History of the Coalition for Nurses
in Advanced Practice                                                                    MS document

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  CNAP’s Beginnings
Initial discussions regarding formation of a coalition of Texas advanced nursing practice nursing organizations occurred during summer 1991, after the third party reimbursement bill introduced in the 1991 Legislative Session died in committee.  It became clear to many of those involved in APN organizations that more resources had to be dedicated to advanced practice nursing issues.  Many groups also felt a need to have direct input into legislative and regulatory issues critically affecting their practices

At this time, some advanced practice nurses (APNs) had dependent prescriptive authority if they practiced in a rural or medically underserved area.  Family and pediatric nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists were eligible to receive Medicaid reimbursement at 65% to 70% of the physician rate.

  CNAP Formation and Structure
Four forward-thinking women are responsible for founding CNAP: Elaine Brightwater, CNM, Carol Cody, WHNP, Ira Gunn, CRNA, and Zo DeMarchi, WHNP. The original members of CNAP included CTCNM (Consortium of Texas Certified Nurse Midwives), Greater Texas Chapter of the National Association of Pediatric Nurse Practitioners (Texas NAPNAP), Houston Area Chapter of the National Association of Pediatric Nurse Practitioners (Houston Area NAPNAP),  Houston Association of Psychiatric Nurses (HAPN), Texas Association ofNurse Anesthetists (TANA), and Texas Nurse Practitioners (TNP).

CNAP was officially incorporated as a 501(c)(6) organization in 1992. The bylaws have not changed since that time. The standing rules outline the operations of the organization and are reviewed annually and updated as needed. A current version of the Standing Rules may be accessed on CNAP’s Website.

CNAP representatives are responsible for the operations of the organization. The most important responsibility for each representative is ensuring their own organization's board is aware of CNAP activities and involved in the decision making process.  Most representatives also write newsletter articles for their organizational newsletters, and report on CNAP activities during state and local meetings.  It is vital that the membership of each organization is aware of CNAP activities and that APNs engage in the legislative process on behalf of the issues that affect their professional lives and the health of their clients.

 CNAP Lobbyists
Coalition representatives hired Kathy Hutto as our lobbyist in December 1991.  Kathy was a social worker for seven years and became interested in governmental affairs while earning her master of social work degree.  Kathy was a Senior Analyst for the Texas Sunset Advisory Commission for five and a half years before beginning her association with Small, Craig & Werkenthin, now Jackson Walker, L.L.P.  Kathy has approximately 10 - 12 clients in addition to CNAP.  Kathy continues to serve as our primary lobbyist and leads the APN lobby team.

Kathy is a great coach in governmental affairs.  She impressed the importance of having a limited number of issues that are well articulated and easily communicated to our memberships, as well as to the legislature.  Our three issues are prescriptive privileges, clinical privileges, and third party reimbursement.  Most importantly, Kathy taught us that regulation is as important as legislation and CNAP continues to review the Texas Register weekly and comment on proposed rules as needed.
 
During legislative sessions, CNAP may hire additional lobbyists to represent APN interests.  In the 1993 Legislative Session, CNAP hired Nub Donaldson, a partner with Small, Craig & Werkenthin.  Before the 1995 Legislative Session, TNA and CNAP cooperated with Texas Nurses Association to establish the Campaign to Achieve Prescriptive Authority.  We raised $200,000 to hire Jack Roberts and Rusty Kelley for the 1995 session.  In 1997, CNAP did not hire an additional lobbyist because all the interested parties had agreed upon the primary APN legislation in advance.  However, the volume of work arising from other legislation impacting the vital interests of APNs in 1997 and the general negative positions taken by the American Medical Association and the Texas Society of Anesthesiologists toward APNs in 1998, led CNAP to hire additional lobbyists before the 1999 session.  Lynda Woolbert, MSN, RN, CPNP, a former CNAP Chair, was hired as the Director of Public Policy to perform both lobbying and organizational services.  Hugo Berlanga, former Texas Representative and Chair of the House Public Health Committee, was also retained to represent CNAP from 1999 – 2003.
 
