Medicaid

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Medicaid Advanced Practice Registered NursesH.
R. 2716

• Eileen Sullivan-Marx, PhD, CRNP, FAAN
• Member, American Nurses Association
• Associate Professor Associate Dean for
  Practice
  
• University of Pennsylvania
• School of Nursing
• August 16, 2005

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Advance Practice Registered Nurses

• Advanced nurse expertise in clinical management
  of health care
  
• Conduct history, physical examinations, make
  assessments and diagnoses, treat conditions,
  follow up on treatment, and educate patients and
  families
• Skilled in team management and communication

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Advanced Practice Registered Nurses

• Nurse Practitioners
• Primary Care Acute Care
• Clinical Nurse Specialists
• Specialty Care Behavioral Health
• Certified Registered Nurse Anesthetists
• Certified Nurse Midwives

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APRN Scope of Practice

• Defined Regulated by State Boards of Nursing
• National Professional Certification at Specialty
  Level
  
• Steady consumer acceptance, support, and advocacy
  for role since 1965

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Nurse Practitioners

• Provide primary care services to children,
  adolescents, adults, and elders
  
• Provide acute care medical and surgical services
  in hospitals
  
• 90,000 nationally, masters degree in nursing
• National Certification categories are family,
  pediatric, adult, geriatric, acute care NPs

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U.S. Health Care Workforce Primary Care
Clinician Supply
Source Cooper RA, et al JAMA 1998 280788-94
and COGMEs Eighth Report, November 1996.
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Clinical Nurse Specialists

• Provide specialty care to individuals and
  families in all health care settings
  
• Diabetes, Heart Failure, Behavioral Health,
  Emphysema, Cancer
  
• Masters Degree in Nursing
• 17,000 nationally

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Certified Registered Nurse Anesthetists

• Anesthesia Services
• Pain Management Services
• 65 all Anesthesia Services in U.S., began in
  1935
  
• 33,000

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Certified Nurse Midwives

• Womens Health Care
• Pregnancy Care and Delivery
• Menopausal Care
• Focus on women at risk and under served
• 8000 midwives in U.S.

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Benefits of APRNs

• Improve Access to Care
• High Quality Consumer Satisfaction
• Prevent High Cost Care
• Reduce visits to ERs
• Reduce hospitalizations
• Reduce fragmentation and inefficiencies in system
  of care
  
• Prevent complications
• Safety Net Provider
• Nurse managed community health centers
• Triage/walk in clinics in ERs

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APRN Medicaid Direct Payment Fits with DHHS 500
Day Plan

• Supporting community-based approaches to closing
  the healthcare gapamong racial and ethnic
  minority populations
  
• Consumers are better informed and have more
  choices
  
• Wellness and prevention are sought as rigorously
  as treatment
  
• Seniors and people with disabilities can be cared
  for in their home or community.
  
• Medicaid is flexible and nimble enough to tailor
  benefits to need, allowing millions more to
  obtain insurance.

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Why do we need H.R. 2716?

• Increase access of care
• Cover all services in all areas and settings that
  APRNs are legally authorized to perform
  
• Provide consistency in federal payment practices
• Remove current barriers of payment inefficiencies
  and misinformation
  

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Current Status - Direct Payment for APRN Practice

• Medicare all settings and geographic areas
• Medicaid limited to pediatric NPs, FNPs, and
  certified nurse midwives
  
• Excludes adult and geriatric nurse practitioners
  who care for elderly and chronically ill!
  
• Managed Care Organizations
• Only 32 have a uniform policy on NPs as primary
  care providers (2005)
  
• Indemnity Insurers
• Vary by state law and insurer, tend to follow
  federal guidelines

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Medicare Payment to APNs

• Early 1980s CRNAs CNMs
• 1985 Physician Payment Review Commission
  supported APRN payment
  
• OBRA 1989 Nursing Homes, rural _at_ 85 physician
  rate
  
• BBA 1997 Direct payment to all NPs and clinical
  nurse specialists _at_ 85 physician rate
  

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ANA AMA Collaborative Medicare/RUC Activities

• Member HCPAC Committee
• 1995 - NP Data in Primary Care CPT Codes
• 1996 NP Data in Home Visit Codes
• 1997-98 - Psychotherapy Codes
• Survey Comment Process
• 2000 2005- Review of Work Values
• Resource-based Practice Expense

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Policy Research Supporting APRNs

• GMENAC Report 1980
• U.S. Congress Physician Payment Review
  Commission 1980s
  
• Congressional Office of Technology Assessment
  Report on NPs, CNMs, and Physician Asssistants
  1986
  
• Medicare Payment OBRA 1989 BBA 1997
• HHS/HRSA training funding 1980-2005

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Current Policy Issues Addressed with H.R. 2716

• Growing Aging Population
• Health Disparities
• Safety
• Allocation of Resources
• Health Profession Shortage