SENATE BILL NO. 53 "An Act relating to advanced practice registered nursing; relating to certified direct-entry midwifery; and providing for an effective date." 1:35:12 PM SENATOR CATHY GIESSEL, SPONSOR, thanked the chair for hearing the bill. She explained that the legislation would update the state's 34-year-old statute titles pertaining to nurse practitioners. The existing title was "advanced nurse practitioner (ANP)" and "nurse anesthetist (NA)" The bill would implement the updated term of "advanced practice registered nurse (APRN)." The bill did not change the scope of practice performed by advanced practice registered nurses. She referred to a chart in members' packets illustrating title changes the bill would put in place (copy on file). She detailed she had served on the National Council of State Boards of Nursing in the past; during her time on the council the title for advanced practice registered nurses was standardized in a consensus model document agreed to by all of the states. She elaborated that prior to the change, each state had its own title for advanced practice registered nurses. The top portion of the chart showed ANP and NA, which were the old terms. Three subspecialties fell underneath the ANP umbrella including nurse practitioner, certified nurse-midwife (responsible for delivering babies), and certified clinical nurse specialist (employed in hospitals). Senator Giessel continued to address the title chart. The proposed statute change was represented in the lower portion of the chart. The title would change to APRN and four subcategories included certified nurse practitioner, certified nurse-midwife, certified registered nurse anesthetist, and certified clinical nurse specialist. 1:37:51 PM Senator Giessel relayed that the bill's only function was to transform state statutes to reflect the updated APRN title change. Part of the reason for the change was due to confusion within insurance companies. She detailed that each state had been using a different title; therefore, sometimes reimbursements were denied because insurance companies (including Medicare and the Veterans' Administration) did not recognize the credential of the person who provided the service. The bill would make Alaska in uniform conformity with other states. Currently there were 1,000 advanced practice registered nurses in Alaska; therefore, the change would impact a large number of clinicians. Co-Chair Neuman referred to Senator Giessel's testimony there had been reimbursements based on confusion about service providers. He asked for examples and the associated value. Senator Giessel explained that a primary care provider could bill insurance for services just like a family practice physician. She was personally an APN or NP under the current category. She detailed if an insurance company did not recognize what ANP stood for, it would question what kind of reimbursement the she would be entitled to for the care of a patient. The bill would standardize the title. Co-Chair Neuman asked if Alaska was behind other states in making the changes. Senator Giessel answered that 13 states had implemented the change in title. Additionally, there were currently about 29 states (including Alaska) working on making the change. Co-Chair Thompson noted Representative Gara had joined the meeting. 1:40:05 PM Representative Gattis asked if the label changes would force any kind of wage change paid by hospitals. She wondered if the bill would make a difference from the hospitals' standpoint. Additionally, she wondered if the change would result in different costs to patients. Senator Giessel responded that it would make no difference in the reimbursement or wage for any of the categories of APNs. In terms of hospital practice, the certified nurse- midwife and the certified registered nurse anesthetist were the two categories that would be practicing both inside and outside hospital facilities. The nurses had been doing so for numerous years if they had hospital privileges. The clinical nurse specialist practiced almost exclusively in a hospital. She relayed the bill should not change their pay category at all. Representative Guttenberg wondered if additional credentials would be necessary if a nurse practitioner's title changed to certified nurse practitioner. Senator Giessel answered that the requirements for certification would remain the same. She detailed that since ANPs had been recognized in Alaska (for 34 years), national board certification was required to receive a license in advanced practice. The bill would not change the requirements. The same national certifying boards would still administer the same examinations and certified in the same way. Representative Guttenberg observed the title chart showed nurse anesthetists as separate under existing law, but it included them under APRNs in the proposed law. He wondered about the bill's impact on nurse anesthetists and asked if they were supportive of the legislation. Senator Giessel explained that the reason ANPs and NAs were separate on the upper portion of the chart was due to the way the statutes had been originally written. The new title would put everyone under the APRN title. All four of the categories under APRN were part of a coalition, which unanimously supported the legislation. Representative Guttenberg appreciated the answer. He commented that sometimes alliances did not always speak out. Co-Chair Thompson called for invited testimony. 