In 2004, facing continuing threats from Texas Society of Anesthesiologists (TSA), the Texas Association of Nurse Anesthetists (TANA) hired three additional lobbyists: Roland Leal, Patricia Shipton, and former state representative Arlene Wohlgemuth. All three worked for TANA under the leadership of CNAP’s primary lobbyist, Kathy Hutto. Their primary goal was to ensure that no language was included in any law that would require physician supervision of CRNAs in the 2005 Legislative Session. Their secondary goal was to obtain an increase in the Medicaid reimbursement rate to 92% of the physician’s fee. Arlene Wohlgemuth and Roland Leal continue as part of the lobby team, and Roland Leal’s efforts were particularly helpful in achieving the increase in the Medicaid reimbursement rate to 92% in 2006.

 Funding CNAP
One of the biggest issues for CNAP is always raising funds for CNAP through individual contributions from APNs.  Dues from member organizations only cover basic operating expenses and the contract with the Executive Director.  The money necessary to contract with lobbyists, and fund special projects must be funded through individual contributions.  CNAP requires substantial individual contributions.  CNAP's current fund raising campaign is called Protect Your Practice & Insure Your Future.  We urge APNs to donate on an annual basis to this campaign, or to become a CNAP Partner by contributing the equivalent of one hour of their salary a month.

2006 marked the beginning of the biggest fund raising effort since 1994 when CNAP and TNA launched “The Campaign to Achieve Prescriptive Authority.” CNAP and its member organizations are asking 1,000 APNs to donate at least $30 a month through 2015. In order to reach this goal, major fund raising efforts will have to occur in every local APN group. A fund raising presentation is available by contacting lynda@cnaptexas.org.

 Medicaid
A continuing issue regarding Medicaid reimbursement is obtaining 100% of the physician rate for APNs.  We would prefer our rate not be based upon that of physicians.  However, after working with the Medicaid staff in 1992, to develop an APN relative value scale, the staff preferred to continue with the present format.  The Medicaid staff was supportive of increasing our reimbursement rate.

Kathy Hutto led our successful effort, in 1992, to increase Medicaid reimbursement to 85% and to make all categories of advanced practice nurses eligible for reimbursement.  The Texas Department of Human Services administered the Medicaid Program, at that time.  Now that function rests with the Texas Health and Human Services Commission, but our relationship with the Medicaid staff remains positive.

Before the 2003 Legislative Session, physician organizations agreed to support an increase in the Medicaid reimbursement rate for APNs to 92% of the physician's rate. However, the agreement was contingent upon an increase in the overall funding for Medicaid Professional and Outpatient Services that would at least equal the estimated $1 million cost of increasing APNs' reimbursement rate. Unfortunately, the state's budget crisis during 2003 went from bad to worse. As a result, the funding for professional and outpatient services was cut, and we were not able to pursue the increase. In 2005, a rider was included in the Appropriations Bill that directed the Health and Human Services Commission (HHSC) to directly reimburse APNs and PAs. This ultimately led to HHSC increasing the reimbursement rate for APNs to 92% beginning March 1, 2006.

Of course, as Medicaid in Texas is increasingly delivered through managed care, CNAP works with Medicaid managed care companies to ensure those companies include APNs on their managed care panels. Lynda Woolbert’s involvement in the 2003-2004 Governor’s Medicaid Reform Task Force ultimately lead to a provision in 2005 legislation that requires participating managed care organizations to include APNs on their provider panels as primary care providers.

Ongoing efforts with Medicaid include updating HHSC Rules to be consistent with current laws on APN practice. In 2008. CNAP petitioned HHSC to form an APN Workgroup and update many Medicaid rules. That work is ongoing.

 CNAP's Legislative Activities
CNAP limits its activities to legislative and regulatory issues within Texas.  During each Texas Legislative Session (held January through May of every odd-numbered year), CNAP reviews and comments on proposed legislation that may impact APN practice or clients' health.  Of course, the major goal is to see that legislation supportive of APNs is passed by both houses of the legislature and signed by the Governor.  This involves grassroots organization.  As part of this effort, CNAP sponsors a Legislative Day in January or February each session. Starting in 2004, CNAP Legislative Day became an annual event, and in 2005, CNAP representatives began lobbying at the Capitol once a month during each Regular Legislative Session.

