenatal Care...46 Low Birth Weight Babies...47 Infant Mortality...48 Heart Disease Deaths...49 Page ii

About This Study This study examines the policies and some general health indicators in the 12 states and Washington D.C. that do not require nurses to enter collaborative agreements with physicians. This study also examines the policies in Arkansas, where collaborative agreements are required. The first section of this study provides some background on nursing and describes how states typically license these healthcare professionals. The next section compares individual states' laws and policies regarding collaborative agreements and. The remaining sections examine whether fewer restrictions on nurses' authority (i.e., the elimination of collaborative agreements) has any real effect on a state's health expenditures, access to health care professionals and services, or overall health statistics. Representatives from the Arkansas Nurses Association and the Arkansas State Nursing Board helped develop the structure of this report and determined what types of information should be collected. The state health outcome indicators, such as the infant mortality rate, were selected as measures of each state's basic medical care. Advanced practice nurses, particularly nurse practitioners, focus on disease prevention and primary care. The Arkansas Medical Society was also asked to suggest additional health statistics that should be compared. David Wroten, Executive Vice President of the Arkansas Medical Society, objected to the study's structure, noting, "The primary problem with that analysis is that it requires making a determination that the differences in health statistics between these states is somehow related to whether or not nurses are required to have a collaborative practice agreement." Instead he suggested comparing the health statistics within a state that previously had a collaborative practice requirement, then repealed it. However, he cautioned that such a study also would have to determine whether any other factors led to the change in statistical health data. Wroten also suggested examining access to primary care in rural counties in states that have repealed collaborative agreement requirements. He suggested looking at the county-by-county distribution of primary care physicians and nurses in those states before and after a collaborative agreement has been repealed. Some of the data Wroten suggested obtaining was collected, and additional charts were included in this report. However, in many cases, the data either was not available or was too limited. Additional analyses may be warranted. Page 1

Executive Summary Most states allow nurses (APNs) to prescribe medications, including controlled substances. However, many, including Arkansas, grant to APNs only if they enter into a written collaborative agreement with a physician. The nursing community sees this requirement as an unnecessary additional burden on an APN's practice. The nursing community believes that if APNs were given more autonomy, they could increase patients' access to care, especially in rural areas that struggle to attract physicians. Because it costs less to see an APN than a physician, APNs practicing more independently could offer access to more affordable care for the state's under-insured or uninsured, the nursing community believes. In Arkansas, 16.8% of the population is uninsured and nearly 23% of the population is enrolled in Medicaid. The physician community, on the other hand, contends that APNs have not had as much training as physicians and should not be allowed to prescribe dangerous medications, including controlled substances, without the oversight of a physician. The safety of patients could be compromised, the physician community believes. Twelve states and Washington D.C. either have never had collaborative agreement requirements, eliminated existing collaborative agreement requirements, or redefined collaboration in a way that effectively eliminated the restrictions they placed on APNs. Seven of the 12 states eliminated existing collaborative agreement requirements. Alaska was the first in 1984, and last year, the state of Washington became the latest state to eliminate its collaborative agreement requirement. This study also examined state health and health care data to see whether the states with the fewest practice restrictions on APNs did better or worse than the national average on selected measures. This study found few trends either way. On total health care expenditures, four states and the District of Columbia had higher costs than the national average, while eight states' costs were lower. In about half the states, a greater percentage of the population than the national average lives in an area considered to be underserved by primary care physicians, while in the other half of the states a smaller percentage than the national average lives in underserved areas. Not surprisingly, a similar state breakdown occurred for the number of primary care physicians per 100,000 population in each state. The term "primary care physicians" refers to family and general practice doctors, internists, pediatricians, obstetricians, and gynecologists. Data on the rate of general or family practice doctors exclusively presents a different picture. Only two of the 12 states Utah and Arizona have rates below the national average. That means that most of the states that do not have a collaborative agreement requirement have more general and family practice doctors to serve their population. There is no national average for the number of nurses per 100,000 population because no organization reliably collects and analyzes that data. However, this study collected the information for the 12 states examined and the District of Columbia. Washington D.C., Alaska, and New Hampshire, which were the first to eliminate their collaborative agreement requirements, have some of the highest rates of APNs. Those two states and Washington D.C. also had the highest rates of nurse practitioners. Page 2

