In 1965, Bonanza was the top show on television and a McDonald’s hamburger cost less than a quarter. (We won’t even talk about the price of gas.) Neil Armstrong had yet to walk on the moon. And the chance of dying following a heart attack was 30%.
Since then, we’ve witnessed the introduction of (among many other things) coronary artery bypass grafts and medications, such as statins, that save and prolong lives. And the chance of dying following a heart attack has dropped below 7%.
What does this have to do with health care reform? Whether you support or object to the Affordable Care Act (ACA), the one undeniable truth is that it has put health care on the front burner across the United States—and leaders in the NP and PA communities say it is an ideal time for their professions to stand up and be counted in a meaningful way.
The contrast with 1965, for example, comes from Tay Kopanos, DNP, NP, American Academy of Nurse Practitioners (AANP) Director of Health Policy–State Government Affairs. One of the key issues that both NPs and PAs have been trying to address in recent years is their inability to order home health care and hospice services for their Medicare patients.
“When it comes to managing Medicare beneficiaries and getting them home health care services and hospice, we are regulated to care standards of 1965,” Kopanos says. “Nowhere else in health care would we find it appropriate to limit a patient’s ability to get health care to standards that are decades old, when new advances have come forward.”
Her counterparts at the American Academy of Physician Assistants (AAPA) are also focused on updating archaic laws and regulations, at both the federal and state levels, that prevent PAs from being effectively utilized.
“We’re finding pretty phenomenal traction in a lot of states toward wanting to remove old, unnecessary barriers to full PA practice,” says Ann Davis, PA-C, AAPA’s Senior Director of State Advocacy and Outreach. “We’re finding good momentum because states are seeking to improve access and remove barriers to care.”
BEST USE OF NPs AND PAs
Whatever happens next with regard to the ACA—whether states opt in to the Medicaid expansion, or the November elections bring change to the White House, or the House of Representatives votes for a 34th time to repeal all or part of the ACA—health care workforce issues are going to remain at the forefront.
“Regardless of how health care reform, from a global perspective, plays out, utilizing the professional health care workforce will continue to be a key challenge and a key area where states will look to make advances,” says Kopanos. “The broad conversation in health care, around the water cooler and at family tables, is ‘How can we get the care that we need at a price we can afford, and who can best keep us healthy?’”
That question dovetails nicely with the discussion of the consequences of the ACA’s insurance mandate, which the Supreme Court notably upheld. Even those who support the principles of the ACA have wondered how the health care system will handle an influx of anywhere from 22 to 32 million newly insured patients.
Part of the answer may be prevention. Kopanos notes that these patients already exist, in or just outside the system, and so do issues of appropriate access to care.
“By reorganizing how we utilize the system, we may come to a place where some of the bottlenecks are alleviated,” she says, “because we are intervening more appropriately through prevention and disease management.”
Or, as Davis says, “It’s much easier to give patients a flu shot than to care for them in the ICU once they have influenza-related pneumonia.”
Improving access typically brings to mind provider volume and distribution. But leaders from AANP and AAPA emphasize that the bigger issue is appropriate utilization of the available workforce: Are NPs and PAs authorized to perform to the highest level of their education and training?
Since both professions are licensed and regulated at the state level, AANP and AAPA have overarching goals for achieving full NP and PA practice in every state. For NPs, the standard is the National Council of State Boards of Nursing (NCSBN) Nursing Model Practice Act; Kopanos says that currently, 33% of states and the District of Columbia “allow patients full access to NP services,” with a goal of 90% or more by 2020. (She notes that some of AANP’s partners, such as the NCSBN and the Center to Champion Nursing, have a more aggressive goal of 100% by 2015.) In the past year, North Dakota and Vermont have updated language in their rules and regulations to be more reflective of the NCSBN model.
“All of NP practice, including prescribing, is now regulated solely by the Board of Nursing in those states, and NPs can provide services without the ‘formal’ relationship with an outside discipline, such as physicians,” Kopanos says. Similar legislation is still “live” in Michigan this year, and Texas has declared its intention to move forward with legislation in the next session. (About 10 other states are in the exploratory stage.)
On the PA side, AAPA identified Six Key Elements of a Modern PA Practice Act (including licensure as the regulatory term and full prescriptive authority) several years ago and has been working to implement them in each state. Overall, Davis says, 55% of states have adopted key elements; in the past two months, three states added a total of five elements (one in New York and two each in Connecticut and Delaware). A chart on the AAPA Web site indicates that three states (North Dakota, Rhode Island, and Vermont) have adopted all six key elements; a total of 24 states have adopted at least four key elements.
“All states would be able to utilize PAs more effectively if the six key elements are enacted,” Davis says. “In addition, we are very eager to have PAs specifically named in laws that deal with care for patients with psychiatric diagnoses and addiction problems.”
Advocacy efforts continue at the federal level, notably with regard to House resolution 2267 and Senate bill 227, which would update the provisions related to ordering home health care and hospice services for Medicare beneficiaries. Another target, says Sandy Harding, AAPA’s Senior Director of Federal Advocacy, is the Federal Workers Compensation Program; neither PAs nor NPs can diagnose and treat federal workers under current regulations, but legislation is in play that would allow them to diagnose and treat traumatic injuries sustained by federal employees on the job—an important first step.
“Not only, again, is it an issue of access to and continuity of care for federal employees who are injured on the job,” points out Harding, “but it can also mean inappropriate utilization of the health care system” if injured workers seek care in the emergency department because a PA or NP in a clinic can’t provide those services.
JOIN THE CONVERSATION
With every advance in their ability to practice, PAs and NPs are better able to provide quality, cost-effective patient care. This is why leaders at AANP and AAPA call on all clinicians to take an active role in advocacy efforts in their state and lend their support to federal initiatives.
“Part of our activity in educating policy-makers is to give them examples of how PAs create better access to care,” says Michael Powe, AAPA’s Vice President for Reimbursement and Professional Advocacy. (He notes that PAs should speak up at the practice level as well, as components of the ACA begin to roll out: “PAs really need to start engaging in conversations within their practice settings, to ensure that those folks who are making decisions understand that they need to include PAs in the contractual process or in dealing with payers.”)
“NPs serve at the intersection of policy and patient care; every day, we see how insurance regulation, policy regulation, and federal law intersect with our patients’ ability to get care—whether it’s getting home health care services, or a script for pain medicine, or handicapped stickers for their car,” Kopanos says. “Get involved. Join the conversation and share those situations with legislators. They carry a lot of weight.”