CNAP also encourages APNs to visit their legislators in their home districts. It is also a reminder that educating legislators about APNs and their practices requires an ongoing educational effort in the home district.

Between legislative sessions, CNAP monitors the rules and regulations written by each state agency to implement the legislation passed in the previous session.  CNAP also develops a legislative agenda for the following session.  CNAP works with the TNA’s Nursing Legislative Agenda Coalition (NLAC) and TNA staff in finalizing legislative goals and writing legislation.  Then, both TNA and CNAP work with other provider groups and legislators to gain the needed support and sponsorship for the proposed legislation.  CNAP also monitors the work of interim legislative committees and arranges testimony on APN issues whenever appropriate.

CNAP activities during each session are summarized below:

     1993 Legislative Session
We introduced two pieces of legislation in the 1993 session.  We felt successful that both the prescriptive and clinical privileges bills received hearings in committee, and many legislators and staff members were educated on our issues.  The third party reimbursement issue was addressed by naming APNs as providers in the small business insurance legislation introduced by Representative Mike Martin in the House and Senator Carl Parker in the Senate.  This legislation was passed and signed by the Governor.  Kathy also successfully prevented TMA from amending the Appropriations Act to prevent any future increase in the Medicaid reimbursement rate for APNs.

      1995 Legislative Session
As a result of problems experienced during the 1993 Legislative Session, it was evident to both TNA and CNAP that closer cooperation was critical for nursing's legislative success.  However, there are basic differences in our philosophies.  Therefore, a mediator was hired and both groups worked to develop legislation and strategy that could be endorsed by both groups. The result was the Campaign to Achieve Prescriptive Authority and language in SB 673 to expand prescriptive authority to additional sites.  Language assuring CRNAs could continue selecting and administering anesthetic agents for patients under an order from a surgeon was also included.  One of the most important advancements from the 1995 session was formation of the Ad Hoc Committee on Collaborative Practice.  This committee includes 5 physicians, 5 APNs, and 5 PAs that report to their respective organizations.  The goal of the group was to work together to solve any problems resulting from implementing SB 673 and to determine what statutory changes were needed in 1997 that were mutually agreeable.  However, the work of this group proved to be mutually beneficial continued through 2003.

      1997 Legislative Session
The major accomplishment of this session was passage of HB 2846.  CNAP and TNA, as well as TMA (Texas Medical Association), THA (Texas Hospital Association, and TAPA (Texas Academy of Physician Assistants) supported this bill.  The provisions in HB 2846 expanded the sites at which APNs and PAs could apply for prescriptive privileges to include school-based clinics.  The requirement for onsite physician's visits in medically underserved clinics was also changed from once a week to once every 10 days the APN is on site.  This bill also contained provisions which, for the first time, advanced third party reimbursement for APNs.  Insurance companies must reimburse APNs for a covered service unless the insurance company specifically excludes services provided by an APN in the insurance policy.  Managed care companies are also required to name the APN or PA on its provider panel if the collaborating physician is on the panel, and the physician and APN or PA request inclusion.  Managed care organizations are also prohibited from refusing to reimburse APNs based on the fact that we are not listed in Article 21.52 of the Texas Insurance Code. However, this final provision is no longer applicable, since APNs were added to Article 21.52, Insurance Code, in 1999. (Article 21.52 is now codified in Chapter 1451, Insurance Code.)

CNAP representatives always review proposed legislation that might impact our interests or those of our clients.  There was a high volume of such legislation in this session.  Through great persistence, APNs were included in the protections afforded other provider groups and their clients in the managed care legislation, Senate Bills 382, 383, 384, 385, 386.

This was the first legislative session in which APNs were able to keep up to date on events during the legislative session through the Internet.  CNAP provided weekly updates, so APNs from all over the State were able to respond to requests for support very rapidly.

