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Texas Gulf Coast Chapter of GAPNA

The 5 NP Political Issues and the One Solution

Posted over 7 years ago by Susan Rinkus Farrell

By Eileen T. O'Grady, PhD, RN, NP, Dr. Loretta C. Ford, RN, EdD, PNP, FAAN, FAANP

This column was written by Eileen T. O'Grady, PhD, RN, NP in collaboration with Dr. Loretta C. Ford, RN, EdD, PNP, FAAN, FAANP, the founding mother of the NP movement, during several really interesting and marvelously entertaining discussions.

The success and rapid expansion of NPs and all APRNs have become a threat to the traditional way that health care is delivered in this country. APRNs have felt the political maneuverings of some (not all) physician organizations as they attempt to hold onto their power and dominance in the health care marketplace. This resistance to APRNs by some organized physician groups is the quintessential definition of politics: the struggle for ascendancy or dominance among groups with different power relationships and agendas. Politics introduces nonrational, divisive, and self-interested agendas into the policymaking process. APRNs must acknowledge that it is highly rational for people and organizations to use the power of government to achieve what they cannot accomplish alone.

It is within this context that APRNs have made a significant movement forward with the publication of The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education.1 Known as the APRN consensus document or LACE, this document and the 3-year-long process that convened all of the APRN stakeholders in its development significantly strengthen the internal cohesion among APRNs and will unquestionably lead to more external validation. The APRN consensus document is by far one of the most important, edgiest set of ideas to come out of nursing in years. It has strengthened and standardized the profession internally, enabling us to more forcefully inoculate ourselves against those political forces that resist APRNs. The consensus document also sets unambiguous national standards, which state regulators can use to create a framework for modernizing the state nurse practice acts across the nation. We see the implementation of the LACE document as the single most important remedy for all of the political issues before us.

After much discussion, we have identified the following 5 major political issues confronting advanced practice nurses.

APRN Invisibility

While research related to the safety and quality of APRNs validates us as competent and comparable to physicians in many aspects, more research is needed to reduce errors and enhance patient safety. Threshold improvement cannot be accomplished without interdisciplinary practice approaches—which will require revolutionary change to flatten the educational and cultural silos separating medicine and nursing education.

It is crucial that APRNs are considered distinct provider types in all interdisciplinary research and administrative and clinical data sets. As the evidence base on interdisciplinary teams is built, APRNs must not remain invisible members of the health care team. Building a research portfolio on APRN practice will require adherence to methodologies that explore APRN quality of care within an interdisciplinary context. Moreover, APRNs must be made distinct and visible in all national data sets used in health services research. For example, APRNs currently are not included in many federal demonstrations looking at health care home models.

Perhaps it is too difficult to include NPs in current cross-national research because the standards and licensure requirements vary so drastically from state to state. This creates a catch-22, rendering comparison or generalization of experience of NPs in one state to the wider nation methodologically impossible. Whether the cause is political marginalization or lack of a national practice standard, APRNs must overcome this invisibility at every level of government and in the health care marketplace.

Graduate Medical Education: An Untapped Potential

Under Medicare Part A, the federal government paid hospitals $8.2 billion in 2006 for the sole purpose of training 110,000 medical residents and fellows.2 Medicare also pays $300 million to hospitals for incurred costs of operating approved training programs. This includes several nursing diploma programs, which most experts both inside and outside of nursing agree need to be shut down.

It will require a high degree of political competence, APRN unity, and a robust research agenda demonstrating the value of APRNs to expand Medicare’s graduate medical education training to include APRNs. We have before us a tremendous political opportunity to crack open graduate medical education. The Medicare Payment Advisory Commission (MedPAC) supports including APRNs, as this would likely provide great value to patients. But the political opposition from physician groups to changing the way the government funds physician training programs will be unrelenting.

APRN State Practice Acts

Even as states look for creative strategies to cover the uninsured, lower health care costs, and improve quality, a considerable segment of the APRN workforce remains underutilized because of state laws and regulations that govern APRN practice. Although the regulation of health professions is intended to protect public safety, some of the restrictions on APRN practice have the opposite effect, not only impeding consumer access but also creating patient safety hazards. For example, some states permit nurse practitioners to prescribe only a 7-day course of medication, creating the potential for incomplete treatments, emergence of drug-resistant microbes, and poor quality.

