NPP Independent Practice

Collaborative practice required

NPs have full practice authority

NP: Independent practice passed by AB 890 in 2020. Two possible pathways.

PA: No legislative attempt since 2019 (SB 697)

NPs practice independently after 750 hours of documented experience with a physician or another NP. PAs have annually attempted to remove physician supervision and move to independent practice.

CO ACEP has successfully opposed such efforts in 2021 and 2022. They introduced SB23-083. Update 1/16/23: The PAs were able to pass legislation last year (after I completed the form you distributed) which moves them to "collaborative agreements" versus supervision in most cases.

We were able to keep supervisory agreements in Level I & II designated trauma centers as well as for new PAs and PAs changing practice specialty. We are currently working this issue through implementation rules.

There is a separate noneconomic damages cap when the practitioner is providing emergency services. Emergency medicine physician caps for all claimants are currently $150k/$300k. Currently, practitioners must carry med mal insurance or self-insure for $250k/$750k required for licensure.

• Licensure Requirements for Physicians: 458.320 - Financial responsibility.
• In 2017, the FL SC struck down a large segment of the caps, but not the Medicaid or Emergency Medical Services caps. The Emergency services caps and Medicaid caps have NOT BEEN CHALLENGED and thus have NOT BEEN FOUND UNCOSTITUTIONAL, and the FL SC composition has changed, and the new court is not expected to rule the same way even if a challenge was filed.

Yearly battles, but no independent practice yet

NP: Independent practice requires 4000h experience, 250h training; no recent expansion bills.

PA: annual expansion attempt, in 2022 with HB 1826 (opposed by ICEP)

No NP or PA independent practice within the state. 5% minimum sign off on all charts (mainly applies to outpatient care). Bills filed yearly trying to gain independent practice without any recent movement. INACEP always opposes. SB 400 this year championed by INACEP which will require onsite physician coverage at all times in all EDs with likely passage later this month.

NPs can practice independently.

PAs have a bill before the 2023 legislature to strike the physician supervision requirement, allowing them to practice independently.

Midwives have a similar bill broadening independence this year

NPs practice independently.

PAs have supervision, but not required to be on site.

NP: Requires collaboration with physician/CPA; not independent. Annual expansion attempt, For 2022 HB 543 did not pass, SB 175 did not pass.

PA: Requires supervision by physician, physical presence not required. For 2022 SB 158 attempt to decrease from supervision to collaborative practice - did not pass.

Chapter 260 of the Acts of 2020 expanded the scope of practice for nurse practitioners, nurse anesthetists, and psychiatric nurse mental health clinical specialists, allowing them to practice independently and prescribe medications.

In this session, the following new bill was introduced: H.2135/S.1354, An Act Relative to Removing Barriers to Care for Physician Assistants (Barber/Cyr). Would allow Independent practice for Physician Assistants.

NPs: No independent practice. Senate Bill 680 introduced in Oct 2021.

PAs: In MI Senate Health Policy, "PAs no longer required to work under supervision or delegation of a physician." Required to work with a "participating physician" according to terms in a "practice agreement."

December 2023 Update: Only bills are on mental health.

Currently, NPs have independent practice in MN. (NPs have independent practice with everything. PA’s still need to be supervised.)

Independent practice is not permitted. NPs are required to have a collaboration agreement with a Physician. During the 2023 session, SB 2796 sought to grant NPs independent practice, but the bill failed in committee. Anticipate a similar bill to be introduced in the upcoming 2024 session.

Momentum for independent practice is building, and NP gains on this issue are more likely than they have been in a long time.

Requires collaborative agreement with physician within 75 miles. Constant battles to increase distance or eliminate the collaborative requirement, none thus far successful.

NPs: IPA since 2015

PAs: IPA since 2020

NPs: Already IPA.

PAs: Fighting for it now.

NJACEP actively opposing current legislation, which would offer APNs independent practice in EM.

PAs already have functional IPA.

NPs: Bill not filed yet, but awful version filled the last 3–4 sessions that allows independent practice - this issue is involved in negotiations over Medicaid Expansion.

PAs: Bill Filed S47/H75 that allows PA's to practice in a team based practice - many changes made for scope concerns.

No independent practice for APRNs. SB 81 cleared both the House and the Senate with near unanimous support and has been sent to the Governor for signature.

The bill makes changes to the APRNs' and physician assistants' scope of practice, but only applies to psych-related care. The bill retains the requirement that APRNs have a standard care arrangement and PAs have a supervisory agreement with a physician.

Under the bill, those agreements could give APRNs and PAs the authority to “sign any document relating to the admission, treatment, or discharge of an inpatient receiving psychiatric or other behavioral health care services.” The APRN/PA and the collaborating physician must be employed by the hospital where the patient is receiving inpatient psychiatric or behavioral health services.

The bill provides some civil liability protection to the physician for adverse action that could arise from the APRN or PA signing the forms. The House also added a provision to allow nurses to access safe haven programs related to impairment, similar to those allowed to physicians and other providers. Also, Senator Roegner has introduced SB 196 - An APRN - SCOPE Bill.

The bill is lengthy but generally grants APRNs the authority to sign forms a physician can sign and make determinations a physician can make (including determining and pronouncing death), establishes certain prescribing protocols for pharmacists, and other scope of practice expansions. The bill does, however, retain the requirement that APRNs have a collaboration agreement with physicians. Ohio ACEP is still in the process of reviewing it.

NPs are able to practice independently. 

SB25: Bill to independent practice of NPs

The PAs had proposed a bill that would have sought to remove all collaborative language from the current law. We were not made aware of this effort in advance, but they have since decided to pull the bill and plan to introduce it again next session.

We continue to fight a Full Practice Authority bill that has been introduced in the subcommittee of the Senate Medical Affairs committee by State Senator Tom Davis. We do not expect this to get much traction this session. We will be starting the second of our two-year session and the head of the committee, Senator Verdin (daughter is Family Medicine Physician) is strongly against the bill and does not plan to give it a hearing. Furthermore, we are keeping an eye out for any movement. 

We met with Senator Davis during our state legislative day with a group of other physicians for approximately one hour to discuss our concerns about unsupervised practice. He did agree that EDs should always have a physician present however we were unfortunately unable to dissuade him to withdraw the bill. He unfortunately seems to be making this a big campaign issue. 

NPs: Have full independent practice.

PAs: Multiple attempts, but have thus-far failed.

TMA and the Physician Assistants worked out a collaborative practice agreement. This passed as SB 2136. Nurses did not pursue their independent practice bill. SB 1727.

Practice under delegation agreements—there are annual attempts to get rid of this requirement.

NPs: Longstanding independent practice.

PAs: Annual expansion attempt, currently need supervision within hospitals.

Legal independent practice (after 2y of collaboration). In practice, IPA is being fought at the hospital association and payor level.

ARNPs have long had independent practice authority in WA. Legislation is currently pending which would grant PAs collaborative practice authority after a period of supervision. The collaborative practice must maintain a connection between PAs and physicians.

NP increased scope of practice bill vetoed by Gov last session, expected to try again this year.