This appendix contains a table that documents the detailed calculations used to compute the new professional practice index for NPs for each of the 50 States plus the District of Columbia. The criteria used in the new index include:

Legal Status (Maximum = 35)

Title Protection suggests acceptance and acknowledgement of the skills required to practice as a professional. Legal protection provides a safeguard for both the public and the professional.]

Licensure as NP indicates full recognition as a professional. Licensure as an RN and certification or registration as NP is the second best situation. RN license only is the minimum. Requirements for recognition to practice in an advanced nursing role vary by State and may include the passing of a national certification examination, the obtaining of an advanced degree (at the master or doctoral level), as well as various levels of pharmacology education for prescriptive authority. Licensure to practice may occur independently of certification to prescribe. In some States, the renewals of licensure and prescriptive authority occur in tandem. In others, licensure and prescriptive authority require separate applications and separate criteria.

Autonomous practice possible provides the most expansive practice options.

Legal relationship with physicians indicates the degree of autonomy in practice for the advanced practice nurse. Statutes vary considerably in their requirements for physician involvement in NP practice. In some laws, physician relationship is not mentioned; in some, collaboration with other health professionals is a requirement; in others, laws demand supervision by a physician for the NP. More independent environments are considered the ideal practice situation for NPs to exercise their professional practice. However, NPs function well in all of these configurations.

Regulation by the State Board of Nursing is the most appropriate design for NP management. Control of various aspects of practice by Boards of Medicine, Boards of Pharmacy, Boards of Consumer Affairs, etc. occurs across the States with regularity, but these insert the interests of other professions into the practice arena. Self-regulation is the goal of most professions.

The requirement to have practice agreements approved or legislated review of records at particular intervals removes the autonomy of the nurse and/or physician with whom s/he practices to exercise discretion over practice conditions. Professionals recognize and seek appropriate safeguards to the suitable and safe delivery of care to patients. The ideal would be to have that standard determined on an individual basis by the nurse and collaborating health professional at the practice level.

Hospital privileges, referrals, and the ability to order testing suggest recognition of the skills of the NP. In order to practice as a true primary care provider, these things are necessary to care adequately for the patient.

Reimbursement (Maximum = 35)

In 1997, the Balanced Budget Act, expanded the locations at which Nurse Practitioners could be reimbursed for services. Since this represented a progression in reimbursement from 1992, a score was awarded to every State for direct Medicare payment.

State reimbursement policy for payment of services rendered to Medicaid-eligible patients varies considerably by State and by profession.

The legal right to be included on the provider panels of health maintenance organizations allows NPs to fully provide patient care within their professional practice. Since NPs are trained with a primary care orientation, this is a desirable privilege.

The legal right to be reimbursed for services provided is critical to the autonomy of the NP. Although services might potentially be provided totally by the NP, the inability to bill third parties for payment as an identified provider could preclude that from happening. This could be a barrier to the provision of care.

Prescriptive Authority (Maximum = 30)

When prescriptive authority is granted as part of the licensure process for advanced practice, it implies recognition of NP skill and education. Separate application suggests special requirements for the privilege that are not fundamental to the educational and clinical preparation of the NP.

Although DEA numbers are a requirement for prescribing controlled substances, a separate score was allotted to emphasize the importance of the privilege of prescribing scheduled drugs.

Definition of the prescriptive privilege in law rather than by individual physicians suggests full recognition of the abilities of the professional. Dependence on physician delegation for prescriptive authority limits the nurse practitioner and creates barriers to efficient practice. Review by another health professional of patient needs and the ordering of appropriate medications is certainly a necessary part of practice as a NP; however, the circumstances under which that consultation occurs may best be determined by the advanced practice professional and collaborator and need not be detailed in law.

The ability to receive and distribute sample medications, to independently sign a prescription and to prescribe medical devices indicate recognition of the competencies of NPs.

Continuing education requirements are important for maintaining the skills and updating the competencies of the NP.

The actual point allocations for NPs for the 50 States are presented below.