• if a prescribing/practice agreement is filed with the state Board of Nursing, Board of Medicine and/or Board of Pharmacy, both annually and when the agreement is modified in any way

• pursuant to rules jointly promulgated by the Boards named above

• if the collaborating or supervising physician’s name and DEA # are also on the script.

• She may not admit or attend patients in hospitals

• • if precluded from obtaining clinical privileges or inclusion in the medical staff,

  • if state rules require physician supervision of NPs in hospitals,

  • if medical staff bylaws interpret “clinical privileges” to exclude “admitting privileges,” or

  • if hospital policies require a physician to have overall responsibility for each patient.

• She may not be empanelled as a primary care provider for Medicaid, Medicare Advantage or many commercially insured managed care enrollees.

• She may not be included as a provider for covered services for Workers Compensation.

• She may be paid only at differential rates (65%, 75%, or 85% of physician scale) by Medicaid, Medicare or other payers and insurers.

• She may not be paid directly by Medicaid.

• She may not be certified as leading a Patient-Centered Medical Home or Primary Care Home.

• She may not be paid for services unless supervised by a physician.

• She may indirectly affect the eligibility of other providers for payment because

  • pharmacies cannot get payment from some private insurers unless the supervising or collaborating physician’s name is on the script, and

  • hospitals cannot bill for APNs’ teaching or supervising medical students and residents and advanced practice nursing students (as they can for physicians who provide those same services).

As this example illustrates, the restrictions faced by APNs in some states are the product of politics rather than sound policy. Competence does not change with jurisdictional boundaries; the only thing that changes is legal authority. Indeed, the point is even more sharply illustrated by those states in which an APN’s authorized scope of practice may vary within the state depending on the geographic location of the practice, the economic status of the patient, or the corporate nature of the practice setting. In sum, this practice environment for APNs echoes the conclusion of a previous Institute of Medicine report, which succinctly described the current regulatory framework for health care providers as “inconsistent, contradictory, duplicative, outdated, and counter to best practices” (IOM, 2001). And that disturbingly accurate conclusion was based only upon explicit regulatory