Executive Summary This study took a closer look at the primary care staffing patterns in Arkansas. The state Department of Health map on page 34 shows the areas of the state that are federally designated as being medically underserved. Fifty-nine of the state's 75 counties are designated as being medically underserved across the entire county, while portions of another 14 counties are medically underserved. Two counties have no medically underserved areas. Currently the number of nurse practitioners with per 10,000 population is most heavily concentrated in central Arkansas. Pulaski, White, Izard and Pike counties had the highest rates of nurse practitioners. The rate of family and general practice doctors is more widely spread throughout the state, with the heaviest concentrations in south and northeast/north central Arkansas. The number of adverse actions disciplinary sanctions, malpractice payments, and other similar issues against nurses is relatively low, according to data from the federal National Practitioner Data Bank and the Health Integrity and Protection Data Bank. The data banks do not document a rate of adverse actions for nurses, nor a national average. Still, there were rarely more than 10 adverse actions reported annually for any of the states examined in this study. This study also examined the number of adverse actions in each state that previously had a collaborative agreement requirement and then repealed it. The data found no increasing or decreasing trend in the number of adverse actions after the collaborative agreement requirement was repealed. Eight of the 12 states had a lower rate of emergency room visits than the national average. In the ranking of the states in overall health, which is published annually by the UnitedHealth Foundation, the states without a collaborative agreement requirement ranked everywhere from 1st to 41st. However, all states ranked higher (i.e., healthier) than Arkansas. The states that eliminated collaborative agreements generally had lower teen birth rates, lower rates of mothers without prenatal care, lower percentages of low birth-weight babies, and lower infant mortality rates than the national averages. All 12 states examined in this study had lower heart disease deaths than the national average. Only the District of Columbia's rate exceeded the national average. While the data found that states without collaborative agreement requirements had similar statistics in child birth indicators and heart disease deaths, this study does not address whether those statistics are the result of fewer restrictions on nurses. Page 3

Background Advanced Practice Nurse An nurse (APN), also known as registered nurse (APRN), is an umbrella term used to describe nurses with advanced clinical experience and a high level of nursing education generally a master's degree or higher. These nurses are more advanced than licensed practical nurses (LPNs) and regular registered nurses (RNs). In many states nurses can operate their own practices and bill for services, separate from a physician's clinic. They have the authority to diagnose and prescribe medications, including controlled drugs. Under this umbrella group, there are four types of nursing specialties/licenses that are commonly considered. Nurse practitioners work in clinics, nursing homes, and hospitals to provide primary and preventive health care services, prescribe medication, and diagnose and treat common minor illnesses and injuries. Certified nurse midwives provide well-woman gynecological and low-risk obstetrical care. They attend births in hospitals, birthing centers, and private homes. Clinical nurse specialists work in hospitals, clinics, and nursing homes and specialize in a particular area of medicine, such as geriatrics, cardiology, or critical care. Certified registered nurse anesthetists (or certified nurse anesthetists) administer anesthesia in collaboration with surgeons, anesthesiologists, and dentists. They practice in every setting in which anesthesia is delivered, including hospitals, surgical centers, and dental offices. State Licensing Each state licenses nurses differently. Some states, like Arkansas, license each of the four types through one section of law dealing with nursing. Others have no umbrella grouping spelled out in law, but license two or three types individually. Prescriptive Authority In many states, nurses are given the authority to prescribe medications, including controlled substances. Some states automatically grant to nurses when they become licensed, while others, including Arkansas, require nurses to apply for separately. Many states only grant after APNs have fulfilled additional requirements, such as completing a course in pharmacology or a year prescribing under the direct supervision of a physician. Page 4

Background All states examined in this study, except Arkansas, allow nurses to prescribe controlled substances for schedules II-V. Arkansas does not allow them to prescribe schedule II medications, which include Ritalin, OxyContin, methadone, and morphine. Collaborative Agreements Some states, such as Arkansas, place restrictions on APNs' by requiring them to document a "collaborative agreement" with a licensed physician. A collaborative agreement is meant to ensure that licensed physicians with the most extensive medical training are involved in the prescriptions that patients receive from APNs. At least one state, Vermont, requires nurses to enter collaborative agreements with physicians in order to be licensed as nurses. Some states require APNs to be supervised by a physician if they want to prescribe. State laws typically define physician "supervision" as a more restrictive arrangement than "collaboration." While many states call for a collaborative agreement or collaboration, the actual level of physician involvement varies from state to state. Some states require minimal involvement defining "collaborating" as simply consulting with a physician as needed. Others require APNs to sign a written agreement with a physician defining practice protocols the APN will use, the method and regularity of communication between the doctor and APN, and the level of oversight physicians will have over the APNs' prescriptions. Page 5

State Laws and Policies Arkansas What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Advanced registered nurse practitioner Certified registered nurse anesthetist Certified nurse midwife Clinical nurse specialist Advanced registered nurse practitioner: 900 Certified registered nurse anesthetist: 414 Certified nurse midwife: 21 Clinical nurse specialist: 116 Total: 1,451 Advanced registered nurse practitioner: 794 Certified registered nurse anesthetist: 0 Certified nurse midwife: 14 Clinical nurse specialist: 66 Total: 874 In 1995, Arkansas began licensing nurses and granting them for controlled substances for schedules III-V. In order to prescribe, Arkansas law (17-87-310) requires APNs to have a collaborative practice agreement with a physician who has a practice comparable in scope, specialty, or expertise to that of the APN. Yes. APNs with can prescribe controlled medications in schedules III-V controlled drugs. They cannot prescribe schedule II. APNs must complete pharmacology coursework, including three graduate credit hours of pharmacology from an accredited college or university, 45 contact hours in a pharmacology course, and three graduate credit hours of pharmacology included as part of an nursing education program. They must also have had at least 300 hours of preceptorial experience in the prescription of drugs, medicines, and therapeutic devices with a qualified preceptor. Source: Arkansas State Board of Nursing Page 6