In recent years, states such as Pennsylvania and California developed health reform plans to expand access to care. As part of those failed reform proposals, the governors in each of those states recognized the need to remove unnecessary restrictions before any expanded access proposal could move forward. The Institute of Medicine’s report Crossing the Quality Chasm3 calls these inconsistencies in state regulations “outdated” and “counter to best practices which must be resolved over time.” With the enormity of the health care problems facing our nation, one sensible policy solution would be to maximize APRN practice by eliminating unfounded restrictive regulations.

The LACE document presents 28 recommendations to guide states in modernizing their practice acts pertaining to APRNs. It clearly outlines the professional standards for titling APRNs, program accreditation, national certification, and licensure—including licensing APRNs as independent practitioners with no requirements for collaboration, direction, or supervision from anybody. These recommendations in LACE may create the strongest leverage for APRNs to confront state policymakers with urgency on the need to modernize antiquated state practice acts. The LACE recommendations could become the centrifugal political force around which other matters arrange themselves, replacing the narrow economic interests of a few physician groups.

APRN Education Evolves to the DNP

The evolution to the doctoral level for APRN education stems from the 3 Institute of Medicine reports, To Err Is Human,4 Crossing the Quality Chasm,3 and Health Professions Education: A Bridge to Quality.5 These publications reported widespread problems related to patient safety and called for dramatic restructuring of traditional education for the health professions. These reports recommended that all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement, and informatics. The point was made that the best-prepared seniorlevel nurses should be in key leadership positions and participate in executive decisions.

Complex practice and delivery system demands create a mandate to expand the clinical education and leadership capacity of APRNs. Graduates of DNP programs are expected to use advanced  communication skills and processes to lead quality improvement and patient safety initiatives in health care systems.

Expanding APRNs’ highly developed relational skills to the policy sphere in all realms is an imperative. The doctoral credential creates more opportunities for APRNs to get appointed to federal and private advisory commissions that oversee or develop quality improvement measures. Key corporate boards would be well served by including a DNP. We need to develop long-term strategies and political capital to get APRNs appointed to those influential boards.

Comparable Worth vs a More Cost-Effective Alternative

Current Medicare payment for APRNs is set at 85% of the physician rate, a payment disparity that the APRN community has quietly accepted. According to MedPAC,6 there is no analytic foundation for the payment differentials.

An even more irrational Medicare payment mechanism regarding APRNs is “incident-to” billing. Sometimes services provided by APRNs are billed as “incident to” the professional services of a physician, but physicians are paid the full fee schedule amount—as though the physicians personally performed the service. Politically, the APRN community has taken a strong stance against APRNs billing as “incident to,” which renders the APRN invisible in the care transaction. However, there has been no strong, public stance on comparable worth and the principle of equal pay for equal work.

In principle, Medicare should set its payments equal for physicians and APRNs who provide the same service.  Then the payment appropriate for the lowest cost provider—that is, the one who uses the least resources to provide the service—would be appropriate for all providers of the service. MedPAC affirms that Medicare pays for resources used, not provider type, in the payment framework for physician specialists; the physician fee schedule does not differentiate among specialties in the payments provided for services.

It is likely that in the future health care will be delivered by high-functioning teams of providers and financing will be bundled. Payment incentives will spur innovative strategies to increase quality and satisfaction among patients and providers by helping to move the health care delivery system toward better coordinated care. Regardless of how Medicare pays for health care in the future, NPs must boldly promote a rational payment structure built on a framework that has integrity across disciplines and that does not render our contribution as “less than.”

The Solution: LACE
The rapid growth and success of the APRN movement have been described as a disruptive innovation because APRNs can in many ways provide the same or better care as physicians, at a lower cost and in more convenient settings. This disruption has contributed to professional turf battles and sharpened the political opposition to APRNs—circumstances that do not promote quality and patient safety.

We hope that all local, state, and national organizations will concentrate on the implementation of LACE and make it a focus of their mission statement. The LACE document has propelled APRNs onto more solid ground that unquestionably will hold the weight of our success. We cannot expect our political issues to vaporize with the implementation of LACE, as the velocity of our success will likely become an even larger threat to the status quo. Therefore, making LACE a reality for the future will necessitate fierce energy, laser-beam focus, and unity among all APRN stakeholders.

References

  1. APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. July 7, 2008. https://www.ncsbn.org/7_23_08_Consensue_APRN_Final.pdf.
  2. Lisk C. Is medical education training our physicians for health care delivery in the 21st century? Presentation made on October 2, 2008. http://www.medpac.gov/transcripts/GME%20panel%20Dr%20Benjamin%20Chu.pdf.
  3. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
  4. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
  5. Institute of Medicine. Health professions education: a bridge to quality. Washington, DC: National Academy Press; 2003. 
  6. MedPAC. Report to Congress: Medicare payment to advanced practice nurses and physicians assistants. June 2002. Washington DC. www.medpac.gov.

