Download Health Care Reform Coordinating Council Health Care Workforce

Health Care Reform Coordinating Council
Health Care Workforce Workgroup
Testimony of Jane Kapustin, PhD, CRNP, BC-ADM, FAANP
September 27, 2010
The Nurse Practitioner Association of Maryland (NPAM) is the largest and only full-time
statewide professional association representing Maryland’s certified nurse practitioners—RNs
with graduate degrees in specialized areas of practice, such as pediatrics or mental health, and
who are licensed as autonomous care providers. NPAM’s primary mission is to assist nurse
practitioners in the delivery of quality, accessible, and affordable health care for the citizens of
Maryland. NPAM is committed to ensuring the success of health care reform, whose goals
reflect the realization of NPAM’s mission and the professional duty of its members.
I am a certified adult nurse practitioner (ANP) with over 25 years of experience as an
advanced practice nurse, the past 15 of which have been in primary care. My current practice is
with the University of Maryland Medical Center’s Joslin Diabetes Center, where I focus on
diabetes management for an inner-city, medically underserved population in Baltimore. In that
capacity, I frequently receive referrals from primary care physicians of their patients with
diabetes. I am also the assistant dean for the master’s program at the states largest nursing school,
the University of Maryland School of Nursing, where I oversee our seven advanced practice
nursing programs: adult/geronotological nurse practitioner (ANP-GNP), family nurse practitioner
(FNP), pediatric nurse practitioner (PNP) psychiatric mental health nurse practitioner (PMHNP),
acute care nurse practitioner (ACNP), nurse anesthetist (CRNA), and clinical nurse specialist
(CNS) programs.
The state of Maryland is overlooking a major asset in solving the primary care
practitioner shortage in Maryland: its 3,400 nurse practitioners, as well as its CNSs, CRNAs, and
certified nurse midwives. But because I am representing the Nurse Practitioner Association of
Maryland, my testimony is going to center largely on NPs.
NPs have been providing an increasingly significant share of primary care in Maryland
for over 30 years, and we are here now practicing in your very midst in rural, inner city, and all
other medically underserved areas of Maryland, in addition to all hospitals. NPs work in
employee health centers, tertiary institutions, student health centers, school health clinics,
nursing homes, assisted living facilities, out-patient clinics, and private offices all over
Maryland. Unfortunately, most NPs function as “ghost providers,” in hospitals and physicians
practices where our work is not acknowledged because we are not listed as primary care
providers on insurer panels, not mentioned in billing (because if reimbursement is at all available
to us, it is not at the same rate as MDs), and not recognized in the quality outcome measures that
are in large part due to the care we provide.
The NP scope of practice under Maryland law is comparable to that of primary care
physicians: we diagnose and manage the full spectrum of health problems such as influenza,
strep throat, back pain, diabetes, hypertension, and many other conditions and diseases too
numerous to mention. We have full prescribing authority under Maryland law for all FDA-
approved medications, including narcotics, and we order and interpret laboratory tests, X-rays,
CT scans, biopsies, and all other diagnostic tests. We consult with the members of our respective
health care teams to provide patients with the best care. We can both refer patients to all
specialists and receive referrals from physicians and other practitioners for areas in which we
may have particular expertise—as I do in diabetes. We can code office procedures and outpatient visits and bill Medicare, Medicaid, CHAMPUS, FEHBP, HMOs, and private insurers for
our services. We work in interdisciplinary teams with physicians, registered nurses, pharmacists,
social workers, psychologists, and dietitians, among others. Our added value, whether in solo
practice or as member of a larger group, is that because we subscribe to the nursing model of
health, we provide holistic care that incorporates health promotion and disease prevention
interventions.
NPs all have at least a master’s degree in nursing, and many have doctorates as well. All
are nationally board certified and licensed by the Maryland Board of Nursing. NPs carry their
own malpractice insurance, and they compare very favorably to other providers in the National
Practitioner Data Bank (NPDB): just seven Maryland-licensed NPs have been reported to the
NPDB since 2005.
One of the biggest gaps in dealing with the primary care shortage in this state was
revealed by the excellent work of this committee, which reviewed all past health care task force
reports, studies, recommendations, and pilots conducted in recent years as a starting point for its
work. The review failed to find a single study, report, or task force that considered NPs. While
one report on the nurse shortage in 2005 was on this committee’s resource list, even that study
only looked at hospital-based RNs, not NPs per se. It should be noted that just 60% of RNs work
in hospitals and hospitals are expected to experience the slowest job growth of any nursing
setting over the next few years (17%) due to the new emphasis on front end interventions
(prevention, wellness, primary care, chronic disease management) that will take place for the
most part in private practices and community health settings (anticipated 43% job growth).
What is most unfortunate about this omission is not that it fails to account for a shortage
that needs to be confronted. Rather, it fails to account for a powerful asset that can go a long
way toward meeting immediate and longer term needs. The ranks of NPs in Maryland are
swelling at a rate of some 200 a year, according to the Board of Nursing, and it is one of the
fastest growing health care professions nationwide. Some 28 states are contemplating changes to
the scope of practice of NPs to mitigate the primary care shortages they are experiencing.
Maryland eliminated the requirement of a collaborative agreement with physicians during the
last session and replaced it with a simple attestation of collaboration (this goes into effect on Oct.