      1999 Legislative Session
Again, through the cooperative efforts of the organizations that developed the legislation in 1997, seven issues were agreed upon and served as the basis for CNAP's primary legislation in 1999.  The centerpiece for the 1999 Legislative Session was passage of SB 1131.  It contains five provisions.  It assures APNs minimum rights in hospital privileging, allows physicians to designate a LVN or RN or call prescriptions to the pharmacy for APNs, allows APNs to perform physicals for cosmetologists' licenses (no longer required), directs state agencies to accept the APN's documentation for services, and adds APNs to Article 21.52, Insurance Code.  SB 1133 adds Registered Nurses to the Professional Procurement Act, and HB 1409 allows APNs to perform federal Department of Transportation physical exams for
school bus drivers.

In addition to our primary legislation, SB 1340 became a very important bill for CRNAs.  This bill, regulating anesthesia provided in office settings, is the first piece of legislation that clearly identifies the Board of Nurse Examiners as the regulatory agency for nurse anesthetists and the Board of Medical Examiners as the regulatory agency for anesthesiologists.

At the end of the 1999 session, SB 1468 passed, allowing physicians to participate in collective bargaining with managed care companies. CNAP spearheaded the addition of an amendment to prohibit physicians from negotiating to limit participation in health plans by other types of health care providers.

1999 marked a turning point for CNAP and advanced practice nurses in Texas.  While much remains to be accomplished, it was the first session in which the term "health care provider or practitioner" became much more common.  Fewer bills were introduced that referred only to physicians when other health care providers could also legally perform the services.  In most of these instances, legislators were very cooperative in expanding the language in bills to include APNs.  It was also the first legislative session in which APNs gained substantially more than we had anticipated at the beginning of the session.

     2001 Legislative Session
Negotiations with medicine stalled early in the 2001 Legislative Session when medicine required that the items negotiated by the Ad Hoc Committee on Collaborative Practice were a package deal tied to nursing's agreement to a 4-year moratorium. The moratorium proposed by medicine would have prohibited CNAP from seeking any legislative or regulatory changes that were not approved by medicine until December 31, 2004. CNAP and TNA declined medicine's offer.  In so doing, we lost medicine's support for two issues: 1) a legislative change that would allow physicians to delegate prescription of Schedule III, Controlled Substances to APNS, and 2) a regulatory change to increase Medicaid reimbursement for APNs from the current 85% of the physician's rate to 92%.

To foster a continued working relationship between medicine and nursing, CNAP and TNA proposed an exit strategy from the negotiations in hopes of re-establishing negotiations after the 2001 Legislative Session. In the end, medicine agreed to support two minor changes in law on delegated prescriptive authority. The result was SB 1166 authored by Senator Frank Madla (D-San Antonio) and Representative Jaime Capelo (D-Corpus Christi). SB 1166 allows a physician in a primary practice site to also delegate prescriptive authority in one alternate practice site where the physician only has to be on site 20% of the time. The bill also grants authority to the Texas State Board of Medical Examiners to waive some of the physician's supervisory requirements that must be fulfilled in order to delegate prescriptive authority to an APN. The physician and APN must demonstrate that those requirements cause an undue burden without a corresponding benefit to patient care. Governor Rick Perry signed SB 1166 into law on May 11, 2001, and it went into effect immediately.

     2003 Legislative Session
As usual, negotiations with medical associations through the Ad Hoc Committee on Collaborative Practice began several months before the opening of the 78th Texas Legislative Session. Those negotiations proved to be more difficult than getting the bill passed. It required many hours of intense negotiation and a mediator to help us reach an agreement.

Ultimately, medical organizations agreed to requiring hospitals, HMOs and PPOs to use a standardized credentialing form for APNs and PAs, and allowing physicians to delegate Controlled Substances, Schedules III – V, with three restrictions. Prescriptions for controlled substances signed by APNs are limited to a 30-day supply. No refills are permitted without prior consultation with the physician (consultation noted on chart). In addition the initial prescription for a controlled substance for children under 2 years of age will require prior consultation (consultation noted on chart). Representative Jaime Capelo filed HB 1095 and Senator Jane Nelson sponsored the bill. It flew through the legislative process and was signed into law by Governor Perry on May 20, 2003. The bill went into effect immediately.

