Legislature(2015 - 2016)HOUSE FINANCE 519

03/16/2016 01:30 PM House FINANCE

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Heard & Held
Heard & Held
+ Bills Previously Heard/Scheduled TELECONFERENCED
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                                                                    
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                                                                    
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                                                                    
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                                                                    
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                                                                         
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                                                                    
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                                                                    
2:01:54 PM                                                                                                                    
AT EASE                                                                                                                         
2:02:51 PM                                                                                                                    

Document Name Date/Time Subjects
HB268 Sectional Analysis.pdf HFIN 3/16/2016 1:30:00 PM
HB 268
HB268 Transmittal Letter.pdf HFIN 3/16/2016 1:30:00 PM
HB 268
HB268 031616 HFIN Presentation.pdf HFIN 3/16/2016 1:30:00 PM
HB 268
SB 53 NEW FN DCCED-CBPL 3-11-16.pdf HFIN 3/16/2016 1:30:00 PM
SB 53