1). But this is not enough to empower NPs to take on some of the primary care load that we are
educated, skilled, licensed, willing, and motivated to assume.
Let me be clear: we are not asking for incentives; we are not asking for expanded scopes
of practice. You don’t have to spend a dime. A few simple regulatory and structural changes are
all that is needed to increase the primary care workforce by thousands—by empowering NPs to
practice to the full extent of their competencies and licensure.
[email protected] 888-405-NPAM
PO Box 540 Ellicott City, MD 21041
2
Maryland has unrecognized capacity to, in a very short time, expand and intensify some
of the most effective interventions for bending the cost curve in health care: prevention,
wellness, and chronic disease management—and to do so with a workforce already adept at and
willing to work with the most vulnerable populations.
1. Give NPs reimbursement parity. NPs are reimbursed by Medicare at just 85% of the
physician rate for performing the same service. Private insurers follow the Medicare
rates, so whether Medicare or private carriers cover our patients, we face the same
unjustifiable compensation discrimination. Worse still, some insurers such as
CareFirst reimburse us at only 75% of the Medicare rates that are already notoriously
low for physicians. But we are not asking for an increase. We just want parity—equal
pay for equal work. The current situation is not just unfair. It discourages physicians
from hiring NPs in multi-provider practices because they won’t get fully reimbursed
for our services. It discourages NPs from opening up solo and group practices (such
as nurse-managed clinics, patient-centered medical homes, health homes) because
they can’t bill enough to cover costs. In short, it limits the potential of Maryland’s
existing workforce, and at a time when we need all hands on deck to accomplish
some very challenging health care reform goals. And, most regrettably of all, it
deprives populations who lack access to care from getting the care they need and
deserve.
2.
Require insurers to credential NPs. Not only do private insurers skimp on
reimbursements, but in Maryland, they can choose not to include fully qualified and
licensed NPs on their provider panels. United Health Care (including MAMSI,
MDIPA, United MCO) and CareFirst HMO Blue Choice are two examples. CareFirst
subtly discriminates in its contract by requiring a physician to sign except when the
company has agreed to “make an exception” for an NP who has been lucky enough to
negotiate this. Again, this creates more roadblocks for patients, especially when they
would otherwise have access to primary care NPs in solo practice. And it creates the
need for “deal-making” with insurance companies to allow NPs to see their insureds.
In some regions of the state, the NP may be the only primary care provider around.
In these instances, patients with one of these insurance carriers will have to pay out of
pocket or do without primary care entirely.
3.
Require BG&E to accept NP signatures for back up electrical supplies. BG&E
will not recognize verification from an NP that a homebound patient needs a back-up
generator for medical reasons in case the electricity is disrupted. Patients who are on
dialysis at home or who are on ventilators to breathe need this documentation. NPs
are, therefore, forced to obtain physician signatures for this purpose, even when the
physician is not the treating provider. This is not only unjustifiable: it is dangerous
because delay (and sometimes expense) to obtain a signature can be life threatening.
4.
Advocate to lift restrictions on NPs ordering home health services. Federal law
restricts NPs from ordering home health services for a patient. An NP can diagnose
and treat the patient for major chronic diseases such as diabetes and hypertension,
[email protected] 888-405-NPAM
PO Box 540 Ellicott City, MD 21041
3
detect and diagnose a complication (such as a life-threatening skin infection arising
from a foot ulcer), order the appropriate prescription drug regimen to treat the
complication, and yet is unable to order home health nurse services to continue
treatment in the patient’s home environment. Ordering home health is a low-level
acuity procedure that involves no risk, no critical decision-making, no risk to the
patient. Home health is a benefit that saves millions of dollars by facilitating transfers
of patients from expensive, dangerous acute care facilities to less expensive and safer
home environments for further healing and rehabilitation. Moreover, there are NPs
who practice in this area as well, making home visits to supervise care. Those NPs
can assess, diagnose, and provide immediate treatment to the patient who would have
otherwise been hospitalized, all without requiring trips to the clinic. Necessary and
timely care is delivered, potentially saving millions of dollars and reducing patient
hardship simply by coordinating care and delivering it in the community where it is
needed. Maryland’s representatives in Congress should support pending legislation
that would add NPs, among others, to the list of home care providers who can bill
Medicare.
5.
Promote the establishment of NP-managed patient-centered medical home
(PCMH) pilots. Although MHCC recently added nurse practitioners to its definition
of providers who can manage a PCMH, it did so very close to the application
deadline. As a result, few if any NP practices applied. Moreover, the information
about PCMHs for consumers and providers on the MHCC website and elsewhere still
fails to include NPs. This should be redressed. A special concerted effort to
encourage NPs to sign up during the next round must be made, including lifting the
barriers listed above to promote entrepreneurship among NPs. Maryland will not be
able to reach its PCMH goals on the backs of primary care physicians alone—nor
does it have to!
In conclusion, NPs are an integral part of the health care system in Maryland, and they
have a long-established track record of providing excellent primary care. We stand ready to
contribute our knowledge, skills, and passion for improving the health status of Maryland’s
population. All you have to do is ask.
[email protected] 888-405-NPAM
PO Box 540 Ellicott City, MD 21041
4