State Laws and Policies Alaska What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Advanced nurse practitioner Registered nurse anesthetist Advanced nurse practitioner: 671 Registered nurse anesthetists: 147 Total: 818 Alaska does not track electronically the number of APNs with. However, the Alaska Board of Nursing's executive administrator estimates that over 90% of the nurse practitioners (about 600) have. She estimates that only about 20% of registered nurse anesthetists (about 30) have. Alaska has no statute addressing the relationship between physicians and APNs. However, in 1984 new regulations took effect allowing independent practice for APNs, granting them and abolishing the collaborative agreement requirement. Yes. Advanced nurse practitioners automatically receive for legend drugs when they receive a license if they request it. They can apply for for controlled drugs after one year of prescribing. Mental health/psychiatric advanced nurse practitioners, however, can request an exemption and receive immediate authorization to prescribe controlled substances. Advanced practice nurses are limited to prescribing only legend drugs for the first year. Then they can prescribe controlled drugs schedules II-V. For authority to prescribe legend drugs, the regulations require 15 contact hours of education in pharmacology and clinical management of drug therapy within the two years before applying for. For authority to prescribe controlled substances, the regulations require one year of experience prescribing legend drugs. Source: Alaska Board of Nursing Page 7

State Laws and Policies Arizona What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Registered nurse practitioners (including nurse midwives) Clinical nurse specialists Registered nurse practitioners (including nurse midwives): 3,170 Clinical nurse specialists: 158 Total: 3,328 Arizona also has 557 certified registered nurse anesthetists, but unlike many other states, Arizona rules do not put certified nurse anesthetists under the umbrella. Registered nurse practitioners: 2,826 Clinical nurse specialists cannot prescribe medications. In Arizona, 478 certified registered nurse anesthetists also have. Advanced practice nurses were formerly required to list the physician with whom they would be collaborating, but in 2001 the Nursing Board eliminated that requirement and changed the definition of "collaborate" in the administrative code. According to the new definition, "collaborate" means "to establish a relationship for consultation or referral with one or more licensed physicians on an as-needed basis. Direct or onsite supervision of the activities of a registered nurse practitioner by the collaborating physician is not required." Yes. Registered nurse practitioners can prescribe medications within their specialty, including controlled substances schedules II-V. Clinical nurse specialists can prescribe durable medical equipment, but cannot prescribe any medications. To obtain, nurses must have a minimum of 45 contact hours of education within the last three years. The contact hours must include either pharmacology or clinical management of drug therapy. Source: Arizona State Board of Nursing Page 8

State Laws and Policies Idaho Categories of APN Certified nurse midwife Clinical nurse specialist Nurse practitioner Registered nurse anesthetist Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Certified nurse midwives: 27 Clinical nurse specialists: 33 Nurse practitioners: 540 Registered nurse anesthetists: 373 Total: 973 Certified nurse midwives: 27 Clinical nurse specialists: 16 Nurse practitioners: 535 Registered nurse anesthetists: 50 Total: 628 In 1998, Idaho gave nurses prescriptive authority for all legend drugs and controlled substances schedules II-V, but all prescribing had to be done under the supervision of a physician. In 2004, the physician supervision requirement was removed. Yes. Advanced practice nurses can prescribe legend drugs and controlled substances schedules II-V. To obtain, nurses must complete 30 contact hours of post-basic education in pharmacotherapeutics. Source: Idaho Board of Nursing Page 9

State Laws and Policies Iowa What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Additional educational requirements for There are four types of advanced registered nurse practitioners: Certified clinical nurse specialist Certified nurse midwife Certified nurse practitioner Certified registered nurse anesthetist Certified nurse practitioners: 1,186 Family nurse practitioners: 636 Pediatric nurse practitioners: 180 School nurse practitioners: 2 Women's health care nurse practitioners: 153 Psychiatric/mental health nurse practitioners: 41 Adult nurse practitioner: 84 Gerontological nurse practitioners: 45 Neonatal nurse practitioners: 17 Acute care nurse practitioners: 27 Perinatal nurse practitioners: 1 Certified nurse midwives: 75 Certified registered nurse anesthetists: 464 Clinical nurse specialists:105 Total: 1,830 All 1,830 nurse practitioners, nurse midwives, nurse anesthetists and clinical nurse specialists have for legend drugs. To prescribe controlled substances, advanced registered nurse practitioners must become registered with the Iowa Board of Pharmacy, which cannot separate out the number with a controlled substance registration. Advanced registered nurse practitioners have always been allowed to practice independently, but in 1992, they were given for some medications. In 1994, they were granted authority to prescribe controlled substances. A Nursing Board rule still requires collaborative agreements when the advanced registered nurse practitioner performs "medically delegated functions," but it doesn't strictly define "collaborative agreement" nor "medically delegated functions." No, not to prescribe legend drugs. However, advanced registered nurse practitioners must register with the Iowa Board of Pharmacy if they want to prescribe controlled substances. Once they are registered with the federal Drug Enforcement Administration and the Iowa Board of Pharmacy Examiners, they can prescribe controlled substances schedules II-V. All that is required is completion of a master's degree program in a nursing clinical specialty area and completion of an advanced practice educational program of study in a nursing specialty area. There is no additional requirement for. Source: Iowa Board of Nursing Page 10