In negotiations, physicians also agreed to support an increase of 7 percentage points in the Medicaid rate for APNs (from the current 85% to 92%). This would be an 8.2% increase in Medicaid payments to APNs billing under their own names. While this is an issue that the Health and Human Services Commission could approve without legislative action, we knew that no state agency would increase an item in their budgets unless there is a legislative directive in the Appropriations Bill to do so. Unfortunately, the budget cutbacks made it impossible to obtain funding for the Medicaid reimbursement increase.

To gain the physicians’ support, we agreed to a full moratorium on any further expansions in scope of practice through the 2007 Legislative Session. There was one exception. The Texas Society of Anesthesiology decided the moratorium on anesthesia issues should end after the 2003 Session, or any special sessions that followed. Since the threat of additional special sessions continued into fall 2004, the moratorium on anesthesia issues lasted through most of 2004, and set the stage for hot debate in 2005.

     2005 Legislative Session
TANA hit the 2005 Legislative Session with an organized effort to deter any legislation from being filed that would require physician supervision for CRNAs. As the session progressed, the weekly visits to the Capitol continued and the focus shifted to deterring any amendment being offered that would require supervision. Not only was TANA successful in any language that would require physician supervision, CRNAs were very successful in educating legislators about CRNAs with their campaign, “How do you say quality anesthesia care? Certified Registered Nurse… A-nes-the-tist.” Another slogan was also quite effective. “If youcan say methodtist, you can say anesthetist.”

Despite the moratorium, and resulting fact that there was no legislation filed on behalf of APNs, the was a very successful session. APNs focused on lobbying for a rider to the Approporations Bill that would require the Medicaid Program to reimburse APNs at 92%. The resulting rider in Article II (two) was not what we expected. At the top of page 88 in Article II item 72 states:
     Advanced Practice Nurse and Physician Assistant reimbursement. The Health and      Human Services Commission shall adopt rules to provide that the Commission shall      not pay for any Medicaid service provided by an Advanced Practice Nurse or      Physician Assistant unless it is billed under the Advanced Practice Nurse's or      Physician Assistant's provider number.

At the time, we assumed this would eliminate the HHSC rule that allows physicians to bill for services provided by APNs and that all APN services would be reimbursed at 92%. HHSC staff did increase the reimbursement rate to 92%. However, HHSC rules continue to allow physicians to bill for services provided by NPs, CNSs and CNMs using an APN modifier andto be reimbursed at 100%.

The 2005 Session was also the year that the issues involving RN First Assistants were finally settled. HB 1718 allows APNs who successfully complete an RN First Assistant course to first assist within their scope of practice without being certified as an operating room nurse (CNOR).

In all there were nine bills that became law that specifically mentioned APNs. Among these was a bill that established a pilot clinic in a state office complex staffed by an NP. If the clinic results in cost savings, the bill allows expansion of the program.

The 2005 Session ended on an exciting note. An amendment was offered on the House Floor that would have gutted the language in SB 1188 requiring HHSC to include language in its contracts with Medicaid managed care companies to include APNs as primary care providers. We were overjoyed when the original language was restored when the bill went to conference committee.

     2007 Legislative Session

This was the final session under which we were constrained by the moratorium. None the less, it was a busy session. The salary grade for state-employed NPs was raised and for the first time it equals that of physician assistants. Eight bills were passed that included amendments supported by CNAP. The Texas Association of Nurse Anesthetists also had a busy session and successfully defeated bills that would have licensed anesthesiology assistants. The nursing board was under review by the Sunset Advisory Commission so there were also some major changes in the Nursing Practice Act, including adoption of the APRN Compact and changing the name of the Board of Nurse Examiners for the State of Texas to the Texas Board of Nursing.

Ad Hoc Committee on Collaborative Practice

As previously stated, the Ad Hoc Committee on Collaborative Practice consisted of five APNs, five PAs, and five physicians.  The physicians represent the Texas Medical Association and various physician specialty organizations, including Texas Society of Anesthesiologists (TSA) and the Texas Academy of Family Physicians (TAFP).  Two APNs represent the Texas Nurses Association and one nurse midwife, one nurse anesthetist and one nurse practitioner represent CNAP.  The five PAs represent the Texas Academy of Physician Assistants.  All of the representatives must currently be practicing in a collaborative arrangement with physicians and APNs or PAs.  The primary lobbyists and attorneys for these organizations also usually attend meetings.  In addition, the Texas Hospital Association (THA) often sends representatives.