1:44:31 PM CARRIE DOYLE, ADULT HEALTH CLINICAL NURSE SPECIALIST, ALASKA CLINICAL NURSE SPECIALISTS ASSOCIATIONS (via teleconference), read from a prepared statement: I am Dr. Carrie Doyle, I am an adult health clinical nurse specialist and represent the Alaska Clinical Nurse Specialists Association. I'm also a member of the Alaska APRN Alliance, which is comprised of all four advanced practice registered nurse specialties, AANA, and the University of Anchorage Alaska, as well as the Board of Nursing. I'd like to thank you for allowing me to testify in support of Senate Bill 53, which is an act related to advanced practice registered nursing that will align Alaska statute with the nationwide movement called the consensus model. Currently, as a clinical nurse specialist I am called a nurse practitioner legally, which is not the role that I perform and can be confusing to patients. So as noted, there are four different specialties. That being the nurse practitioner, the clinical nurse specialist, the nurse-midwife, and the CRNA or nurse anesthetist. The statute will separate these categories. As I mentioned, the consensus model is a nationwide movement that includes all four specialties. It was comprised or built by the National Council of State Boards and Nursing in conjunction with an APRN workgroup that comprised of 48 different national nursing organizations. The consensus model does seek uniformity in APRN licensure, accreditation, certification, and education. Uniformity will expedite insurance reimbursement as noted by Senator Giessel and by eliminating confusion about service providers, which in turn, eliminates the confusion with our patients. It will also allow APRNs from other states to more easily obtain Alaska licensure. Senate Bill 53 does not change the scope of practice for ANPs and nurse anesthetists who will still be able to continue to provide that same high-quality, safe, accessible care that they have provided to Alaskans across the state for the last 34 years. It will just have a new name: APRN. I thank you for your time today and ask that you support Senate Bill 53. 1:47:02 PM LAURA SARCONE, CERTIFIED NURSE-MIDWIFE AND PAST CO-CHAIR, ADVANCED PRACTICE REGISTERED NURSE ALLIANCE (via teleconference), read from a prepared statement: Good afternoon. My name is Laura Sarcone. I am a certified nurse-midwife and I am the immediate past co-chair of the APRN Alliance. Thank you for this opportunity to testify in support of SB 53. The four advanced practice nursing groups have been working on this issue for nearly five years. The APRN Consensus Model is a national "best practice" act. It puts consumers, employers, APRNs, the Board of Nursing, insurance companies, and the legislature on the same page. It standardizes licensing, accreditation, certification, and educational requirements for APRNs. Thirteen states have already fully implemented the Model. Another 29 states plus the District of Columbia are more than fifty percent implemented. Only 8 states are less than 50 percent implemented and 33 states use the title "APRN." The APRN Alliance has reviewed the fiscal note. We understand that the $7500 cost will be recovered through licensing fees and not general funds. We would like to thank Senator Giessel for sponsoring this bill, and for championing this issue on behalf of her fellow APRNs. I urge you to vote in favor of SB 53. Thank you. Representative Gara asked Ms. Sarcone about why it took five years for the various nursing groups to come together on the issue. He wondered what the dispute had been. Ms. Sarcone corrected that the nursing groups had been working on the issue for nearly five years; it had not taken the groups that time to come together. She explained it had taken five years for the groups to work through the Board of Nursing, getting language together, and requesting the bill through Senator Giessel. 1:49:47 PM GAIL BERNTH, EXECUTIVE ADMINISTRATOR, BOARD OF NURSING (via teleconference), read from a prepared statement: Thank you for hearing this bill and for permitting me to address this hearing. The Board of Nursing has requested that I voice their support of this bill to update our regulations. This will help to bring Alaska into compliance with the national consensus model developed by the National Council of State Boards of Nursing. I thank you. 1:50:19 PM TRACEY WIESE, FAMILY and PSYCIATRIC NURSE PRACTITIONER, and CO-CHAIR, ADVANCED PRACTICE REGISTERED NURSE ALLIANCE (via teleconference), urged support of the bill. Co-Chair Neuman referred to the bill's sectional analysis (copy on file) and observed that Section 10 deleted vocational nursing and added a paragraph requiring the Department of Commerce, Community and Economic Development to set fees to practice registered nursing. He asked about the reason for the change. Senator Giessel relayed that the bill would remove the term "vocational" because it was no longer used; it had been removed from most of the state's statutes by legislation approximately five years earlier; the term that would be deleted in the current bill had been missed when the changes had been made in the past. Co-Chair Neuman asked for verification it was conforming language. Senator Giessel answered in the affirmative. Representative Neuman remarked that Section 13 would amend statute to add advanced practice registered nurses to the persons authorized to supervise a practical nurse. He did not know what the current qualifications were. He believed the bill seemed to do more than merely change the name. He observed the bill provided for more services or duties nurses could do. He asked for detail on the change in Section 