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StateoftheUnion:NPPracticeinPennsylvania

Lori Martin‐Plank, PhD, CRNP, FAANP

Barbara Todd, DNP, ACNP, FAANP

Susan Schrand, MSN, CRNP

FederalLegislativeUpdate2014

Lori Martin‐Plank, PhD, CRNP, FAANP

PA State Representative for AANP

November, 2014

• House of Representatives

• 233 Republicans

• 199 Democrats

• Senate

• 55 Democrats

• 45 Republicans

LegislativeBranch

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2014MidtermElections• 36 Senate seats 

• 21 Democrats and 15 Republicans

• All 435 Members of the U.S. House 

• 22 House Members are retiring and 5 others are running for a different office

• 8 of these Members sit on committees of jurisdiction for health care issues

Possible OutcomeRepublicans must win at least 6 seats to take control of the Senate and are likely to remain in control of the House

AANP’sFederalPolicyAgenda• Retire ALL federal barriers to nurse practitioner practice

• Home Health• NPs can provide face‐to‐face assessments of patient needs,  but current law requires that a physician document the encounter. 

• Please Cosponsor H.R. 2504/S. 1332, the Home Health Care Planning Improvement Act of 2013. 

• Durable Medical Equipment• Current law requires physician documentation when ordering certain types of DME, causing increased cost and unnecessary delays. 

• CMS has delayed the implementation of this law but legislative action must occur to remove this barrier.

• Please Cosponsor H.R. 3833 which would authorize NPs to document evaluations for certain DME. 

AANP’sFederalPolicyAgenda• Veterans Health Administration

• VHA is updating their nursing handbook which would include allowing all APRNs to practice to their full scope throughout the VHA system.

• Urge Congress to support VHA’s move forward in recognizing NPs to practice to their full scope throughout the VA system. 

• Alignment of Medicaid to Medicare Primary Care Reimbursement Rates

• Under the current program, expiring on 12/31/14, only NPs under the direct supervision of a physician are eligible to participate in program.  

• Any extension of the program must make ALL NPs eligible to participate.

• Please Cosponsor S. 2694, the Ensuring Access to Primary Care for Women and Children Act

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EmergingIssues• Primary Care

• Educating Members of Congress on the number of NPs that are primary care providers

• Ensuring that policy makers understand the importance of NPs being eligible for increases or additional reimbursements made to health care providers providing primary care

• ICD‐10• As we approach the new implementation date of 10/1/15, ensuring that while testing occurs, nurse practitioners are eligible to be part of the testing group and their concerns regarding the use of ICD‐10 are heard

• Provider Non‐Discrimination – Section 2706 of the ACA

AANPSuccesses• Health Policy Conference: over 200 AANP members attended 

• AANP Senior Leadership and Staff engage with senior administration officials at the White House on a regular basis 

• House and Senate briefings held informing Members of Congress and their staffs on NPs

• Home Health Bill has more cosponsors than ever before

• DME regulation delayed 

• Over 24,000 messages sent to policymakers in 2014

• AANP activist database now has over 68,000 contacts 

• Federal regulations relaxed regarding physician supervision in a number of settings

• AANP selected to represent the nursing community at a New Democratic Caucus meeting 

WeNeedYourHelp

• Communicate with Members of Congress

• Meet with them in their District/State office

• Invite them to your practice – Let them see you at work

• Attend a town hall meeting and ask them a question

• Send them a letter 

• District work periods provide great opportunities to get to know your Member of Congress or their staff

• Elected officials need to hear from, meet, and interact with NPs

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SavetheDate

AANP 2015 Health Policy ConferenceMarch 29 ‐ 31, 2015

Hyatt Regency Washington on Capitol Hill ~ Washington, D.C.

Don’t Miss This Exciting Opportunity!

Presentations by leading health policy authorities

Up to the minute health policy updates

Network with NP leaders from across the country

Visit with elected officials during NP Hill Day

Please visit www.aanp.org

YourFederalGovernmentAffairsTeam

• MaryAnne Sapio, VP Federal Government Affairs

• Debra Swan, Associate VP Federal Government Affairs

• Jan Towers, Sr. Policy Consultant

• Clark Princell, Director PAC and Grassroots

CMSGraduateNurseEducationDemonstrationProject:HospitalUniversityof

Pennsylvania

Barbara A. Todd, DNP, ACNP‐BC, FAANPDirector, GNE Network of Greater PhiladelphiaDirector, Advanced PracticeHospital University of Pennsylvania 

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NationalProjectionsforPrimaryCare

