1. VCNP Government Relations Strategic Planning June 16, 2007 Mary Duggan RN, MS, CCRN, ACNP Chair, Government Relations Committee Michele Satterlund Lobbyist, Macaulay & Burtch, PC

2. Overview Government Relations Committee Government Relations Committee Legislative & regulatory history Legislative & regulatory history Practice environment 2007 Practice environment 2007 Direction of Government Relations Direction of Government Relations

3. VCNP Government Relations Committee Chairperson, representative from each VCNP region, VCNP President, Past-president, President-elect and lobbyist Chairperson, representative from each VCNP region, VCNP President, Past-president, President-elect and lobbyist Responsibilities: Responsibilities: Coordinate legislative activities of the VCNP Coordinate legislative activities of the VCNP Monitor legislation of interest to Nurse Practitioners and advise VCNP Board and members Monitor legislation of interest to Nurse Practitioners and advise VCNP Board and members Monitor the regulatory process Monitor the regulatory process Meet regularly (conference call, VCNP Board meetings) Meet regularly (conference call, VCNP Board meetings) Educate NPs (yearly program at VCNP Conference) Educate NPs (yearly program at VCNP Conference) Collaborates with VCNP lobbyist to develop strategic plan for VCNP legislative agenda Collaborates with VCNP lobbyist to develop strategic plan for VCNP legislative agenda

4. VCNP Government Relations Committee ChairpersonMary Duggan ChairpersonMary Duggan Blue RidgeNancy Wilson Blue RidgeNancy Wilson CentralDebbie Erickson CentralDebbie Erickson FredericksburgOPEN FredericksburgOPEN No ShenandoahDiane Inkley No ShenandoahDiane Inkley No VirginiaConnie Henry & Lynn Poole No VirginiaConnie Henry & Lynn Poole PeninsulaJennette Cook PeninsulaJennette Cook PiedmontCarol Lynn Maxwell-Thompson PiedmontCarol Lynn Maxwell-Thompson RichmondElaine Ferrary RichmondElaine Ferrary ShenandoahOPEN ShenandoahOPEN SouthwestRebecca Mullins SouthwestRebecca Mullins TidewaterMark Coles & Michele Smith TidewaterMark Coles & Michele Smith

5. Legislative & Regulatory History  1973 Virginia Medical Practice Act amended – expanded nursing practice - NPs may perform medical practice acts under physician supervision. Regulations to be promulgated under the Board of Nursing & Board of Medicine - Joint Boards  1975 & 1976 First Regulations for the Certification of NPs – including CRNAs and CNMs  1980 Advisory Committee to the Joint Boards was formed – 4 physicians and 4 NPs (CRNA, CNM, NPs)

6. VCNP History  1975 Nurse Practitioner Professional Practice Group (VNA)  1984 VCNP became a council under the VNA  1987 Coalition of Virginia Nurses in Advanced Practice (COVNAP) formed to discuss and coordinate legislative activities to benefit all groups and interests (NPs, CRNAs, CNMs, CNSs) and streamline legislative efforts  1990 HB 768 - First attempt to obtain prescriptive authority

7. VCNP Lobbyist 1985 VNA lobbyist Pat Baker 1985 VNA lobbyist Pat Baker 1991 Mark Rubin 1991 Mark Rubin 1991 Leslie Herdegen (Rohrer) 1991 Leslie Herdegen (Rohrer) 2006 Michele Satterlund 2006 Michele Satterlund

8. Virginia NP Legislation 1991 - Schedule VI 1991 - Schedule VI 1995 - Ratio of MD/NP supervision of NPs with prescriptive authority raised from 2:1 to 4:1 with sunset clause to revert back in 2000 1995 - Ratio of MD/NP supervision of NPs with prescriptive authority raised from 2:1 to 4:1 with sunset clause to revert back in 2000 1998 - NPs conduct school physicals 1998 - NPs conduct school physicals 1999 - MD/NP supervision sunset clause lifted 1999 - MD/NP supervision sunset clause lifted 1999 - dispense manufacturers samples 1999 - dispense manufacturers samples 2000 - schedule III – VI prescriptive authority 2000 - schedule III – VI prescriptive authority 2002- NPs order Physical Therapy services 2002- NPs order Physical Therapy services 2004 - Signature and certification 2004 - Signature and certification 2006 - Schedule II 2006 - Schedule II 2007 - Immunity 2007 - Immunity

9. VCNP Strategic Planning  1998 VCNP Government Relations Committee  Each region to provide legislative representative  Survey regions for needs  Plan and timeline:  Phase I: Remove the sunset clause for prescriptive authority supervision from 2:1 to 4:1  Phase II: Expanded prescriptive authority with 1998 and 1999 spent educating NPs about the legislative process and educating the General Assembly about NPs and their role as providers of healthcare services to citizens of Virginia.

