Achieving full practice authority may require an incremental approach. This is the case in Maryland where the requirement for nurse practitioners (NPs) to collaborate with a physician was eliminated in 2010. Another achievement that year was revising regulatory control so that NPs are now regulated by the State of Maryland Board of Nursing (BON) rather than the Board of Physicians.

There was, however, a cost to this success. During the 2010 legislative session, MedChi, the Maryland State Medical Society, claimed that eliminating the collaboration requirement would adversely affect patient safety. A compromise was crafted to require Maryland NPs to complete an attestation form that indicates the physician with whom collaboration will occur if needed.1 NP leaders agreed to this with a plan to revisit the requirement in 5 years.

Access to care

Attestation causes a significant access to care problem. Insurance companies and managed care organizations (MCOs) require that for an NP to be reimbursed, the insurance company must credential the physician who is listed on the attestation. Many NPs who committed to accepting and caring for Medicaid MCO patients cannot be credentialed under the current rules. Maryland continues to face a Medicaid provider shortage and patients continue to access care through EDs. Eliminating the attestation requirement could increase access to care for 66% of Medicaid patients.2

According to Elaine Crain, MSN, CNP, Executive Director of the Maryland Advanced Practice Alliance, the Maryland Academy of Advanced Practice Clinicians (MAAPC) compared the cost of wellness care between full practice and restricted practice states for Medicaid patients.3 Prices for a Medicaid well visit are almost $7 higher in states that require supervision of NPs. Maryland could save $8 million annually on Medicaid well visits with NP full practice authority. Research shows that states with NP full practice authority have 4.9% fewer avoidable Medicaid hospitalizations than states without full practice authority.4

The APRN Practice Alliance

The Maryland BON has reported that there have been no patient safety issues with the elimination of the collaborative agreement. The Maryland Academy of Advanced Practice Clinicians and the Nurse Practitioner Association of Maryland have partnered, along with the Maryland Nurses Association, to introduce legislation during the General Assembly of Maryland 2015 Regular Session to repeal the attestation requirement. The Senate bill, SB0723, is sponsored by Senator Conway. The House bill, HB0999, is sponsored by Cullison and 21 other delegates. The Senate bill received a hearing and vote in committee; however, the House bill was amended and passed by the Health and Government Operations Committee and also read for the second time by the full House on April 1, 2015. The amendment makes the statement that new graduates will have a mentor for the first year of practice; however, the attestation will still be eliminated. The House bill must still pass a third reading and also must be passed by the Senate to become law. At the time this article went to press, session ended on April 13, 2015. Monitor the status of each bill at http://mgaleg.maryland.gov/webmga/frmLegislation.aspx?pid=legisnpage.

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