State Laws and Policies Maine What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Certified nurse practitioner Certified nurse midwife Certified registered nurse anesthetist Certified nurse specialist Certified nurse practitioners: 922 Certified nurse midwives: 84 Certified registered nurse anesthetists: 412 Certified nurse specialists:154 Total: 1,572 Certified nurse practitioners: 922 Certified nurse midwives: 84 Total: 1,006 All certified nurse practitioners and certified nurse midwives have, but certified registered nurse anesthetists and certified nurse specialists do not have. Maine has never had legislation on collaborative agreements, but a rule change in 1997 allowed APNs to practice independently. Graduates of nurse practitioner programs must practice for at least 24 months under the supervision of a physician or supervising nurse practitioner or be employed by a clinic or hospital with a physician medical director. No. All certified nurse practitioners and certified nurse midwives are authorized to prescribe drugs related to their specialty area, including controlled substances schedules II-V. Certified nurse practitioners and certified nurse midwives who have not prescribed in the previous two years must complete 15 contact hours of pharmacology Source: Maine State Board of Nursing Page 11

State Laws and Policies Montana What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Nurse practitioner Midwife Anesthetist Clinical specialist Nurse practitioners: 468 Midwives: 47 Anesthetists: 185 Clinical specialists: 41 Total: 741 509 Montana does not track this statistic by type of nurse. Montana has never required physician supervision or collaborative agreements. Yes. Montana Administrative Rules allow nurses to prescribe "prescription drugs in the prevention of illness, the restoration of health, and/or the maintenance of health," including controlled substances schedules II-V. To obtain, nurses must complete 15 hours in pharmacology and/or the clinical management of drug therapy. Source: Montana Board of Nursing Page 12

State Laws and Policies New Hampshire What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for One category: advanced registered nurse practitioner 1,350 1,350 New Hampshire advanced registered nurse practitioners have been allowed to practice independently since the 1980s, but until 1991 they could prescribe only under physician supervision. That year they were given independent. No. New Hampshire statute provides all advanced registered nurse practitioners with full for controlled and noncontrolled medications. However, a group known as the Joint Health Council produces an exclusionary formulary, which lists the drugs that advanced registered nurse practitioners cannot prescribe or can only prescribe within certain limitations. General advanced registered nurse practitioners certification requires completion of at least five hours in pharmacology. Source: New Hampshire Board of Nursing Page 13

State Laws and Policies New Mexico What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Certified nurse practitioners Certified nurse specialists Certified registered nurse anesthetists Certified nurse practitioners: 710 Certified nurse specialists: 146 Certified registered nurse anesthetists: 199 Total:1,055 The nursing board could not provide exact numbers of advanced practice nurses with, but the associate director guessed that all nurse practitioners and certified registered nurse anesthetists have, and about half of the certified nurse specialists have it. The New Mexico statute was changed in 1991 to establish independent practice for certified nurse practitioners, registered nurse anesthetists, and clinical nurse specialists. Nurse practitioners received the authority to prescribe controlled drugs in 1993. Clinical nurse specialists received that authority in 1997 and certified registered nurse anesthetists received it in 2001. Yes. All three categories can obtain authority to prescribe controlled substances, schedules II-V within their clinical specialty and practice setting. To be granted, all APNs must complete 400 hours of work experience in which prescribing dangerous drugs has occurred within the two years prior to applying for prescriptive authority or 400 hours of prescribing in a preceptorship. In addition to the 400 hours, certified nurse specialists are required to complete a three-credit-hour pharmacology course, a three-credit-hour assessment course and a three-credit-hour pathophysiology course that are included as part of a graduate level nursing education program. Source: New Mexico Board of Nursing, New Mexico Legislative Council Service Page 14

State Laws and Policies Oregon What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Nurse anesthetists Clinical nurse specialists Nurse practitioners (This category includes nurse midwives.) Only nurse practitioners and clinical nurse specialists are granted. Nurse practitioners 2,150 Certified registered nurse anesthetists: 440 Clinical nurse specialists: 180 Total: 2,770 Nurse practitioners: 2,250 Clinical nurse specialists: 12 Nurse anesthetists are not granted. Oregon has never had a collaborative agreement requirement. Clinical nurse specialists and nurse practitioners were granted in 1979 for controlled drugs schedules III-V and in 2001 for schedule II. Yes. Oregon Administrative Rules require all applicants for a nurse practitioner license to obtain prescribing authority. Schedules II-V For, clinical nurse specialists and nurse practitioners must complete 45 contact hours of pharmacology and a directly supervised clinical practicum of at least 150 hours. Source: Oregon State Board of Nursing Page 15

