Letter to House and Senate Leadership to Support Continuation of Certain PHE Waivers
The Honorable Kevin McCarthy
Speaker of the House
United States House of Representatives
Washington, DC 20515
The Honorable Hakeem Jeffries
House Minority Leader
United States House of Representatives
Washington, DC 20515
The Honorable Charles E. Schumer
Senate Majority Leader
United States Senate
Washington, DC 20510
The Honorable Mitch McConnell
Senate Minority Leader
United States Senate
Washington, DC 20510
Dear Speaker McCarthy, Leader Schumer, Leader McConnell, and Leader Jeffries,
On behalf of the 52 undersigned organizations representing the Nursing Community Coalition (NCC), we write to express our support for the continuation of the impactful actions to patient access to care during the Public Health Emergency (PHE) through various waivers and regulatory efforts, including but not limited to telehealth. As a cross section of education, practice, research, and regulation within the nursing profession, the Nursing Community Coalition recognizes the critical contributions made by nurses, including Advanced Practice Registered Nurses (APRNs),1 to deliver high-quality, lifesaving, preventive, and palliative health care across all care settings, geographic areas, and social determinants of health. Collectively, we have advocated for the removal of barriers to practice and encouraged innovation, especially as our nation’s frontline providers respond to COVID-19.
The NCC appreciates Congress’ action in the Consolidated Appropriations Act, 2023 to extend the Medicare telehealth waivers through 2024. While a strong first step as we continue to provide access to the highest quality nursing care, we urge Congress to take legislative action to guarantee that other critical non-telehealth waivers are also continued.
As we near the end of the PHE on May 11th, we must ensure there is no lapse in the high-quality APRN-provided care our patients have relied upon these past three years. We respectfully urge that Congress acts to make the following waivers permanent to ensure access is preserved for patients.
• Physician Services. 42 CFR §482.12(c)(1)–(2) and §482.12(c)(4): Waiving requirements that Medicare patients admitted to a hospital be under the care of a physician, allowing other practitioners to practice to the top of their licensure, while authorizing hospitals to optimize their workforce strategies. For example, a recent report outlined that Certified Registered Nurse Anesthetists (CRNAs) in states that experienced a major impact due to executive orders (including the removal of both state and federal requirements), were significantly more likely to experience expanded clinical practice.2
• Physician Visits. 42 CFR 483.30(c)(3): Allowing Nurse Practitioners (NPs) and clinical nurse specialists (CNSs) to perform all mandatory visits in a skilled nursing facility (SNF) has enabled practices and SNFs to maximize their workforce. This waiver improves continuity of care and infection control by reducing unnecessary contacts between patients and multiple providers. In May of 2022 this waiver was discontinued, yet research has shown the value of NPs providing care in these facilities,3 making it more critically important to ensure that SNF patients continue to receive prompt access to the high-quality care provided by NPs.
• Physician Delegation of Tasks in SNFs. 42 CFR 483.30(e)(4): Allowing APRNs to practice to the top of their licensure ensures, especially during this PHE, that patients continue to receive immediate access to high quality healthcare. As noted above, this waiver was also discontinued in May of 2022, and it is critically important to make this flexibility permanent to ensure patient access to high-quality SNF care.
• Responsibilities of Physicians in Critical Access Hospitals (CAHs). 42 CFR § 485.631(b)(2): Making the physician physical presence waiver permanent allows certain APRNs in CAHs to practice to the full extent of their education and clinical training and enables the entire health care team to practice to its fullest capacity in provider shortage areas.
• Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): Physician Supervision of NPs in RHCs and FQHCs. 42 CFR 491.8(b)(1): Waiving the physician supervision of NPs in RHCs and FQHCs requirement has provided much needed workforce flexibility in rural and underserved communities where provider shortages are being exacerbated by COVID-19. Research has found that NPs are more likely to practice in rural and underserved communities and provide care to vulnerable populations. Waivers that remove barriers to practice on NPs in rural and underserved communities are important to addressing issues of health equity and access to care in these communities.4 We appreciate that CMS has extended this flexibility until the end of the year in which the PHE ends and is exploring options to make this flexibility permanent,5 and strongly encourage Congress to act as well.
• Anesthesia Services. 42 CFR §482.52(a)(5), §485.639(c)(2), and §416.42 (b)(2): Allowing CRNAs, in accordance with a state emergency preparedness or pandemic plan, to practice to the full extent of their license by permanently extending the CMS waiver removing physician supervision as a Condition of Participation.