• “With the Affordable Care Act, by 2015, it is estimated that a total of 25 million Americans who are newly insured will be seeking care, further straining an already overburdened primary care system.  86 Million more who have improved coverage are also likely to obtain primary care at higher rates than before. Federal and state policymakers will need to ensure there are sufficient resources and support for the primary care workforce to provide needed services to these individuals. “ 

Realizing Health Reform’s Potential  ‐ January 2011, The Commonwealth Fund. Melinda Abrams, Rachel Nuzum, Stephanie Mika, and Georgette Lawlor

PurposeofDemonstration

• HUP‐ one in five nationwide hospitals selected to receive federal funding from the Centers for Medicare and Medicaid Services (CMS) for participation in the GNE Demonstration (July 2012)

• Funding‐ $200M over 4 years to the five selected sites: CMS authority for up to $50M/year (2012‐2016)

• GNE Demonstration payment for reasonable costs for qualified clinical training for Advanced Practice Registered Nurses (APRNs)

• Purpose:

Provide Medicare beneficiaries with improved access to health care provider services by significantly increasing the number of APRNs educated in the Greater Philadelphia Region

Create an efficient partnership collaborative, replicatable, networking model between hospitals, regional nursing schools and clinical partners 

Allows monitoring, collection and information exchange (‘best practices,” etc.) through coordinated communication between regional health care systems, nursing programs, and clinical partners    

CMS5DemonstrationHospitalsSelected

• Hospital of the University of Pennsylvania,       (Philadelphia, PA )

• Duke University Hospital   (Durham, N.C.)

• Scottsdale Healthcare Medical Center   (Scottsdale, Arizona)

• Rush University Medical Center    (Chicago, Ill.)

• Memorial Hermann‐Texas Medical Center Hospital (Houston, Texas)

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HospitalUniversityofPennsylvania

• Owned and operated by the University of Pennsylvania

• Among the top 10 ranked hospitals in the country

• Magnet designated hospital for nursing excellence

• Part of University of Pennsylvania Health System

• 4 major hospitals

• 14 hospital affiliates

• Numerous primary care affiliates

• Largest employer in the region

• Employer of > 500 APRNs

HUPGNESchoolofNursingPartners

• GNE Network of Greater Philadelphia 

• University of Pennsylvania

• Drexel University

• Thomas Jefferson University 

• Villanova University

• Temple University

• Widener University

• LaSalle University

• Neumann University

• Gwynedd‐Mercy University

APRNProgramsSON NP CNS CRNA CNM

University of Pennsylvania

♥ ♥ ♥ ♥

Thomas Jefferson ♥ ♥

Drexel ♥ ♥

Villanova ♥ ♥

LaSalle ♥ ♥ ♥

Widener ♥ ♥

Temple ♥

Gwynedd ♥ ♥

Neumann ♥

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DemonstrationClinicalFootprint

Community Healthcare Partnerships across the state with over 800 clinical training Partnerships including:

Hospital and university based partners

Community Clinics

Federally Qualified Health Centers

Nurse Managed Centers

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GeographicClinicalTrainingFootprint

GeographicClinicalTrainingFootprint

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GoalsandProjectedOutcomes

Demonstration Year 1 and 2  (NPs)  

• Increase in graduates from baseline

• Increase in enrollment from baseline

• Increase in clinical training from baseline

BestPractice

• Partnership with National Nurse Center Consortium (NNCC)

• Partnership with City Health Centers

• “MATCH” for pediatric placements

• Pipeline strategy to meet workforce demands

EarlyChallenges

• Incremental Payment Methodology

• Contracts

• Primary care definition

• Increasing clinical training capacity

• Preceptor Recognition

• Sustainability after 2016

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PrioritiesDY‐3andDY‐4

• Building the case for a national roll out

• Stakeholder engagement

• Targeted focus on UPHS APRN workforce

• Preceptor development

• Piloting preceptor models

• Developing new and innovative preceptor models that will be sustainable post demonstration

CareforPennsylvania:AchievingFullPracticeAuthority

SusanSchrand,MSN,CRNP,NP‐CCEO,PACoalitionofNursePractitionersRWJF2013ExecutiveNurseFellow

November8,2014

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PCNPworkseverydaytorepresenttoadvocateforNPs

• SuccessfulTrackRecord• PAPrescriptiveAuthority– 20yearsinthemaking

• HandicapPlacardSignatoryAuthority

• SingleBoardOversight• PassageofAct48– homehealth,DME,PT,RT,andDietaryreferrals,TANFforms,Methadoneassessments

• Teacher’sPhysicalFormSignatoryAuthority

• DeathCertificateSignatoryAuthority

Progressin2014

• In2014,PCNPwaschargedtogetoverhalfofthemembersofthePASenatetosignoninsupportofFullPracticeAuthority.