State Laws and Policies Utah What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Utah recognizes two types of registered nurses: Advanced practice registered nurse Advanced practice registered nurse-certified registered nurse anesthetist Advanced practice registered nurses: 1,209 Advanced practice registered nurse-certified registered nurse anesthetists: 398 Total: 1,607 Utah also licenses 131 certified nurse midwives, but does not consider these nurses to be. Advanced practice registered nurses: 1,147 Advanced practice registered nurse-certified registered nurse anesthetists: 0 (APRN-CRNAs do not have. Instead, 189 of them are granted the authority to administer controlled substances.) Total: 1,147 Additionally, five certified nurse midwives have prescriptive authority. Advanced practice registered nurses have had prescriptive authority for at least the last two decades. However, until about 13 years ago, they were required to prescribe controlled substances only in consultation with a physician. Since the law changed in 1995, registered nurses have been allowed to prescribe controlled substances schedules IV and V without physician consultation. They still need a written physician consultation plan if they want to prescribe schedules II and III. Yes. Advanced practice registered nurses can independently prescribe schedules IV-V, and they can prescribe schedules II-III in accordance with a consultation and referral plan. "Consultation and referral plan" is defined as "a written plan jointly developed by an registered nurse and a consulting physician." No additional requirement beyond those required for APRN licensing. Licensing requirements include three courses in diagnosis and treatment, patient assessment, and pharmacotherapeutics. Source: Utah Division of Occupational and Professional Licensing Page 16

State Laws and Policies Washington State What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Washington recognizes advanced registered nurse practitioners (ARNPs) and designates 10 specialties, including certified registered nurse anesthetist and certified nurse midwife. ARNP-acute care nurse practitioners: 43 ARNP-adult nurse practitioners: 549 ARNP-certified nurse midwifes: 345 ARNP-certified registered nurse anesthetists: 683 ARNP-family nurse practitioners: 1,709 ARNP-geriatric nurse practitioners: 95 ARNP neonatal nurse practitioners: 71 ARNP-pediatric nurse practitioners: 248 ARNP psychiatric mental health nurse practitioners: 496 ARNP-women's health care nurse practitioners: 269 Total: 4,508 1,413 Washington first granted in 1979. In 1988 the state began licensing nurses, and in 1992 ARNPs obtained the ability to prescribe controlled substances. The statute was expanded in 2000 to allow ARNPs to prescribe schedule II drugs but only under a Joint Practice Agreement. The Joint Practice Agreement language was repealed by the legislature in 2007. Yes. Schedules II-V. Washington law specifically prohibits ARNPs from prescribing schedule I. Washington requires 30 contact hours of education in pharmacotherapeutics. Source: Washington State Department of Health, Nursing Care Quality Assurance Commission Page 17

State Laws and Policies Washington D.C. What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Four types of nurse practitioners: Nurse practitioner Nurse anesthetist Clinical nurse specialist Nurse midwife Nurse practitioners: 827 Nurse anesthetists: 147 Clinical nurse specialists: 46 Nurse midwives: 81 Total: 1,101 Nurse practitioners: 827 Nurse anesthetists: 147 Clinical nurse specialists: 46 Nurse midwives: 81 Total: 1,101 Nurse anesthetists, certified nurse midwives, and nurse practitioners were first licensed as nurse practitioners in 1984. Clinical nurse specialists were not included then because they were licensed and allowed to practice independently under another law. At that time, nurses were required to practice in collaboration with physicians direct, immediate, or general collaboration. They also were required to have a protocol agreement with a physician in order to prescribe. In 1994 that law was amended to included clinical nurse specialists and to allow nurses to perform actions of medical diagnosis, treatment, prescription. It repealed the collaboration requirement. The District of Columbia now requires nurses to carry out acts of APRNs in collaboration with a licensed health care provider. This does not require a collaboration agreement. It just requires APRNs to collaborate with other health professionals as appropriate in the course of their practice. No. Schedules II-V In granting, the District of Columbia does not require any additional education beyond that required for licensing. Source: District of Columbia Board of Nursing Page 18

State Laws and Policies Wyoming What categories of nursing does the state recognize? Total number of nurses Number of APNs with Statutory and regulatory history Does an APN need a separate certification to prescribe? What schedule drugs can APNs prescribe? Educational requirements for Four categories of registered nurse Clinical specialist Nurse practitioner Certified registered nurse midwife Certified registered nurse anesthetist Nurse practitioners: 261 Certified registered nurse midwives: 14 Certified registered nurse anesthetists: 165 Clinical specialists: 18 Total: 458 Nurse practitioners: 241 Certified registered nurse midwives: 13 Certified registered nurse anesthetists: 6 Clinical specialists: 15 Total: 275 The Wyoming Nurse Practice Act was changed in 2005 to establish APNs as independent practitioners and eliminate the collaborative agreement requirement. Yes. Schedules II-V To obtain, APNs must complete two semester credit hours, three quarter credit hours, or 30 contact hours of course work approved by the Wyoming State Board of Nursing in pharmacology and clinical management of drug therapy or pharmacotherapeutics. They also must complete 400 hours of advanced nursing practice. Source: Wyoming State Board of Nursing Page 19