10. VCNP Strategic Planning Legislative Agenda May 19, 2001 Signature project Signature project Maintain a paid lobbyist Maintain a paid lobbyist NP in political office by 2011 NP in political office by 2011 Continue participation in political process Continue participation in political process Identify VCNP members who serve on state and national committees and boards Identify VCNP members who serve on state and national committees and boards Gain PT prescribing privileges Gain PT prescribing privileges Eliminate barriers to supervision Eliminate barriers to supervision Third party reimbursement Third party reimbursement PCP status PCP status Serve on insurance panels Serve on insurance panels

11. VCNP Legislative Strategic Planning October 26, 2002 Priority Issues PCP status / reimbursement PCP status / reimbursement Schedule II authority Schedule II authority Recognition issues Recognition issues Protocol requirements Protocol requirements Supervision requirements Supervision requirements Joint Board regulation Joint Board regulation Supply of NPs Supply of NPs Hospital scope of practice issues Hospital scope of practice issues

12. 2002 Legislative Timeline 2003Reimbursement issues work Schedule III effective in July Joint Commission convenes 2004Continue work on reimbursement Introduce legislation regarding supervision 2005Introduce legislation supervision step II Introduce reimbursement legislation Introduce schedule II legislation 2006Pass reimbursement bill 2007Reintroduce schedule II if did not pass

13. So what happened to all those good ideas?

14. 2006 Legislative Strategic Planning September 30, 2006 Considerations Considerations  Signature bill (2004) and Schedule II (2006) passed using the “supervision ticket”  Multi-state Reimbursement Task Force formed and looking regionally at reimbursement  Members expressing need for Durable Do Not Resuscitate (DDNR) order signature  Physician Immunity bill (HB 1110) passed previous session  CNMs passed collaboration legislation 2006  Convenient Care Clinics

15. 2006 Legislative Strategic Plan 2007 – 08DNR 2007 – 08Physician Immunity 2008 – 09Pronouncing Death 2009 – 10Signing Death Certificates Future considerations: Supervision / Collaboration Supervision / Collaboration Physician and Joint Boards Physician and Joint Boards Reimbursement Reimbursement PCP status PCP status NP Compact NP Compact

16. 2007 General Assembly Session DDNR avoided due to political sensitivities in election year DDNR avoided due to political sensitivities in election year Immunity Bill Immunity Bill Great grassroots effort Great grassroots effort Defeated in sub-committee Defeated in sub-committee Lessons learned? Lessons learned? Are we at a crossroads?

17. Survey 2007 VCNP Conference Survey at breakfast session Survey at breakfast session 94/110 respondents 94/110 respondents 61 FNP, 14, ANP, 11 ACNP, 5 WHNP, 3 PNP, 2 GNP 61 FNP, 14, ANP, 11 ACNP, 5 WHNP, 3 PNP, 2 GNP 59 office/clinic, 16 hospital, other 59 office/clinic, 16 hospital, other

18. 2007 Survey Issues Medicaid reimbursement Medicaid reimbursement Private insurance reimbursement Private insurance reimbursement Lack of empanelment in insurance plans Lack of empanelment in insurance plans Physician supervision Physician supervision Lack of PCP status Lack of PCP status Lack of recognition of NPs as autonomous professionals Lack of recognition of NPs as autonomous professionals Inability to sign DDNR forms Inability to sign DDNR forms Restrictions on hospital admitting & staff privileges Restrictions on hospital admitting & staff privileges Mail order prescriptions refused Mail order prescriptions refused Malpractice premiums Malpractice premiums Other Other