The success and rapid expansion of NPs and all APRNs have become a threat to the traditional way that health care is delivered in this country. APRNs have felt the political maneuverings of some (not all) physician organizations as they attempt to hold onto their power and dominance in the health care marketplace. This resistance to APRNs by some organized physician groups is the quintessential definition of politics: the struggle for ascendancy or dominance among groups with different power relationships and agendas. Politics introduces nonrational, divisive, and self-interested agendas into the policymaking process. APRNs must acknowledge that it is highly rational for people and organizations to use the power of government to achieve what they cannot accomplish alone.

It is within this context that APRNs have made a significant movement forward with the publication of The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education.1 Known as the APRN consensus document or LACE, this document and the 3-year-long process that convened all of the APRN stakeholders in its development significantly strengthen the internal cohesion among APRNs and will unquestionably lead to more external validation. The APRN consensus document is by far one of the most important, edgiest set of ideas to come out of nursing in years. It has strengthened and standardized the profession internally, enabling us to more forcefully inoculate ourselves against those political forces that resist APRNs. The consensus document also sets unambiguous national standards, which state regulators can use to create a framework for modernizing the state nurse practice acts across the nation. We see the implementation of the LACE document as the single most important remedy for all of the political issues before us.

After much discussion, we have identified the following 5 major political issues confronting advanced practice nurses.

APRN Invisibility

While research related to the safety and quality of APRNs validates us as competent and comparable to physicians in many aspects, more research is needed to reduce errors and enhance patient safety. Threshold improvement cannot be accomplished without interdisciplinary practice approaches—which will require revolutionary change to flatten the educational and cultural silos separating medicine and nursing education.

It is crucial that APRNs are considered distinct provider types in all interdisciplinary research and administrative and clinical data sets. As the evidence base on interdisciplinary teams is built, APRNs must not remain invisible members of the health care team. Building a research portfolio on APRN practice will require adherence to methodologies that explore APRN quality of care within an interdisciplinary context. Moreover, APRNs must be made distinct and visible in all national data sets used in health services research. For example, APRNs currently are not included in many federal demonstrations looking at health care home models.

Perhaps it is too difficult to include NPs in current cross-national research because the standards and licensure requirements vary so drastically from state to state. This creates a catch-22, rendering comparison or generalization of experience of NPs in one state to the wider nation methodologically impossible. Whether the cause is political marginalization or lack of a national practice standard, APRNs must overcome this invisibility at every level of government and in the health care marketplace.

Graduate Medical Education: An Untapped Potential

Under Medicare Part A, the federal government paid hospitals $8.2 billion in 2006 for the sole purpose of training 110,000 medical residents and fellows.2 Medicare also pays $300 million to hospitals for incurred costs of operating approved training programs. This includes several nursing diploma programs, which most experts both inside and outside of nursing agree need to be shut down.

It will require a high degree of political competence, APRN unity, and a robust research agenda demonstrating the value of APRNs to expand Medicare’s graduate medical education training to include APRNs. We have before us a tremendous political opportunity to crack open graduate medical education. The Medicare Payment Advisory Commission (MedPAC) supports including APRNs, as this would likely provide great value to patients. But the political opposition from physician groups to changing the way the government funds physician training programs will be unrelenting.

APRN State Practice Acts

Even as states look for creative strategies to cover the uninsured, lower health care costs, and improve quality, a considerable segment of the APRN workforce remains underutilized because of state laws and regulations that govern APRN practice. Although the regulation of health professions is intended to protect public safety, some of the restrictions on APRN practice have the opposite effect, not only impeding consumer access but also creating patient safety hazards. For example, some states permit nurse practitioners to prescribe only a 7-day course of medication, creating the potential for incomplete treatments, emergence of drug-resistant microbes, and poor quality.

In recent years, states such as Pennsylvania and California developed health reform plans to expand access to care. As part of those failed reform proposals, the governors in each of those states recognized the need to remove unnecessary restrictions before any expanded access proposal could move forward. The Institute of Medicine’s report Crossing the Quality Chasm3 calls these inconsistencies in state regulations “outdated” and “counter to best practices which must be resolved over time.” With the enormity of the health care problems facing our nation, one sensible policy solution would be to maximize APRN practice by eliminating unfounded restrictive regulations.