State Laws and Policies Other States Three other states are considering or have recently considered a rule change or legislation to eliminate their collaborative agreement requirements. Vermont Since 1984, Vermont's administrative rules have required registered nurses to have a collaborative agreement with a physician. (The state's laws do not address collaborative agreements.) Unlike in Arkansas, where APNs must have a collaborative agreement to prescribe, in Vermont, APRNs must have a collaborative agreement to be licensed as APRNs. The Vermont State Board of Nursing is currently trying to change its rules to eliminate the collaborative agreement requirement. The board, which anticipates opposition to the rule change, would like to eliminate the requirement for licensing and for. Nebraska Nebraska law requires nurse practitioners who want to prescribe to have a written "integrated practice agreement" with a collaborating physician. The statute states that the nurse practitioner and the physician have "joint responsibility for patient care," and it gives the physician responsibility for the "supervision" of the nurse practitioner. The law defines supervision as "the ready availability of the collaborating physician for consultation and direction of the activities of the nurse practitioner." During the state's regular session earlier this year, the legislature considered a bill that would have eliminated the integrated practice requirement for nurse practitioners who have practiced as a nurse practitioner for at least five years. The bill did not pass and was "indefinitely postponed." New York New York law allows nurse practitioners to diagnose and treat patients "in collaboration with a licensed physician." It also requires nurse practitioners to have a "written practice agreement" and "written practice protocols." Any prescriptions written by the nurse practitioner must also be covered under the practice agreement and protocols. Two bills were introduced in the state's 2008 legislative session that would have eliminated the requirement that nurse practitioners collaborate with a physician. Both bills were sent to committees, where they remained through the session's end. Page 20

Health Care Expenditures Total Health Care Expenditures Per capita by state of residence, 2004 D.C. ME AK $6,540 $6,450 $8,295 NH IA U.S. WY WA MN OR AR NM ID AZ UT $5,432 $5,380 $5,283 $5,265 $5,092 $5,080 $4,880 $4,863 $4,471 $4,444 $4,103 $3,972 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 Source: The Henry J. Kaiser Family Foundation, www.statehealthfacts.org Page 21

Health Care Expenditures Expenditures: Hospital Care Percent of each state's total health care expenditures, 2004 D.C. MT WY AK MN IA AR U.S. ID UT AZ NH ME OR WA 41.3% 41.1% 40.2% 39% 38.9% 38.1% 37.7% 37.1% 36.1% 36.1% 35.7% 35.3% 34.3% 33.9% 49.2% 30 35 40 45 50 Source: The Henry J. Kaiser Family Foundation, www.statehealthfacts.org Page 22

Health Care Expenditures Expenditures: Physician and Other Professional Services Percent of each state's total health care expenditures, 2004 OR AZ WA AK WY ID UT MT AR U.S. NH ME IA NM D.C. 23.4% 29.6% 28.6% 28.3% 28.3% 28.3% 28.2% 28.2% 27.7% 26.9% 26.4% 33.4% 33% 32.8% 32.7% 20 25 30 35 Source: The Henry J. Kaiser Family Foundation, www.statehealthfacts.org Page 23

Health Care Expenditures Expenditures: Drugs and Other Medical Nondurables Percent of each state's total health care expenditures, 2004 UT AR AZ U.S. NH ID NM IA ME WA OR WY MT AK D.C. 7.2% 14.5% 14.3% 13.9% 13.7% 13.5% 13.3% 12.7% 12.2% 12% 11.7% 11.3% 10.6% 9.9% 16.6% 5 10 15 20 Source: The Henry J. Kaiser Family Foundation, www.statehealthfacts.org Page 24

Access to Health Care Population Lacking Primary Care, 2007 This table shows the percent of the population living in an area designated by the U.S. Department of Health and Human Services (DHHS) as being underserved by primary care physicians in 2007. Primary care doctors include family or general practice physicians, internists, pediatricians, obstetricians, and gynecologists. An underserved area has a limited number of doctors for the population. D.C. NM WY MT ID AZ UT U.S. AK AR WA IA OR ME NH * N/A 13.1% 11.4% 11.1% 10.6% 9.8% 9.1% 7.7% 6.4% 5.9% 5.3% 16.9% 20.5% 20.2% 30% 0 5 10 15 20 25 Source: Health Care State Rankings 2008 *The Health Care State Rankings data did not include Washington D.C. Page 25

Access to Health Care Population Lacking Primary Care, 1992-2007 This table shows the percent of the population living in an area designated by the U.S. Department of Health and Human Services (DHHS) as being underserved by primary care physicians. Primary care doctors include family or general practice physicians, internists, pediatricians, obstetricians, and gynecologists. An underserved area has a limited number of doctors for the population. Data on this measure for 1997 was not included in the Health Care State Rankings series. 30 U.S. AK 25 AZ AR 20 ID IA 15 ME MT 10 NH NM 5 OR 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: Health Care State Rankings series *The Health Care State Rankings data did not include Washington D.C. UT WA WY Page 26

Access to Health Care Rate of Physicians in Primary Care, 2006 Total primary care physicians per 100,000 population *D.C. ME OR WA AK NH U.S. NM MT WY AR AZ UT IA ID 84 82 76 76 71 70 91 109 107 105 104 104 99 97 243 50 100 150 200 Source: Health Care State Rankings 2008 *The Health Care State Rankings data did not include Washington D.C. Instead, the rate for the District of Columbia was calculated by using data from the American Medical Association and the U.S. Census Bureau. Page 27

