PHILADELPHIA and HARRISBURG, Pa. - Before an overflow crowd at the University of Pennsylvania School of Nursing, Gov. Ed Rendell signed five laws launching his extensive health care initiative, "Prescription for Pennsylvania." Rendell told the audience at the July 20 ceremony that the legislation "unleashes nurse practitioners to do all the things they're trained to do and recognizes them as the true scientists they are."

The initiative's nurse practitioner component, HB 1253, grants NPs a wide range of privileges including ordering home health and hospice care and durable medical equipment; giving verbal orders in health care facilities; referring patients for physical, occupational and respiratory therapy and nutrition counseling; assessing patients for welfare benefits; issuing home schooling certificates; and performing and signing initial assessments for methadone treatment.

Christine Peterson, a gerontological nurse practitioner at Philadelphia VA Medical Center who attended the ceremony, said she'd been waiting 15 years - the totality of her NP career thus far - to see this law signed. She told ADVANCE that the governor's attention to NPs this year is politically astute because NPs are particularly well suited to carry out health care reform.

Addressing Opponents
Despite the virtues of nurse practitioners, the legislation wasn't a shoo-in. Earlier versions of the bill encountered fierce objections from the state physician and psychiatric organizations, which objected to provisions revising limits on NP prescribing, eliminating collaboration ratios and allowing NPs to sign involuntary commitment orders.

At a public hearing before the House Professional Licensure Committee on May 29, Mark Piasio, MD, president of the Pennsylvania Medical Society, told lawmakers that some of the rules and regulations restricting NP practice, such as those preventing NPs from ordering home health care and medical equipment, are "ridiculous."

But Piasio contested the portion of the bill that would allow physicians to collaborate with more than four nurse practitioners who write prescriptions. "We're not even at one- to-one [collaboration]," he said, implying that prescribing NPs should have no problems finding physician collaborators. "As a human being, how many people can I work with and safely know what's happening?" he asked.

Tine Hansen-Turton, executive director of the National Nursing Centers Consortium, countered that 40 states have no collaboration limits and, indeed, eight of the states with the lowest NP malpractice rates have no limits.

Rosemarie Greco, director of the Governor's Office of Health Care Reform, emphasized that the bill wasn't about disputed territory, but access; it wouldn't expand NP scope of practice, but merely eliminate unfair barriers to practice.

As the hours of scheduled testimony wore on, the number of committee members in the room shriveled. Committee chairman Rep. William Adolph declared, "I'm not qualified to make this decision. I'm not comfortable making this decision."

Influential Backing
The players met in private the next week to hammer out details of a bill that the House, and eventually the entire General Assembly, might support. Negotiating for NPs were Mona Counts, president of the American Academy of Nurse Practitioners (AANP); Jan Towers, legislative chairwoman for the Pennsylvania Coalition of Nurse Practitioners (PCNP) and for AANP; Deb Hartman, a psychiatric-mental health nurse practitioner; and PCNP president Pat Schwabenbauer. After negotiations, NPs consented to dropping the bill's mental health component, and the groups agreed to fight the battles over prescribing restrictions and ratios in the regulatory arena.

(On June 22, the Board of Nursing passed new regulations expanding prescriptive authority and eliminating the collaboration ratio. Morgan Plant, lobbyist for the Pennsylvania Coalition of Nurse Practitioners, stressed that although the regulatory review process could take more than 18 month, it has begun.)

From the beginning, nurse practitioners held the influence of the governor's office on their side. NPs had worked with the Rendell administration over the past 5 years to remove practice barriers, and that visibility paid off when the governor made them part of his reform plan.

"The governor's willingness to have a health care team that really worked to get this done was key," Hansen-Turton told ADVANCE. Plant confirmed that the pace of negotiations was "dizzying," and she credited Greco of the governor's team with moving the bill forward.

Pat Schwabenbauer, president of PCNP, told ADVANCE, "All the officers of PCNP - Sharon Spear, Lori Martin Plank, Cindy Schmeltz and I - as well as Jan Towers, Mona Counts and Morgan Plant, spent long hours telephone conferencing to resolve very involved and complicated issues during further negotiations with PMS."

The House passed the revised bill unanimously on June 26 and sped it to the Senate.

Political Process
The support of the governor, which had been an asset for NPs throughout the process, threatened to become a liability in the Senate at the end of June. Rendell linked HB 1253 and several other reform measures to the state's annual budget, which was scheduled to run out on July 7.  

"Ultimately this will be a political decision, not based on what is best public policy," Plant told ADVANCE before passage. "The political overlay is that this is part of the Democratic governor's health care reform bill."

Budget negotiations grew nasty, eventually shutting down nonessential state services and requiring a court injunction to maintain slots-casino operations. The Republican-controlled Senate threatened to hold up bills already passed by the Democratic-majority House, and it looked as if the NP bill would be held hostage to a transportation bill and a potential public smoking ban, among other measures.

Late on July 9, lawmakers called a truce and passed the new budget, clearing the way for other pending legislation. The Senate passed the NP bill unanimously by the end of the week.

Take-Home Message
Hansen-Turton is delighted to put this battle behind her. The take-home message, she said, is that nurse practitioners are team players. This year the administration was willing to look at all options to get health care reform passed. Despite politics and resistance from the medical community, she concluded, lawmakers "went above that to make all of us better."

Jill Rollet is the senior associate editor at ADVANCE for Nurse Practitioners. Reach her at jrollet@merion.com.