13. Senator Giessel explained that a practical nursing degree was typically two years. She read from Section 13 of existing statute: "a practical nurse shall work under the supervision of a licensed registered nurse..." She explained that a registered nurse was a higher level licensure that qualified a registered nurse to supervise a licensed practical nurse (LPN). She elaborated that an advanced practice registered nurse was at minimum a master's degree (most of the education was moving towards a doctoral degree). The section added the doctorally prepared nurse who would also supervise the LPN. 1:54:01 PM Co-Chair Neuman referred to Sections 52 through 54. He stated that the bill would add APRNs to the list of practitioners who may, under statutory provisions concerning mental health commitment, determine if a person may be administered psychotropic medication without a person's consent. He remarked that in other occurrences pertaining to the medical industry, doctors were sensitive to the ability to administer different prescription drugs because of the amount of education they received, particularly with the use of psychotropic drugs. He wondered why the language was needed and believed it advanced a nurse's authority substantially. Senator Giessel began with Section 52. She clarified that the underlined words in the bill draft represented areas that would change current statute. The existing statute read "as determined by a licensed physician or a registered nurse..." She emphasized a registered nursing degree was either two to four years (a bachelor's degree) and an advanced practice registered nursing degree was a master's or doctorate. Under existing statute an advanced practice registered nurse could administer psychotropic medication. The language simply clarified the statute by inserting "advanced practice registered nurse" as well. She specified that an advanced practice registered nurse was a higher level registered nurse with prescriptive authority; a registered nurse did not have prescriptive authority. Senator Giessel moved to Section 53 related to the definition of a mental health professional. The existing statute applied to a registered nurse with a master's degree in psychiatric nursing, which was the definition of an APRN. She stated it was possible for an RN to have a master's degree in psychiatric nursing, but not be an APRN. She detailed it clarified that a nurse with a master's degree or a doctorate could also be categorized as a mental health professional. She referred to testimony by Dr. Tracey Wiese who is a doctorally prepared mental health professional. The definition did not extend or expand the scope of practice. Senator Giessel moved to Section 54 on page 25 of the legislation. The original language had been "...reviewed by a registered nurse licensed under..." The section pertained to reviewing a residence assisted living plan. She explained that an APRN was also an RN (the individuals held two licenses and paid twice to the State of Alaska). The language had been updated to clarify the inclusion of APRNs. 1:57:34 PM Co-Chair Neuman assumed that specific training would be required for an APRN to administer psychotropic medication. Senator Giessel answered that a nurse practitioner held either a master's or doctoral degree and were currently statutorily authorized to prescribe. She furthered that with drug enforcement authority, nurse practitioners also prescribed controlled substances should they decide to apply for the authorization. She explained that nurse practitioners had full prescriptive authority just like a family practice or other physician. Co-Chair Neuman remarked that nurses performed some of the clinical work in villages and some health centers without doctors. He believed the bill would provide increased opportunities within the state. He asked if it was part of the reason for the legislation. He spoke to the need to continue to reduce the budget, while ensuring medical services were available throughout the state. Senator Giessel answered that he was speaking to her heart. She clarified that the bill did not change anything that did not currently exist. She elaborated that many APRNs practice in rural areas where no other healthcare was available (including an Indian Health Service clinic). She detailed that one of the provisions in another bill that would come before the committee related to Medicaid would allow nurse practitioners (particularly practitioners in mental and behavioral health) to expand their ability to practice. She thanked him for the question. She reiterated SB 53 did not expand work performed by APRNs in rural Alaska or in any other venue. 2:00:03 PM Vice-Chair Saddler asked if the bill changed the membership of the Board of Nursing such that it would impact the professional licensing fee. Senator Giessel replied in the negative. She explained there was currently a seat on the Board of Nursing for an APRN and the bill would make no changes to the area. Vice-Chair Saddler asked which professional board would regulate APRNs. He wondered if it would change the "universe of license fee payers" and the required rate. Senator Giessel responded that the bill would make no changes to the area. She explained that currently APRNs fell under the Board of Nursing; the board regulated about 12,000 licensees from certified nurse aides up to a doctorally prepared APRN. Senator Giessel thanked the committee for its time. SB 53 was HEARD and HELD in committee for further consideration. 2:01:54 PM AT EASE 2:02:51 PM RECONVENED