Access to Health Care Rate of Physicians in Primary Care, 1992-2006 Total primary care physicians per 100,000 population 110 100 U.S. AK AZ AR 90 ID IA 80 70 60 ME MT NH NM OR UT 50 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 WA WY Source: Health Care State Rankings series *The Health Care State Rankings data did not include Washington D.C. Page 28

Access to Health Care Rate of Physicians in General/Family Practice, 2006 Total general/family practice physicians per 100,000 population AK WY WA MT ME AR NM IA ID OR *D.C. NH U.S. UT AZ 25 30 29 49 47 47 46 44 41 39 39 38 37 37 58 0 10 20 30 40 50 60 70 Source: Health Care State Rankings 2008 *The Health Care State Rankings data did not include Washington D.C. Instead, the rate for the District of Columbia was calculated by using data from the American Medical Association and the U.S. Census Bureau. Page 29

Access to Health Care Rate of Physicians in General/Family Practice, 1992-2006 Total general/family practice physicians per 100,000 population 60 55 50 U.S. AK AZ AR ID 45 40 35 30 25 20 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 IA ME MT NH NM OR UT WA WY Source: Health Care State Rankings series *The Health Care State Rankings data did not include Washington D.C. Page 30

Access to Health Care Primary Care Doctors as Percent of All Doctors Nonfederal primary care physicians as a percent of total physicians, 2007 AK WY IA ME AR ID OR NM NH MT WA AZ UT U.S. D.C. 33% 36% 37% 44% 44% 43% 43% 42% 41% 41% 41% 41% 40% 39% 47% 25 30 35 40 45 50 Source: The Henry J. Kaiser Family Foundation, www.statehealthfacts.org Page 31

Access to Health Care Rate of Advanced Practice Nurses Total per 100,000 population, 2008 D.C. AK ME NH WY 87.6 102.6 119.7 119.3 187.2 MT OR WA UT ID AZ IA NM AR 77.4 73.9 72.6 65.7 64.9 61.3 61.2 53.6 51.2 50 100 150 200 Source: Each state's board of nursing provided the number of nurses it licenses. Population information came from the U.S. Census Bureau's July 1, 2007 population estimates. There is no national average for the number of nurses per 100,000 population because no national organization systematically collects and analyzes reliable data. State APNs Population Alaska 818 683,478 Arizona 3,885* 6,338,755 Arkansas 1,451 2,834,797 Idaho 973 1,499,402 Iowa 1,830 2,988,046 Maine 1,572 1,317,207 Montana 741 957,861 New Hampshire 1,350 1,315,828 New Mexico 1,055 1,969,915 Oregon 2,770 3,747,455 Utah 1,738** 2,645,330 Washington 4,508 6,468,424 Washington D.C. 1,101 588,292 Wyoming 458 522,830 * The Arizona number includes 557 certified registered nurse anesthetists, though the state does not recognize them as. ** The Utah number includes 131 certified nurse midwives, though the state does not recognize them as. Page 32

Access to Health Care Rate of Nurse Practitioners Total per 100,000 population, 2008 D.C. NH AK 98.2 102.6 140.6 ME OR WA AZ WY MT UT IA NM ID AR 57.4 53.8 50 49.9 48.9 45.7 39.7 36 36 31.7 70 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 Source: Each state board of nursing provided the number of nurse practitioners it licenses. Population information came from the U.S. Census Bureau's July 1, 2007 population estimates. There is no national average for the number of nurses per 100,000 population because no organization systematically collects and analyzes that data. State NPs Population Alaska 671 683,478 Arizona 3,170 6,338,755 Arkansas 900 2,834,797 Idaho 540 1,499,402 Iowa 1,186 2,988,046 Maine 922 1,317,207 Montana 468 957,861 New Hampshire 1,350 1,315,828 New Mexico 710 1,969,915 Oregon 2,150 3,747,455 Utah 1,209* 2,645,330 Washington 3,480** 6,468,424 Washington D.C. 827 588,292 Wyoming 261 522,830 * The Utah number includes all registered nurses except those licensed as nurse anesthetists. ** The Washington number includes all advanced registered nurse practitioners licensed in Washington except nurse midwives and nurse anesthetists. Page 33

Access to Health Care Arkansas's Medically Underserved Areas The U.S. Department of Health and Human Services Health Resources and Services Administration identified these areas of Arkansas as being medically underserved. Areas are designated as medically underserved based on four criteria: the ratio of primary care physicians per 1,000 population, the infant mortality rate, the percentage of the population with incomes below the poverty level, and percentage of the population age 65 or over. The term "primary care physicians" refers to family and general practice doctors, internists, pediatricians, obstetricians, and gynecologists. Page 34

Access to Health Care Area Health Education Centers Seven of the 12 UAMS Area Health Education Center locations operate medical clinics and family medicine residency programs. The two AHEC locations in the north central region and the three locations in the Delta region do not have clinics. Source: UAMS Area Health Education Centers Annual Report August 2008 http://www.uams.edu/ahec/reports/ahecannualreport.pdf Page 35