From 1995 - 2003, the Ad Hoc Committee continued to develop legislation and worked cooperatively with many state agencies to resolve problems affecting the practice of APNs and PAs.  Because of TAPA's involvement in the Ad Hoc Committee, most APN legislation currently includes PAs.  There are differences in the practices of APNs and PAs, however. PAs are legally required to be supervised by a physician in all aspects of their practice and are regulated by the Texas Medical Board (TMB). As long as the APN is functioning within the scope of his or her practice, APNs perform most functions under their own RN licensure and APN authority. Only certain aspects of medical care are delegated by a physician, primarily the authority to make medical diagnosis and sign prescriptions. Of course, APNs in Texas are regulated by the Board of Nursing.

As stated above, the Agreement with Medical Organizations (moratorium) resulted from the work of the Ad Hoc Committee on Collaborative Practice. Our organizations agreed to a full moratorium on any further expansions in scope of practice through the 2007 Legislative Session. There are only two exceptions. The Texas Society of Anesthesiology decided the moratorium on anesthesia issues should end after the 2003 Session. The agreement also permitted discussions after the 2005 Session on a physician-based model for delegating prescriptive authority. However, in 2006, the medical organizations were not interested in opening serious discussions on expanding prescriptive authority beyond the current site-based model, and medical organizations’ commitment to restricting physicians who want to
work with APNs continues to be a stumbling block.

 Participation in the Texas RN/APN PAC
CNAP is also one of three participating members in the Texas RN/APN PAC.  When the RN PAC became the RN/APN PAC in late 1995, TANA chose to remain an individual member of the PAC.  The other members include TNA and CNAP.  A Political Action Committee raises funds from individuals and unincorporated groups.  These funds are then contributed to political candidates who support nursing issues.  CNAP helps determine which candidates receive these funds, and in turn, is responsible for a proportional share of the administrative costs for the PAC.  CNAP member organizations are asked to meet yearly PAC fund raising goals by soliciting their own members, and it is the organization's responsibility to pay the costs of those fund raising activities. The Texas RN/APN PAC contribution form is online.

Participation in the Patient Choice Alliance

In 2004, the lobbyists and executive directors for several organizations started meeting on a regular basis. The foundling organization was a coalition of providers whose practices overlap with medicine, and called itself the Coalition of Independent Health Care Providers. The coalition included the following organizations.

• Texas Optometric Association
• Texas Nurses Association
• Texas Podiatric Medical Association
• Texas Chiropractic Association
• Texas Psychological Association
• Coalition for Nurses in Advanced Practice

In response to growing threats posed by two medical association coalitions, the Scope of Practice Partnership on the national level and PatientsFIRST on the state level, in 2006, the Independent Health Care Providers Coalition decided to become a formal organization called the Patient Choice Alliance (PCA). The Patient Choice Alliance is a coalition of independent health care provider associations supporting the rights of patients to choose their own health care practitioners. The stated purpose of the organization is to “promote patient choice in health care, to improve patient access to quality care, to remove artificial barriers to safe, well-educated and cost-effective health care providers.”

 Current CNAP Membership, Outreach and Education
Current members of CNAP include Consortium of Texas Certified Nurse Midwives (CTCNM), Greater Texas Chapter of the National Association of Pediatric Nurse Practitioners (Texas NAPNAP), Gulf Coast Gerontological Nurse Practitioners, Houston Area Chapter of the National Association of Pediatric Nurse Practitioners (Houston Area NAPNAP),  Texas Association of Nurse Anesthetists (TANA), Texas Clinical Nurse Specialists, and Texas Nurse Practitioners(TNP).

CNAP prints two brochures.  One explains the purpose of CNAP and is distributed to APN groups and students.  It also contains a form soliciting individual contributions.  The brochure describes Advanced Practice Nurses.  Any APN may give the brochure to legislators, employers, or managed care organizations to explain the role of APNs in Texashealth care delivery.

