Friday, September 21, 2012

Repost: Different States, Different Rules

One of the biggest areas of frustration for students, stakeholders, and nurse practitioners are the seemingly lack of consistency among state regulations regarding NP practice. The rules in one state may not necessarily apply in the next (and even neighboring state). I have known NPs that lived near state borders, licensed in both states, yet had completely different sets of rules regarding what they can/can't do, requirements for collaboration versus autonomy and prescribing ability.

Barton Associates created this free interactive tool that lets you visually compare all 50 states' (plus DC) NP scope of practice. It is ultra handy and can help one decide whether to practice in one state that is very prohibitive compared to one that offers autonomy.

 There is also a push for the APRN Consensus Model whose aim is to have consistency among the states when it comes to regulations.  

 If moving out of the state isn't feasible, well, the alternative is to become involved, active, and supportive of  a national and local  nurse practitioner organization (it is helpful to be supportive whether your state is autonomous or not since there are constant threats to your practice!)

 An example of the advocacy that membership affords was evidenced this past week. The American Academy of Family Physicians (AAFP) put out their white paper, "Primary Care for the 21st Century." I looked forward to reading this report based on the title and hoped that I would find innovation and new ways of enhancing care for our patients based on the primary care model. To my surprise (and dismay), I found myself reading the executive summary and seeing terms like "nurse practitioners are not doctors"   and "the ideal practice ratio of nurse practitioners to physicians is 4:1" and on. Huh? "How is this a report about primary care?" I thought.

 Then I realized that it wasn't, it was an attack on a profession by another wrapped in a pretty looking monograph with old data. It might as well have been called "Lets Denigrate the NPs Under the Auspices of Solving the Ills of the Health Care System Report." At least I would have known what to expect.

 To be completely honest, I really couldn't read it beyond the executive summary (I looked at the Table of Comments and further became ill). Luckily, one of our national NP organizations (the AANP) did read the whole thing (I am unsure if they became ill or not) and responded. Here is one of the benefits of advocacy for nurse practitioners that benefits all nurse practitioners.

 All areas of the health care sector must better work together to achieve outcomes that are truly patient-centric. Do reports like the one referenced above help? I am highly doubtful. We have real issues to deal with and turf wars will continue to distract from them.

This post was first published at Online Nurse Practitioner Programs

Monday, July 30, 2012

Repost: Let Us Be Heard

I started this blog, A Nurse Practitioner’s View, 3 years ago because there were very few health stories that even mentioned nurse practitioners as part of the health care landscape. Right before I started the blog, I would respond to other health policy articles published on the Web by writing comments to the websites – only to be subjected to baseless and factually incorrect statements. It was soon thereafter that I decided I would write my own perspective on health policy, trends, and news. I also felt it important from a credibility aspect to not blog anonymously but to put my name on it.
I recall those few early blog posts that I proudly wrote and would feverishly check my blog visitor stats to see if people were reading. Well, it was a bit slow going in the beginning with about 10 – 15 readers but as they say, “if you build it, they will come.” Today, the blog enjoys hundreds of visits a day, has a Facebook following, has enabled me to be “discovered” to blog at Online Nurse Practitioner Programs, and I have communicated with people across the country.
I hold a sense of satisfaction that today, nurse practitioners are readily referred to in articles as one of the possible solutions to the healthcare system (not that I attribute it solely to my blog of course) through the body of evidence and hard work that each nurse practitioner performs every day. We have also seen great advocacy efforts at the Federal and State level by our nurse practitioner organizations, and let us not forget the IOM landmark report,The Future of Nursing published in 2010.
While there is still opposition out there about the role nurse practitioners should perform (and I imagine this will always be the case in some way), we are part of that conversation. You can imagine my utter disappointment when I read yesterday’s New York Times front page article, “Doctor Shortage Likely To Worsen With Health Law” and the only mention of NPs was towards the end of the article:
“Dr. Smith said building more walk-in clinics, allowing nurses to provide more care and encouraging doctors to work in teams would all be part of the answer. “
Did you catch that? “Allowing nurses to provide more care.”  I assume that’s the part referring to nurse practitioners. Today, in 2012, I would think that when there is talk about the current and future state of health care, the conversation about health care would be more inclusive of the actual professions comprising the health care system.
Our health system simply cannot continue with the status quo and present the primary solution being “graduate more doctors.” New care models, health information technology enabling more efficient and cost-effective care, increased patient engagement, enhanced payment structure and yes, even the use of nurse practitioners must be the embedded in that conversation.
Now is the time for nurse practitioners to be heard. I invite every nurse practitioner, nurse practitioner student and patient partnered with a nurse practitioner to write to the NY Times to present a viable alternative to “graduate more doctors.” With over 160,000 nurse practitioners across the United States, now is not the time for silence, but is the time for all stakeholders to understand the solution that NPs offer (and will be even more so when out-dated and unnecessary practice barriers are removed).
I am writing and e-mailing ( my letter today to the NY Times to shine some nurse practitioner light on the gloom and doom scenario presented in the article on the future of health care providers. Please consider joining me in writing one too. Let us be heard.
This post was first published at Online Nurse Practitioner Programs

