Federal Legislative Update – 2009

This is going to be a rough and tumble year on the Hill as new staffers replace old ones and the remaining oldies become mentors at a time of turmoil, transition, and hope. With the economic downturn, our expensive health care system will not be immune to shedding what to some will seem like dead weight and others important healthcare initiatives. This is also a time of tremendous opportunity. We know that APRNs provide high quality cost-effective health care focusing on education and prevention. We excel in the areas of primary care and chronic disease prevention and management. This is our moment and the legislatures are starting to realize that. Word has it that the Obama initiatives have inclusive language….stay tuned as we explore and report on the new bills and proposals that are coming to fruition.

Old Business revisited….

Medical Home

As many of you may recall, there was a provision in H.R.6331, The Medicare Improvement for Patients and Providers Act of 2008, to expand the Medicare Medical Home Demonstration project. Attached is a letter to The Department of Health and Human Services (HHS) urging them to use the new authority granted by H.R.6331 to include nurse practitioners among the health care providers eligible to lead medical home demonstrations. Below is a letter that Senator Bernie Sanders signed onto supporting the inclusion of NPs as Medical Home Leaders.

September, 2008

The Honorable Mike Leavitt

Secretary

Department of Health and Human Services

200 Independence Avenue, SW

Washington, DC 20201

Dear Secretary Leavitt:

We write to you regarding the provision in H.R.6331, The Medicare Improvement for Patients and Providers Act of 2008, to expand the Medicare Medical Home Demonstration project. As the Department of Health and Human Services (HHS) moves forward with implementation of the project, we urge you to use the new authority granted by H.R.6331 to include nurse practitioners among the health care providers eligible to lead medical home demonstrations. Nurse practitioners serve in the role of primary care provider in all types of payer plans, and are key to our nation’s primary care health system. In many rural and underserved areas of the country, nurse practitioners are often the only available primary care providers for Medicare beneficiaries.

Section 133 of H.R.6331, “Expanding Access to Primary Care,” revises the medical home demonstration project as first enacted in the Tax Relief and Health Care Act of 2006. This revision includes granting the Secretary the authority to expand the duration and scope of the project if the expansion (a) will improve the quality of patient care without increasing spending under the Medicare program, and/or (b) will reduce spending under the Medicare program.

The June 2008 report released by the Medicare Payment Advisory Commission (MedPAC), Reforming the Delivery System, includes a discussion on “Promoting the use of primary care” (Chapter 2). The Commission recognizes the potential value of the medical home model and the value of nurse practitioners in providing primary care services. The Commission delineates stringent criteria for a medical home, recommending that programs meet the following criteria: (1) furnish primary care (including coordinating appropriate preventive, maintenance, and acute health services); (2) conduct care management; (3) use health information technology for active clinical decision support; (4) have a formal quality improvement program; (5) maintain 24-hour patient communication and rapid access; (6) keep up-to-date records of beneficiaries’ advance directives; and (7) maintain a written understanding with each beneficiary designating the provider as a medical home. Nurse practitioners can meet these criteria and lead medical homes. Furthermore, nurse practitioners epitomize the delivery of high-quality, cost-effective care that is recognized by the Commission as crucial to the medical homes model.

MedPAC’s analysis of 2006 claims show that nurse practitioners receive a higher percentage (65.4%) of Medicare fee schedule payments for primary care services than physicians in geriatric medicine (65%), family medicine (62.5%), and internal medicine (44.4%), as well as physician assistants (34.8%). A 2008 study of the General Accounting Office (GAO) also reports that the general numbers of nurse practitioners in primary care practice are growing faster than those of primary care physicians. In addition, the overwhelming majority (over 83%) of nurse practitioner graduates continue to be prepared in educational programs with a primary care focus. At a time when our country so greatly needs primary care providers, excluding nurse practitioners from a lead role in medical homes would seem counterintuitive and would disregard the compelling evidence that nurse practitioners are a significant component of our primary care workforce.

We strongly encourage HHS to include medical home demonstrations that allow nurse practitioners to participate fully – including leading the team and serving as a personal provider – in the medical home model. If Congress and the Executive Branch are to rely on the data from the Medicare Medical Home Demonstration project to determine future application of the medical home model on a large scale, it is imperative that the demonstrations include providers who currently provide primary care services to our nation’s seniors.

Thanks Bernie…….

S.3613 H.R. 7114

Senator Wyden (D/OR) and Rep Markey (D/MA) have introduced their “Independence at Home” bills that will create and study “medical homes” in the home care setting. The home health physician group that was pushing this bill where in agreement to include “NP led” practices.

The Home Health Care Planning Improvement Act would ensure that our Medicare beneficiaries get the home health care they need in a timely manner by allowing physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives to order home health services in accordance with state law. This bill is supported by the American Academy of Nurse Practitioners, the National Association for Home Care and Hospice, the American Nurses Association, the American Academy of Physician Assistants, the American College of Nurse Midwives, the American College of Nurse Practitioners, and the Visiting Nurse Associations of America.

For more information, or to join Representative Schwartz in cosponsoring this important legislation, please contact Kate Gross on my staff at Kate.Gross@mail.house.gov.

S.2112

Nurse-Managed Health Clinic Investment Act of 2007 - Amends the Public Health Service Act to direct the Secretary of Health and Human Services to award grants for the cost of operating nurse-managed health clinics that provide primary care for underserved or vulnerable populations and are associated with a school, college, or nursing department, federally qualified health center, or independent nonprofit health or social services agency. Requires a grant application to contain assurances that a clinic will: (1) provide all required comprehensive primary health services for a period of not to exceed two years (subject to a waiver); and (2) establish a community advisory committee to provide input into the clinic's decision-making process. Permits grant funds to be used for primary care and additional health services for the management of clinic programs, salaries, training, and the acquisition and leasing of buildings and equipment.

FECA S.1795 H.R. 4651

The provision of worker compensation services for federal employees. While NPs provide reimbursable services to federal employees under the Federal Employee Health Insurance Program Bill S.1795, we are unable to authorize and provide services if a federal employee is receiving workers compensation. As a result, injured federal employees often are forced to travel long distances and use hospital emergency rooms to receive care under this program. Federal employees who are covered by the Federal Health Benefits Program routinely and receive health care provided by an NP must seek alternate care if injured on the job. New Business

Economic Stimulus Package

The Obama Stimulus package is working it's way through the legislature. It has been passed in the House and is being discussed on the floor of the Senate. Title VIII (nurse education funds) stimulus is still in the bill and our specific inclusion as nurse practitioners in the Medicaid IT and grants section is holding firm. The section focusing on a Medicare stimulus package for IT is still limited to the 1861(r) definition of physician. As we discussed, a $30,000,000,000 reduction in planned allocation for this section and a too high CBO estimate for NPs, put us on the back burner for now. The good news is that there is significantly more money with no penalties in the Medicaid pot than we could get in the Medicare pot. (The Medicare incentive includes penalties for not accomplishing a working IT system by specific dates ) Note, that physicians who opt to apply for the Medicare incentive, cannot also collect from the Medicaid program. While, of course, we'd like to collect under all options, there are more pluses than negatives in this package. We are in close communication with representatives of the committees of jurisdiction who are working with us on these issues.