38 CFR Part 17.415 - Short for "VA Doesn't Care About Veterans"

(Editor's comment: today we are taking a detour from personal finance to address an issue I feel very strongly about.  Let's talk about the thorny topics of health care policy and veteran affairs.)

Unless you live under a rock, you've probably caught wind of VA's proposed rule to expand the scope of practice for Advanced Practice Registered Nurses (APRN).  It's generated 66,978 comments as of this writing.  I have heard a lot about the rule in the last month but until now, I have not read the original document myself.  Well, I read it and my blood is boiling...

The Cliffnotes:

The document itself is ridiculously dry and I had about as much fun reading it as watching paint dry.  But I did it so you don't have to.  Let's get to the meat of the matter:

  • The proposed scope of practice expansion affects 4 types of APRNs:  Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), or Certified Nurse-Midwife (CNM). (Note: the VA doesn't actually employ any CNMs, but the proposed rule included them in case they hire any in the future.)
  • The expansion of scope gives "Full Practice Authority" to APRNs when working for the VA - without physician supervision.
    • For example: "a CNP would have full practice authority to provide the following services: Comprehensive histories, physical examinations and other health assessment and screening activities; diagnose, treat, and manage patients with acute and chronic illnesses and diseases; order, perform, supervise, and interpret laboratory and imaging studies; prescribe medication and durable medical equipment and; make appropriate referrals for patients and families; and aid in health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases."
  • The proposed rule would preempt any applicable State laws limiting the practice scope of APRNs, with the exception being any State laws limiting prescribing of controlled substances.

The Controversy:

Since the proposed rule was posted on Regulations.gov, it has garnered 66,978 comments and pitted physician societies against nursing societies - The American Society of Anesthesiologists (ASA) against American Association of Nurse Anesthetists (AANA).  The American Medical Association (AMA) against the American Nurses Association (ANA).  Not to mention the political outcry of the Federal government once again trying to pull one over on the States.  The spin from each side can be easily summarized:

  • The MDs believe APRNs are not as well trained as physicians and therefore such a proposed change will negatively impact patient care.
  • The APRNs believe they are just as well trained and offer a cheaper solution to the congestion at the VA.

The Facts:

  • Physicians cost more than nurses - we cost more to educate, to train and to employ.
  • The VA needs more providers to meet the needs of veterans.
  • 21 states and D.C. does not make up "50% of the nation." Do the math.
  • The definitions of "qualified healthcare professional" and "quality health care" are inherently subjective.  But I think most reasonable people can agree that the "full extent of education and training" of APRNs is not as vigorous or comprehensive as that of a physician's.

Future Proof Soapbox:

Before reading the original document, I bit my tongue because I didn't want to sound like an idiot talking about something I didn't understand.  Well, I read it, now my blood's boiling, so allow me to step on my soapbox:

  1. To whoever wrote "order, perform, supervise, and interpret laboratory and imaging studies" - ARE YOU INSANE!?  How many non-radiology physicians can interpret CTs and MRIs competently?!  You want to open that door to APRNs?!  In a system with practically no recourse for malpractice?! 
  2. I have great friends who are NPs or physician assistants.  When I brought up this topic to them, they were all surprised that the proposed rule was so broad.  None of them expressed any desire to interpret images.
  3. To the nurses who want full autonomy in practice - go to medical school and become a physician.  I had classmates who went that exact route.  There is no shame in switching careers.
  4. To the bureaucrats at the VA - we all have money problems.  But please don't gamble with veterans' healthcare.  These are people who have sacrificed more than most.  They deserve better.
  5. To the veterans - we understand that the VA has been a dumpster fire for some time now, but do you really think the solution is to take the most qualified professional out of your healthcare team?  

Sure I am an MD so I've got "skin in the game" so to speak.  But if I'm ever faced with a decision between saving money vs. saving lives, I'm always going to choose saving lives.  For anyone who reads this article, please go to http://www.safevacare.org/ and do the right thing.