Monday, June 18, 2012

Modernizing Nurse Practitioner Regulations

It's been a busy last few months as the legislative agenda has heated up of the NP organization where I am the Chair-Elect. I have been to some fundraisers and legislative visits to try and garner support from lawmakers to sponsor and support the bill that will eliminate statutory collaboration between a physician and nurse practitioner in New York State. The bill is known as the NP Modernization Act.

We have been at this for about the last 5 years and up until now, there has not been much forward movement. While we had a sponsor for the bill and many co-sponsors, it was stuck in both the Senate and Assembly's Higher Education Committee (where all of the professions in NY state are regulated). The bill basically sat idle in these respective committees. We finally experienced a breakthrough after countless visits and grassroots efforts. The IOM Future of Nursing report absolutely helped make the case for increasing access to care as did the positive press that nurse practitioner partnered continues to receive. Some of the lawmakers were willing to act upon the bill albeit with some amended language.

Since then, the bill has been reported out of the Assembly's Higher Education Committee and should soon be on the floor for full Assembly vote. The same must also happen in the Senate and if it passes the Committee, will go to the Senate floor for a vote. We are staying positive that we will see movement in the Senate but this is one of the significant challenges right now. Oh, and the legislative session ends in 3 days. The bill must then be signed by the governor for to take effect. If it doesn't pass in this legislative session, the process starts all over next year since bills have a 2 year life cycle and this is the second year of the current bill. All is not lost however, since any legislative victories carry some momentum the next go-around.

Of course, there is opposition to the bill. Organized medicine largely does not support the bill and I'm sure that even some nurse practitioners aren't thrilled with it. But in the end, the NP Modernization Act in New York will allow enhanced access to care (while the Patient Protection and Affordability Care Act hangs in the balance of the Supreme Court). And at the end of the day, this is what it is all about - giving patients the opportunity and allowing them to choose care that is delivered in partnership with a nurse practitioner.

On another note, I will be in Orlando Florida this week attending the American Academy of Nurse Practitioners Annual Conference. You can follow updates from the conference on Twitter at #AANP12 plus I will be tweeting from @StephenNP.

