WE HAVE MET THE ENEMY…
I love the fact that you stand up for NP/PA rights with your November editorial [Onieal M-E, Danielsen R. Who is the enemy? Clinician Reviews. 2012;22(11): cover, 3-4]. I am an independent family practice ARNP in Washington State, where we are completely autonomous.
There was never a more important time for NPs and PAs to take a stand than right now, with health care reform happening right around us. Reform has many benefits for containing costs and getting health care to the many without insurance, but there are major drawbacks also, as I am learning. One change that has occurred in the past six months in Washington State is the adoption of Aetna and now Premera insurance to pay “midlevel providers” only 85%, following the standard set by Medicare. It is supposed that other insurance companies will follow suit. Getting the Medicare 15% pay deduction has not been refuted in the courts to date (although the battle is ongoing), and this fundamental discrimination in our pay, for the same services provided, will only further cost our profession its autonomy, its rights, and its payments.
It is easy to be too busy with our work and lives to get involved in the legislative process, but if we don’t band together on these issues, our professions will soon lose the independence we have fought so hard for. I encourage much more discussion about this subject to spread the word and stand strong together. Write letters to your representatives—something I have never done until now. We have to show the insurance companies and the medical community that we are strong as a unit.
Kirstin Curtis, ARNP, Bellingham, WA
As Dr. Onieal is aware, I obtained my DNP at Rocky Mountain University last year. Additionally, I opened my own family practice in September 2010. Despite the fact that I love independent practice, it has been one political battle after another.
Last week, I received a letter from Premera [Blue Cross, Seattle], letting me know that they would be “aligning with Medicare” and reducing my reimbursement by 15%, starting in March 2013. (They did list some exclusions: NPs/PAs in the hospital and community health clinic settings, and midwives; God forbid we take money away from the big institutions!) I fully expect that other insurance companies will soon follow their lead and regulate lower pay for “midlevels.” (Ugh, I hate that word! I am not mid-anything, but that is a whole other issue.) Once this happens, I will likely not be able to stay in business.
With the already adjusted fee scales for insurance reimbursement, a 15% reduction will be significant; as most know, family practice is not exactly where you get rich. In any case, it is just one more political battle we as NPs must face, and yes, we must address the “rising negative tide,” as the editorial states. If we do not, I am afraid nursing as a profession will have taken a step backward, and we may never recover.
In addition to the reimbursement battle, I have also faced other tremendous challenges in the last year. I have referred patients to specialists only to have them tell my patients that I am “not a real doctor.” Of course all of my patients know I am a nurse practitioner; that is made evident everywhere in my office. Suffice it to say I am proud to be a nurse and certainly could have been a physician had I wanted to go that route.
I have also been denied the ability to prescribe home health care or follow my patients if they are admitted to long-term care facilities—thanks again, Medicare! I have been denied affiliate privileges at the local hospitals unless I have a “supervising physician.” Funny: I would have to have someone supervise me just to be able to read my patient’s chart, as that is all that affiliate privileges allow.
Yes, this is all despite the fact that I own an independent practice, have more than 1,000 patients in my panel, and manage them independently without the help of a physician. Might I also add that I have been featured on the local news, and in the local papers for providing quality health care to my patients? I am sure they would vouch for the quality of care I provide, which in my opinion is really beyond what most family practice providers in this town offer.
So what do we do? I have written to legislators, but it only seems to get worse. I need help now and cannot wait until 2020 for 90% of the states to have plenary authority, as mentioned by Dr. Golden [Angela K. Golden, DNP, FNP-C, FAANP, President, American Academy of Nurse Practitioners] in your cover article [Hoppel AM. Speaking of presidents … Clinician Reviews. 2012;22(11): cover, 12, 13, 15-17]. While I appreciate those long-term efforts, most of us need action now to stop the downward spiral.
I am frustrated and sad to say for the first time in 20 years that I am considering getting out of the nursing profession (even though my loans for the DNP are still in the red!). I live in a small town where the “good ol’ boy” attitude reigns, so as a female and an NP, I sometimes feel doomed.
Raney Commet, DNP, ARNP, FNP-C, Yakima, WA
Having read [the editorial and the cover article, interviews with Angela Golden and James E. Delaney, PA-C, President, American Academy of Physician Assistants], I was a little taken aback by both the tone and some of the substance expressed. I am the director of an integrated service of more than 80 NPs and PAs who provide a wide range of care to oncology patients (including stem-cell transplant patients) here at the Seattle Cancer Care Alliance. The focus in both articles seemed to be the need for greater effort to delineate the roles of NPs and PAs in distinction to, and at times superior to, those of physicians. Pushing a model that separates the care of NPs and PAs from physicians’ care is counterproductive and fosters bad clinical care. The correct model is collaborative and integrated and is the basis for the growth of our combined professions as we face the future with demographic challenges and projected physician shortages.