19. 2007 Survey Results Priority issues Priority issues Recognition / autonomy ????? Recognition / autonomy ????? Reimbursement - restrictions Reimbursement - restrictions Medicaid Medicaid Medicare reimbursement Medicare reimbursement Commercial insurers Commercial insurers Empanelment, PCP Empanelment, PCP Physician supervision Physician supervision

20. Additional Comments Continued barriers Continued barriers Pharmacy Pharmacy Mail order, NP name on bottle Mail order, NP name on bottle DDNR order DDNR order Medicare restrictions (federal) Medicare restrictions (federal) Admit to SNFs Admit to SNFs Home Health & Hospice Home Health & Hospice Medicaid restrictions - resolved? Medicaid restrictions - resolved? Private insurers Private insurers Recognition & autonomy Recognition & autonomy

21. Environmental Scan New Directions 2007 Toward Unencumbered Independent Practice ? Legislative Legislative Regulatory Regulatory Professional Practice Professional Practice Outreach - Networking - Partnering Outreach - Networking - Partnering Fundraising Fundraising

22. Membership Membership Public Relations Government Relations

23. Brainstorming Strategic Planning BIG Picture

24. Toward Unencumbered Independent Practice ?

25. Legislative Focused Strategy – Regional efforts Focused Strategy – Regional efforts Key legislative contacts Key legislative contacts Key groups – members & non-members Key groups – members & non-members Grassroots mass – mobilizing contacts Grassroots mass – mobilizing contacts Phone calls Phone calls E-mails E-mails Clear cohesive message Clear cohesive message Visibility – fundraising $$$$$$$$ Visibility – fundraising $$$$$$$$ PAC contributions PAC contributions

26. Legislative Legislation Legislation DDNR DDNR Pharmacy labeling Pharmacy labeling NP on BON NP on BON Immunity for NPs Immunity for NPs

27. Legislative Monitor other legislation Monitor other legislation Collaborate with Legislative Coalition – Summit Collaborate with Legislative Coalition – Summit Collaborate with VNA – Nurses Legislative Day Collaborate with VNA – Nurses Legislative Day Support NP & nurse candidates Support NP & nurse candidates Collaborate with CNMs, PAs, Pharmacists Collaborate with CNMs, PAs, Pharmacists Educate NPs on legislative issues & action Educate NPs on legislative issues & action Website Website Conference Conference Blast e-mails Blast e-mails

28. Legislation Federal legislation Federal legislation Reimbursement Reimbursement Medicare Medicare Medicaid Medicaid NPs ordering hospice NPs ordering hospice Admit to skilled nursing facilities Admit to skilled nursing facilities NPs ordering home health NPs ordering home health Collaborate with ACNP & AANP

29. Regulatory BON review of NP regulations BON review of NP regulations BON & BOM opioid management NOIRA BON & BOM opioid management NOIRA Attorney General’s regulatory review Attorney General’s regulatory review Monitor other boards Monitor other boards BOM BOM Pharmacy Pharmacy

30. Professional Practice Education ! Education ! Members and all NPs Members and all NPs Legislators Legislators Align with national NP organizations Align with national NP organizations ACNP and AANP ACNP and AANP Practice Models Practice Models Convenient Care Clinics Convenient Care Clinics NP owned NP owned

31. Professional Practice Reimbursement Reimbursement Medicaid payment for all categories of NPs Medicaid payment for all categories of NPs Virginia should cover all by August (NPI) ? Virginia should cover all by August (NPI) ? Multistate Reimbursement Alliance Multistate Reimbursement Alliance 9 states (Ohio, Pennsylvania, Kentucky, Illinois, West Virginia, Virginia, Michigan, Indiana, Delaware) 9 states (Ohio, Pennsylvania, Kentucky, Illinois, West Virginia, Virginia, Michigan, Indiana, Delaware) Survey Survey Current efforts Current efforts

32. Outreach Networking & partnering Networking & partnering Governor’s Healthcare Reform Commission Governor’s Healthcare Reform Commission Medical Society of Virginia (MSV) Medical Society of Virginia (MSV) Pharmacy Pharmacy Business Business Convenient Care Clinics Convenient Care Clinics Colleges Colleges Non health related partners Non health related partners

33. Fundraising $$$$$$ Membership Membership PAC contributions PAC contributions

34. Where To Go From Here? StrategySession