Friday, March 30, 2012

Repost: What Nurse Practitioners MUST Know About ACOs

With all the recent discussion on the Affordable Care Act (ACA) being heard before the Supreme Court, I wanted to discuss one of the programs that was borne from the ACA. The Centers for Medicare & Medicaid (CMS) define Accountable Care Organizations (ACOs) as "... groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors."
Wow, this sounds great so far, and seems to be congruent with nurse practitioner-partnered care, what could be wrong with this model? Read on.
The "ACO Professional" is defined, " a physician (as defined in section 1861(r)(1) of the Act) or a practitioner described in section 1842(b)(18)(C)(i) the Act (that is, a physician assistant, nurse practitioner or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act))."
Wow, a win-win all around - a new model of care that is coordinated to reduce waste and duplication, utilizes nurse practitioners and is part of federal legislation. What's the catch?
It is embedded here in the Federal Register:
Thus, although the statute defines the term ‘‘ACO professional’’ to include both physicians and non-physician practitioners, such as advance practice nurses, physician assistants, and nurse practitioners, for purposes of beneficiary assignment to an ACO, the statute requires that we consider only beneficiaries’ utilization of primary care services provided by ACO professionals who are physicians. The method of assigning beneficiaries therefore must take into account the beneficiaries’ utilization of primary care services rendered by physicians. Therefore, for purposes of the Shared Savings Program, the inclusion of practitioners described in section 1842(b)(18)(C)(i) of the Act, such as PAs and NPs in the statutory definition of the term ‘‘ACO professional’’ is a factor in determining the entities that are eligible for participation in the program (for example, ‘‘ACO professionals in group practice arrangements’’ in section 1899(b)(1)(A) of the Act). However, assignment of beneficiaries to ACOs is to be determined only on the basis of primary care services provided by ACO professionals who are physicians.
Did you catch that? Yes, that's right, while NPs are included as "ACO Professionals," if a Medicare patient utilizes a nurse practitioner as their provider, they are not eligible to participate in the ACO unless the beneficiary is assigned to a physician. If that seems non-sensical to you, that's because it is.
So what can NP practices do who want to participate in this money saving model of care (where half of the savings are reaped by the practice)? Unfortunately, the public comment period has closed on this issue. Right now, if an NP-owned practice wanted to participate in a similar type of shared savings model, they would have had to apply for a grant under the CMS Innovation Program and hope to get a similar award for what an ACO would bring. That deadline was due in January and the actual awards should be announced any day.
This is where NPs get shut out of the system. Yes, NPs may participate in an ACO, will improve care, reduce costs and duplication, but the only party benefitting is the physician or hospital-owned ACO. We must let our representatives know how backwards this is. The national nurse practitioner organizations have weighed in on this issue via the NP Roundtable but nothing has really changed. Doesn't seem fair, does it?

Wednesday, February 22, 2012

Oregon: Health Care Politics at Play

I've been following plight of the Oregon Nurse Practitioners regarding reimbursement rates. It seems that back in 2009, NP reimbursement rates from insurance companies were arbitrarily cut by up to 55% for no apparent reason. An attempt to correct that was introduced in the form of legislation. While it appears that the bill itself contained some flaws, it is now destined to flounder in committee once again.

The sad thing here is politics at play. Heavy lobbying from the insurance companies and from organized medicine guaranteed the bill's demise. The lobbyists relied on the "costs will go up" tagline to shoot down the bill. This is laughable. Did those who were insured costs go down when they saw a nurse practitioner? Nope. The NPs diagnosed and treated the patients as they were educated and trained to do - not from some alternative medicine crack pot cookbook. It came from recognized health care standards, procedures, and guidelines. Yet, the insurance companies want to reimburse NPs less for the same work done and reap the rewards. Not fair.

I am not debating the whole physician versus nurse practitioner compensation argument here - we can save that for another time. This reaks of greed and is putting patient lives at risk - especially those in rural areas where these NPs are practicing and are often the sole provider in that area. Unfortunately, it seems as if this practice will continue unabated and those having the power to do something about it will sit idle and hope that maybe someone else will pick up the slack.

Tuesday, February 7, 2012

Advancing Nurse Practitioner Practice

I saw 2 notable articles in the news last week about nurse practitioner practice that I wanted to share. The first one is about two new bills introduced in Missouri that would eliminate the collaborative practice requirement between a nurse practitioner and physician and would allow NPs to prescribe controlled substances as indicated. Missouri is one of the most restrictive states when it comes to NP practice and if this legislation passes, they will move to the forefront of of autonomy. They will have substantial opposition but the bills would allow these NPs to practice to the full extent of their training and education. 

The other article is about the first nurse practitioner to practice in Bermuda. She will begin this summer and work in King Edward VII Memorial Hospital. She is scheduled to be the first student to complete their NP program. 

It is great to see NP practice evolve and have regulations that reflect a scope of practice that is congruent with the training and education of NPs. While there is much work to do (just look at some of the comments from the 1st article), it is becoming clear that NPs can make a meaningful difference in the health care landscape caring for patients.