The LACE document presents 28 recommendations to guide states in modernizing their practice acts pertaining to APRNs. It clearly outlines the professional standards for titling APRNs, program accreditation, national certification, and licensure—including licensing APRNs as independent practitioners with no requirements for collaboration, direction, or supervision from anybody. These recommendations in LACE may create the strongest leverage for APRNs to confront state policymakers with urgency on the need to modernize antiquated state practice acts. The LACE recommendations could become the centrifugal political force around which other matters arrange themselves, replacing the narrow economic interests of a few physician groups.

APRN Education Evolves to the DNP

The evolution to the doctoral level for APRN education stems from the 3 Institute of Medicine reports, To Err Is Human,4 Crossing the Quality Chasm,3 and Health Professions Education: A Bridge to Quality.5 These publications reported widespread problems related to patient safety and called for dramatic restructuring of traditional education for the health professions. These reports recommended that all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement, and informatics. The point was made that the best-prepared seniorlevel nurses should be in key leadership positions and participate in executive decisions.

Complex practice and delivery system demands create a mandate to expand the clinical education and leadership capacity of APRNs. Graduates of DNP programs are expected to use advanced  communication skills and processes to lead quality improvement and patient safety initiatives in health care systems.

Expanding APRNs’ highly developed relational skills to the policy sphere in all realms is an imperative. The doctoral credential creates more opportunities for APRNs to get appointed to federal and private advisory commissions that oversee or develop quality improvement measures. Key corporate boards would be well served by including a DNP. We need to develop long-term strategies and political capital to get APRNs appointed to those influential boards.

Comparable Worth vs a More Cost-Effective Alternative

Current Medicare payment for APRNs is set at 85% of the physician rate, a payment disparity that the APRN community has quietly accepted. According to MedPAC,6 there is no analytic foundation for the payment differentials.

An even more irrational Medicare payment mechanism regarding APRNs is “incident-to” billing. Sometimes services provided by APRNs are billed as “incident to” the professional services of a physician, but physicians are paid the full fee schedule amount—as though the physicians personally performed the service. Politically, the APRN community has taken a strong stance against APRNs billing as “incident to,” which renders the APRN invisible in the care transaction. However, there has been no strong, public stance on comparable worth and the principle of equal pay for equal work.

In principle, Medicare should set its payments equal for physicians and APRNs who provide the same service.  Then the payment appropriate for the lowest cost provider—that is, the one who uses the least resources to provide the service—would be appropriate for all providers of the service. MedPAC affirms that Medicare pays for resources used, not provider type, in the payment framework for physician specialists; the physician fee schedule does not differentiate among specialties in the payments provided for services.

It is likely that in the future health care will be delivered by high-functioning teams of providers and financing will be bundled. Payment incentives will spur innovative strategies to increase quality and satisfaction among patients and providers by helping to move the health care delivery system toward better coordinated care. Regardless of how Medicare pays for health care in the future, NPs must boldly promote a rational payment structure built on a framework that has integrity across disciplines and that does not render our contribution as “less than.”

The Solution: LACE
The rapid growth and success of the APRN movement have been described as a disruptive innovation because APRNs can in many ways provide the same or better care as physicians, at a lower cost and in more convenient settings. This disruption has contributed to professional turf battles and sharpened the political opposition to APRNs—circumstances that do not promote quality and patient safety.

We hope that all local, state, and national organizations will concentrate on the implementation of LACE and make it a focus of their mission statement. The LACE document has propelled APRNs onto more solid ground that unquestionably will hold the weight of our success. We cannot expect our political issues to vaporize with the implementation of LACE, as the velocity of our success will likely become an even larger threat to the status quo. Therefore, making LACE a reality for the future will necessitate fierce energy, laser-beam focus, and unity among all APRN stakeholders.

References

  1. APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. July 7, 2008. https://www.ncsbn.org/7_23_08_Consensue_APRN_Final.pdf.
  2. Lisk C. Is medical education training our physicians for health care delivery in the 21st century? Presentation made on October 2, 2008. http://www.medpac.gov/transcripts/GME%20panel%20Dr%20Benjamin%20Chu.pdf.
  3. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
  4. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
  5. Institute of Medicine. Health professions education: a bridge to quality. Washington, DC: National Academy Press; 2003. 
  6. MedPAC. Report to Congress: Medicare payment to advanced practice nurses and physicians assistants. June 2002. Washington DC. www.medpac.gov.


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