Other victories:• Ensured that NPs are 

included among those who can prescribe and establish protocol in schools for epinephrine injections.

• Ensured that NPs were included to lead medical homes, and on statewide medical home advisory council

Whathappenedthisyear?Whydidn’tSB1063passintolaw?• Unfortunately,thisyearinHarrisburgwasoneofthemostgridlockedinmemory.

• Lawmakerswerefocusedonseveralkeybills,likepensionsandliquor,thatdidnotpass.

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TopGoalin2015:FullPracticeAuthority

2015Campaign:CareforPennsylvania

FullPracticeAuthorityreferstoachangeinstatelawthatwouldallowNursePractitionerstopracticetothefullextentofourtrainingandlicensing.

• Formallyknownas“independentpractice”or“autonomouspractice”

• Exclusivelicensureauthoritytoevaluatepatients,diagnose,orderandinterprettests,initiateandmanagetreatments‐includingRX

TheCaseforFullPracticeAuthority

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TheTimeisNow

• Over500,000PennsylvaniansareabouttogaininsurancecoveragethroughtheMedicaidexpansioncalledHealthyPA.

• Moreinsuranceformorepeopleisgreatnews.Butpatientswillonlybeabletogetcareifthereareenoughhealthcareprofessionalstoseethem.

• Only1outofevery3physicians’officesisacceptingnewMedicaidpatientsinPA,accordingtoarecentstudybytheUniversityofPennsylvania.

PAneedstocatchup• 19statesplusWashington,DCnowgiveNursePractitionersFullPracticeAuthority.

• ConnecticutandMinnesotajoinedthislistthisyear.

Source: AANP

NPCareisontheRise

Health Affairs, June 2013

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Expertsoverwhelminglyagree:NPsImprovePatientCare

• Over100studieshaveshownthatNP‐ledcareleadstopositivepatienthealthoutcomesasgoodorbetterthanphysician‐ledcare.

• Non‐partisanexperts,RepublicansandDemocratshaveallcometothesameconclusion.

PApatientsfaceaprimarycareshortage

• TheUSDepartmentofHealth&Humanservicesprojectsaprimarycarephysicianshortageof20,400bytheyear2020.

• HHSsaysNursePractitionerscouldhelptocutthatshortagebymorethanhalf.

• 22%ofPennsylvanians– including55of67counties–resideindesignatedshortageormedicallyunderservedareas.

TheAARPhasendorsedFullPracticeAuthority

• “DecadesofevidencedemonstratethatAPRNsprovidethesamehighqualityofhealthcareasphysicians.ThishighqualityofcareisevidentwhetherornotAPRNsaresupervisedbyphysicians.”– PAAARP

• “ReducingbarrierstofullAPRNpracticeissupportedbyleadersinpolicyandscience.”– PAAARP

• Othersupportingorganizationsinclude:• BucksCountyWomen’sAdvocacyCoalition• NationalNursingCentersConsortium

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It’sgoodforMedicaidandMedicarepatients

• ArecentNursingOutlook studyfoundstateslikePAwithoutFullPracticeAuthorityhavenearly50%morepotentiallyavoidablehospitalizations.

• Forevery1,000person‐yearsamongMedicare‐Medicaidbeneficiaries.

Itboostscareinruralareas• RuralPennsylvanianshaveabouthalftheaccesstoprimarycarephysicianspercapitacomparedtoothers.

• NPsaretwiceaslikelyasMDstopracticeinruralareas.

WhyisthisPolitical?

• FPArequiresstatelawmakershavetochangestatelicensurelaws

Imagefrom:www.kesherisrael.org

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WhatisPCNPdoingtomakeFullPracticeAuthorityareality?

• Two‐prongedapproach• Communications– talkingtonewsmedia,keyinfluencersandthegeneralpublic

• Lobbying– totalkdirectlytolawmakers• In2015,PCNPwillbeworkingintheHousetoo,notjusttheSenate.

• Aftersuccessfullyrecruiting26Senatesupporters,we’regoingtoadaptthecampaigntocorrespondwiththeregionalgroups.

Howcouldanylawmakeropposesomethingthatimproveshealthcare?

• Thoughwe’vebeenaroundfordecades,NursePractitionersarearelativelynewformanylawmakers.

• Somepeoplestilldon’tunderstandwherewefitinthehealthcaresystem.

• Somepeoplearesimplycomfortablewiththestatusquoandwaryofchange.