Access to Health Care Community Health Centers of Arkansas Federally funded community health centers provide primary medical, dental, mental health and preventive health care services on a sliding-fee scale. The community health centers serve medically underserved areas. Arkansas currently has community health center sites in 59 communities. Source: Community Health Centers of Arkansas http://www.chc-ar.org/health_maps_intro.html Page 36

Access to Health Care Family and General Practice Physicians per 10,000 Population Page 37

Access to Health Care Nurse Practitioners with Prescriptive Authority per 10,000 Population Page 38

Access to Health Care Adverse Actions for Advanced Practice Nurses This table shows the number of adverse actions taken against nurses as reported to the federal National Practioner Data Bank (NPDB) and the Health Integrity and Protection Data Bank (HIPDB). Adverse actions include payments made to settle malpractice claims, any disciplinary measure taken by a state licensing board, and any hospital termination. The NPDB and the HIPDB did not provide a national average, but the national totals are provided along the top of the chart. It is important to note that one incident could result in multiple actions. For example, an egregious malpractice incident could result in a malpractice settlement payment and the termination of the nurse's license. It should also be noted that the numbers of adverse actions in each state are very small, making annual decreases or increases appear more significant. Since 1995, the Arkansas State Board of Nursing has taken just 17 licensure actions against nurses. 30 25 20 15 10 5 0 U.S. 2003 2004 2005 2006 2007 275 327 382 355 625 2003 2004 2005 2006 2007 Source: National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank AK AZ AR ID IA ME MT NH NM OR UT WA DC Page 39

Access to Health Care Adverse Actions in States That Repealed Collaborative Agreement Requirements The following tables show the number of adverse actions reported against nurses in the states that had a collaborative agreement requirement, but repealed it. The large red square in each graph indicates the year in which the repeal occurred. Alaska, which repealed its collaborative agreement requirement in 1984, was excluded because the Data Banks only began collecting adverse action data in 1991. The state of Washington was also excluded because it repealed its collaborative agreement requirement in 2007 and there is no adverse action data available beyond 2007. 10 9 8 Idaho 7 6 5 4 3 2 1 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Page 40

Access to Health Care 10 9 New Hampshire 8 7 6 5 4 3 2 1 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 Utah 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Page 41

Access to Health Care 10 9 8 Washington D.C. 28 7 6 5 4 3 2 1 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 10 9 8 Wyoming 7 6 5 4 3 2 1 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Page 42

Access to Health Care Hospital Emergency Room Visits Total visits per 1,000 population 700 675 650 625 600 575 550 525 500 475 450 425 400 375 350 325 300 275 250 1999 2000 2001 2002 2003 2004 2005 2006 Source: The Henry J. Kaiser Family Foundation, www.statehealthfacts.org AK AZ AR ID IA ME MT NH NM OR UT WA WY D.C. U.S. Page 43

State Health Indicators State Health Ranking This table shows the ranking of the states each year from the UnitedHealth Foundation's annual America's Health Ranking report. The Foundation examines each state based on about 20 health indicators, such as the smoking rate, the percentage of people who are uninsured, and the infant mortality rate. The healthiest state ranks 1st, and the least healthy state ranks 50th. 50 45 40 35 30 25 20 15 10 5 0 2001 2002 2003 2004 2005 2006 2007 AK AZ AR ID IA ME MT NH NM OR UT WA WY Source: UnitedHealth Foundation. The Foundation's annual state health rankings do not include Washington D.C. Page 44

State Health Indicators Teen Births Number of births per 1,000 females ages 15 to 19 75 AK AZ AR ID 50 IA ME MT NH NM 25 OR UT 0 2001 2002 2003 2004 2005 Source: Annie E. Casey Foundation, Kids Count Data Center WA WY D.C. U.S. Page 45

State Health Indicators Births to Women Receiving Late or No Prenatal Care Percent of births to mothers who received prenatal care only in the third trimester of their pregnancy or no prenatal care 10 9 8 7 6 5 4 3 2 1 0 2001 2002 2003 2004 2005 Source: Annie E. Casey Foundation, Kids Count Data Center AK AZ AR ID IA ME MT NH NM OR UT WA WY D.C. U.S. Page 46

State Health Indicators Low Birth Weight Babies Percent of babies born who weighed less than 5.5 pounds 10 AK AZ 9 AR ID IA 8 ME MT NH 7 NM OR UT 6 WA WY 5 2001 2002 2003 2004 2005 Source: Annie E. Casey Foundation, Kids Count Data Center D.C. U.S. Page 47

State Health Indicators Infant Mortality Deaths occurring to infants under 1 year of age per 1,000 live births 10 AK AZ 9 AR ID 8 IA ME 7 MT NH 6 NM OR 5 UT WA 4 WY 3 2001 2002 2003 2004 2005 Source: Annie E. Casey Foundation, Kids Count Data Center D.C. U.S. Page 48

State Health Indicators Heart Disease Deaths Deaths per 100,000 population, 2005 D.C. 268.2 AR U.S. IA WY AZ NM ME NH ID WA MT 191.4 186.9 185 184.5 182.7 179.4 177.9 174.3 169.4 211.1 249.5 OR UT AK 164.7 162.6 162.6 150 175 200 225 250 275 Source: Annie E. Casey Foundation, Kids Count Data Center Page 49