With over four million licensed Registered Nurses (RNs), APRNs, and nursing students, the profession embodies the drive and passion to ensure the health of patients, families, and our
country continues to improve.6 The models of care implemented during these unprecedented times helps inform and improve healthcare throughout the nation. Therefore, we urge Congress to take legislative action to make permanent the above waivers so nurses and APRNs can continue to provide high quality health care to patients in all communities, including in rural and underserved areas, now and into the future. As these conversations continue, and if our organizations can be of any assistance or if you have any questions, please do not hesitate to contact the coalition’s Executive Director, Rachel Stevenson, at email@example.com.
Academy of Medical-Surgical Nurses
Academy of Neonatal Nursing
American Academy of Ambulatory Care Nursing
American Academy of Emergency Nurse Practitioners
American Academy of Nursing
American Association of Colleges of Nursing
American Association of Critical-Care Nurses
American Association of Heart Failure Nurses
American Association of Nurse Anesthesiology
American Association of Nurse Practitioners
American Association of Post-Acute Care Nursing
American College of Nurse-Midwives
American Nephrology Nurses Association
American Nurses Association
American Organization for Nursing Leadership
American Public Health Association, Public Health Nursing Section
American Psychiatric Nurses Association
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
Association of Nurses in AIDS Care
Association of Pediatric Hematology/Oncology Nurses
Association of periOperative Registered Nurses
Association of Public Health Nurses
Association of Rehabilitation Nurses
Association of Veterans Affairs Nurse Anesthetists
Commissioned Officers Association of the U.S. Public Health Service
Dermatology Nurses’ Association
Friends of the National Institute of Nursing Research
Gerontological Advanced Practice Nurses Association
Hospice and Palliative Nurses Association
Infusion Nurses Society
International Association of Forensic Nurses
International Society of Psychiatric-Mental Health Nurses
National Association of Clinical Nurse Specialists
National Association of Hispanic Nurses
National Association of Neonatal Nurse Practitioners
National Association of Neonatal Nurses
National Association of Nurse Practitioners in Women’s Health
National Association of Pediatric Nurse Practitioners
National Association of School Nurses
National Black Nurses Association
National Forum of State Nursing Workforce Centers
National League for Nursing
National Nurse-Led Care Consortium
National Organization of Nurse Practitioner Faculties
Nurses Organization of Veterans Affairs
Oncology Nursing Society
Organization for Associate Degree Nursing
Preventive Cardiovascular Nurses Association
Society of Pediatric Nurses
Society of Urologic Nurses and Associates
Wound, Ostomy, and Continence Nurses Society
House Majority Leader Steve Scalise
House Majority Whip Tom Emmer
House Minority Whip Katherine Clark
Senate Majority Whip Richard Durbin
Senate Minority Whip John Thune
Chairman Ron Wyden, Senate Finance Committee
Ranking Member Mike Crapo, Senate Finance Committee
Chair Bernie Sanders, Senate HELP Committee
Ranking Member Bill Cassidy, Senate HELP Committee
Chairman Cathy McMorris Rodgers, House Energy & Commerce Committee
Ranking Member Frank Pallone, House Energy & Commerce Committee
Chairman Jason Smith, House Ways & Means Committee
Ranking Member Richard Neal, House Ways & Means Committee
1 APRNs include certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNSs) and nurse practitioners (NPs).
2 Callan, Vicki, et al. Impact of COVID-19 Pandemic on Certified Registered Nurse Anesthetist Practice, (August 2021). Retrieved from: https://www.aana.com/docs/default-source/aana-journal-web-documents-1/callanr.pdf?sfvrsn=c3a59f71_4.
3 National Academies of Sciences Engineering, and Medicine. The National Imperative to Improve Nursing Home Quality, at page 236. Retrieved from: https://nap.nationalacademies.org/catalog/26526/the-national-imperative-toimprove-nursing-home-quality-honoring-our.
4 The American Enterprise Institute. Nurse Practitioners: A Solution to America’s Primary Care Crisis, (September 2018). Retrieved from: https://www.aei.org/research-products/report/nurse-practitioners-a-solution-to-americasprimary-care-crisis/.
5 Centers for Medicare & Medicaid Services. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. Page 12-13. (October 13, 2022). Retrieved from: https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf
6 National Council of State Boards of Nursing. (2023). Active RN Licenses: A profile of nursing licensure in the U.S. as of March 9, 2023. Retrieved from: https://www.ncsbn.org/active-rn-licenses.
Promoting America’s Health Through Nursing Care www.thenursingcommunity.org