WhoOpposesFullPracticeAuthority?

• Medicaltradegroups

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Whataretheysayingaboutit?

• TheysayNPsaren’tadequatelytrained.• That’sfalse.Over100studieshavecomparedNP‐ledcarefavorablytophysician‐ledcareanddisproventhisclaim.

• TheysayNPswon’tpracticeinruralareas.• That’sfalse.WherearemyNPsfromruralcounties?NPsaretwiceaslikelyasMDstopracticeinruralcommunities.

• TheysayFullPracticeAuthoritywouldthreatenteam‐basedcare.• That’sfalse.Team‐basedcareisaliveandwellinthe19statesthatalreadyhaveFPA.

Whatyouneedtodo

• PCNPhasyourback.Anywayyouwanttoengageyourcommunity– lawmakers,newspapers,organizations–wewillhelpyoudoit.

• Visitwww.pacnp.organdclickonthe“ContactUs”linkabovethestethoscope.Tellusthatyou’reinterestedinhelping.

• Talktoyourregionalgroupleadersandvolunteertobeacampaignliaison.

• Visitwww.pacnp.organdclickonthe“ContactUs”linkabovethestethoscope.Tellusthatyou’reinterestedinhelping

• Thinkofpotentialcoalitionpartners.

SocialMedia

• EngagePCNPonsocialmedia.• Takeoutyoursmartphoneandgotofacebook.com/PACoalitionofNPs andlikePCNP

• Goto@PCNP_News andfollowPCNPonTwitter

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Videoproject

• WewanttohighlighttheimportantroleofeveryNP.

• GonextdoorandsitdownwithKeegantotakeashort,testimonialvideo.

• We’regoingtocompiletheseonlinetosendaclearmessage:NPsareakeypartofourcommunities.

Lobbying• PCNPwillhelpprepareyoutotalkwithyourlawmaker,eitherinpersoninyourdistrict,inHarrisburgduringLobbyDay,onthephoneorvialetter.

• Followlawmakersonsocialmedia• VOTE!Whoyouvoteforissecret.Whetherornotyouvoteispublicrecord.

WhatMotivatesYou?

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PCNPOrganizationalUpdate

• Sept 2014 Board Retreat

• Rapid growth, need for improved structure

• Strategic planning to occur in 2015

• 2015 Conference will incorporate a General Membership Meeting to continue building communication

• PCNP is committed to building Nurse Leaders, as recommended by the 2010 IOM Future of Nursing.

Thankyouforyourattention!

Haveafantasticconference!

ReferencesSlide 8:  Rhodes, K., Kenney, G., Friedman, A., Saloner, B., Lawson, C., Chearo, D., Wissoker, D., & Polsky, D. (2014).   Primary Care Access for New Patients on the Eve of Health Care Reform.  JAMA Intern Med.  174 (6):  861‐869

Slide 10:  Kuo Y‐F., Loresto F., Rounds L. and Goodwin J. (2013).   States with the least restrictive regulations experienced the largest increase in patients seen by Nurse practitioners. Health Affairs, pages 1236‐1243.

Slide 14:  Oliver, G.M., Pennington, L., Revelle, S., & Rantz, M. (2014) Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nursing Outlook, pages 1‐8.

Slide 15: Pennsylvania Rural Health Care Association Issues Brief. (2010).   Retreived November 3, 2014.http://www.baltichealthcapitalcentre.eu/assets/Knowledge‐center/Rura‐remote‐areas‐health/PARuralHealth‐StatusCheck5.pdf

AANP 2009‐2010 National Sample Survey. Retrieved September 6, 2010, from http://aanp.org/NR/rdonlyres/0952E2EF‐CE8F‐4B26‐AC0019041F1B8E59/0/OnlineReport_General2.pdf.

Office of Technology Assessment: Nurse practitioners, physician assistants and certified nurse‐midwives: a policy analysis, health technology case study. OTA Publication. No.37 [OTA‐HCT‐37]. U.S. Government Printing Office,Washington, DC, 1986; (a) p.8.

Office of Technology Assessment: Health care in rural America. Publication No. OTA‐H‐434, U.S. Government Printing Office, Washington DC, 1991.

GAO Primary Care Report, 2008. General Accounting Office Senate Testimony. Retrieved September 6, 2010, from http://www.gao.gov/new.items/d08472t.pdf.

Slide 20:  AANP Clinical Outcomes:  The Yardstick of Educational Effectiveness.   Retrieved November 3, 2014. http://www.aanp.org/images/documents/publications/clinicaloutcomesyardstick.pdf