House Bill 818 (HB 818) of the 2000 General Assembly Session expanded the prescriptive authority of nurse practitioners (NPs). Specifically, the prescriptive authority for NPs changed from the authority to prescribe only Schedule VI drugs to a time table (over a period of several years) providing for the authority to prescribe Schedules III-VI drugs. An enactment clause in HB 818 required the Joint Commission on Health Care (JCHC) to report on the issue of prescriptive authority for NPs prior to the 2004 General Assembly Session. Specifically, the Commission is required by the enactment clause:

"…to study nurse practitioner prescriptive authority as provided in this act to determine the impact of the authority to prescribe Schedules III through VI controlled substances and devices on patient care, provider relationships, third-party reimbursement, physician practices, and patient satisfaction with nurse practitioner treatment."

Based on research and analysis conducted during this review, JCHC staff found the following concerning NPs and NPs with prescriptive authority in Virginia:

• The number of nurse practitioners (NPs) in Virginia has more than doubled between 1994 and 2003. As of June 2003, the number of licensed NPs was 4,621 and the number of NPs with prescriptive authority was 2,347. Because one category of NPs, nurse anesthetists, is not eligible for prescriptive authority, the number of eligible NPs with prescriptive authority is approximately 74 percent.

• The Board of Nursing (BON), which collects information about NPs, does not collect information regarding the practice locations of NPs or the changes to the written practice agreements between physicians and NPs, which delineate the NPs’ authority to prescribe medication. The lack of information concerning NP practice locations meant that the extent to which NPs practice in medically underserved areas could not be determined.

• A number of studies conducted in the United States have shown that quality care is being provided by NPs and that patient satisfaction exists with NP services generally. Available data about disciplinary actions against NPs and NPs with prescriptive authority in Virginia showed a low occurrence of complaints and sanctions. This finding indirectly suggests that Virginia NPs are providing quality care and that patient satisfaction is likely to be relatively high.

• All states allow some type of prescriptive authority for NPs. The majority of states, including Virginia, allow NPs to prescribe drugs including controlled substances with some type of physician involvement. Five states allow NPs to prescribe drugs excluding controlled substances with physician involvement. And, 12 states allow NPs to independently prescribe drugs including controlled substances.

• Virginia is in a more restrictive category in regards to NP scope of practice. Virginia requires physician supervision for prescriptive authority and is one of only five states that have scope of practice authorized by both a board of nursing and a board of medicine.

• In addition, although Virginia does not provide NPs with mandated direct third-party reimbursement status or primary care provider status, the fives states that border Virginia mandate both for NPs.

It should be noted that NPs only received the authority to move to Schedule III on July 1, 2003. Therefore, no conclusive findings could be made regarding the authority to prescribe Schedule III controlled substances during this study.

A number of policy options were offered for consideration by the Joint Commission on Health Care regarding the issues discussed in this report. These policy options are listed on page 29. The Commission ultimately voted to support an amended Option III, requiring the Board of Nursing to collect data regarding practice locations and levels of prescriptive authority for licensed nurse practitioners.

Kim Snead
Executive Director
December 2003