In our service, we recognize that PA or NP education, no matter how advanced or how many initials one can tack on a nametag, is not the same as medical school, residency, and fellowship. Our goal is to work with our physician colleagues to allow them to participate in those aspects of patient care in which their particular skills and training can be maximally utilized. Defining the initial diagnosis and laying out the plan for therapeutic intervention is the responsibility of the physician who is leading the particular team; the NP or PA works with the patient, using the outlined plan to monitor progress, intervene when toxicity is noted, and ensure that both the patient and the physician are aware of the current status.
Framing this discussion in an adversarial manner does a disservice to the work of our colleagues and sets up barriers to the needed discussions about future recruitment, training, and utilization. Our future is not so much about defining a separate identity as ensuring that the public, the legislators, the third-party payers, and most importantly the patients understand our unique skills and contributions within an overall team approach to health care.
William Levy, PA-C, Seattle, WA
You are not overreacting. In fact, this matter needs a more aggressive approach, one that benefits the patients we serve. Enough of the disparaging rhetoric from the medical community! It is about time they come to the table of health care in a far more collegial manner—one that facilitates positive patient outcomes, rather than spending idle time critiquing our abilities. If we are guilty of engaging in this behavior, then we need to clearly focus on the goal.
Finally, if they choose not to be part of the solution but prefer being a part of the problem, then we need to present a united front and attack from both policy changes to political action to allow us to provide the care and services that we are capable of.
D. Dempsey, DNP
I was so pleased to see your November 2012 editorial. Having just left my clinical practice in Texas, I have felt the bias and disrespect in the practice environment firsthand. The comments you quoted by Louis Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, are shortsighted and represent a pervasive and oppressive attitude within the medical community in Texas.
An interesting observation was made to me by a member of the Board of Directors of the Texas Academy of Physician Assistants (TAPA), when (to her credit) she called me to ask why I had not renewed my membership in TAPA. I expressed my dissatisfaction with the practice environment in Texas in general, the unfriendly and cliquish behaviors I experienced at the last conference I attended, and the clear evidence that NPs are treated with greater respect than are PAs. She agreed and commented that in Texas, NPs contribute almost twice the amount to their political action committees as do PAs. Consequently, NPs have better representation at the state/political level. (Maybe PAs should look into that?)
However, as long as we work against each other, compete with each other, and disparage each other, we are not working in the best interest of the patient. As long as we spend our time trying to limit the practice privileges of NPs and PAs, we are not building a framework to support the silver tsunami that is coming. As long as we do not support each other, both the health care system and the patient care suffer. We should be talking about our patients’ needs and disease prevention and treatment, not which of us is better than the other.
All states have their challenges, but I have returned to Washington State, where the practice environment is much more supportive of PAs and NPs. Keep up the insightful work you do to support all of us in clinical practice.
Raylene Lawrence, PA-C, Colfax, WA
AND SPEAKING OF THE SILVER TSUNAMI …
Thank you for the article, “Bracing for the Silver Tsunami” [Hoppel AM. Clinician Reviews. 2012;22(9): cover, 5-9]. I was aware of the change in curriculum for nurse practitioners. I received my geriatric NP training at the University of Colorado in 1983-84. There were only eight students in our class. We were to work in nursing homes primarily. However, while waiting for a job opening, I worked in home care and hospice. I also worked as a consultant in a small hospital in Iowa and for Norfolk Housing Authority in Virginia, where I counseled older apartment dwellers. I retired in 1997 at age 65.
As I deal with many chronic problems, I have been increasingly concerned about the lack of coordinated care given, particularly in Virginia. I feel that physicians are mainly concerned with acute care and do not adequately address chronic diseases. I have attempted to find an NP here, but they are few and far between, and one who was highly recommended would not accept Medicare. I have partially solved the problems by going to specialists in Baltimore and Richmond, Virginia, but this is difficult. So I pretty much have to manage my own care—but am concerned about other seniors who do not have my background.
We need more NPs who have some geriatric background. We need a better payment system, so that we can use NPs.
I also see a lack of geriatric education in nurses and nursing assistants. A few treat me as a knowledgeable human being, but others act as if I am demented.
Thanks again for your article—and for “listening.”
Jessie Bryant, NP, Hampton, VA