Since 1997, CNAP e-mailed weekly Legislative Updates to any APN requesting those updates. This continues to be a very effective tool for keeping Advanced Practice Nurses up-to-date on Texas legislative issues.  In 1999, the communication efforts expanded to include occasional CNAP Interim Updates. To request CNAP Updates, email your request with your name, APN role and population focus, home address and contact phone numbers to Lynda or register on CNAP’s Legislative Action page.

In 2006, CNAP expanded its outreach and grassroots organization by adding voterVOICE as a feature on its website. Through voterVOICE, CNAP can easily send messages to APNs, even targeting APNs in particular legislative districts.

Several CNAP representatives make presentations for student or professional APN groups.  They also testify (or find APNs who will testify) before legislative and regulatory bodies. Lynda Woolbert, CNAP’s Executive Director, also lectures in many APN role courses and speaks at many APN conferences throughout the state.

In 2006, CNAP started holding stakeholder retreats to develop and refine our legislative agenda for 2009.  We Texas needs to end physician-delegated prescriptive authority, and developed a strategy to achieve that goal. In April 2008, CNAP held its third stakeholder retreat and fine tuned its tactical plan to achieve this goal. Since 2007, we also make presentations at local groups and APN conferences on BON-Granted Prescriptive Authority.

CNAP now produces documents and manuals to educate APNs, employers, hospitals and managed care companies about the legal requirements of practicing in Texas. In 2004, CNAP published a sample practice protocol for sale. In 2005, CNAP published a manual for Texas hospitals that credential and privilege NPs and CNSs. In September 2006, CNAP and Texas Nurse Practitioners offered the first edition of A Guide to APN practice in Texas. In September 2008, the 2nd edition of the APN Guide was published. All CNAP publications are electronic documents and may be purchased online.

Recent Talks with Medical Organizations

CNAP continues to be committed to work with medical organizations. In January 2008, TMA approached CNAP and TNA to explore if there was a possibility to reach an agreement on legislation for 2009. The groups met five times from February through September 2008. Negotiations at the May and June meetings appeared hopeful.  While physicians clearly would not support BON-Granted Prescriptive Authority, it appeared they might be willing to end site-based restrictions and controlled substances restrictions. However, in the end they insisted that site-based restrictions were important to ensure physician supervision occurs. They indicated that individual physicians could not be trusted without these site-based restrictions.

Further negotiations are not likely to occur as long as medical organizations insist on preserving site-based prescriptive authority.  However, given the recent AMA and TMA initiatives on scope of practice, and physician negotiators’ recent change of heart on eliminating site-based restrictions, we are not optimistic this will happen. 

However, CNAP believes organizations that participate in substantive discussions ultimately benefit through the opportunities to communicate and resolve problems cooperatively.  It improves the image and credibility of all of the organizations with the Texas Legislature and state agencies.  Of course, ultimately, the big winners when medical and nursing organizations work together to solve problems are Texans who have better access to health care and the MDs, PAs, and APNs who provide their care.

 Current Issues
CNAP is preparing for the 2009 Legislative Session. Just as in 2005 and 2007, one big battle we anticipate involves the Texas Society of Anesthesiology. Our organizations will continue to be vigilant for efforts to add language to the Medical Practice Act requiring physicians to supervise CRNAs. No such language has ever existed in Texas law, and to allow supervisory language to be added would be a big step backward for health care in Texas. After all, CRNAs still administer 65% of all anesthetics in Texas and 85% of all anesthetics in rural Texas. Adding unnecessary supervision does nothing to improve quality and inevitably adds to health care costs. In addition, we will continue efforts to defeat any bills that wouldlicense anesthesiologist assistants.

Of course, CNAP’s big issue this session is to achieve BON-Granted Prescriptive Authority. This would change law to authorize the BON to allow APNs to diagnose and prescribe. This would eliminate physician-delegation for diagnosis and prescribing. It would also end the delegation of drugs and devices necessary to administer anesthesia or an anesthesia related service delivered by CRNAs. In addition, it would end limitations on APNs who need to prescribe controlled substances for patients.

CNAP’s three central issues remain prescriptive authority, clinical privileges, and third party reimbursement for APNs. CNAP will continue to monitor legislation and regulatory changes very carefully to be sure that any law or rules that go into effect do not add any new restrictions to APN practice and include APNs anytime it is consistent with current law.