Wisconsin Nurses Association Advanced Practice Nurse Forum

1. Wisconsin Nurses AssociationAdvanced Practice Nurse Forum Mary Beck, MSN, APRN, BC, APNP, President Business Meeting Address Pharmacology & Clinical Update Radisson Hotel & La Crosse Center May 5, 2007

2. 2006-’07 APN Forum • Mary Beck, NP – President • Kate Harrod, CNM – Vice President • Gayle Mason, NP – Secretary/Treasurer • Gina Bryan, CNS • Marleen Bryan, CNS • Kristin Haglund, NP • Raandi Schmidt, NP • Kerry Twite, CNS

3. WNA Staff • Gina Dennick-Champion, RN, MSN, MPH – executive director • Megan Leadholm – director of educational programs • Sue Carter – member services assistant • Mary Thony – executive assistant • Beth Prater – office assistant for education

4. APN Forum Mission Provide a forum for APNs to organize and act on • professional • educational • economic • legislative issues

5. APN On-line Directory • Help combat barrier of invisibility; improve communication between APNs; promote APN practice in Wisconsin • Provide colleagues and consumers access to our specialty info, work contact information, areas of expertise • Will be linked from WNA website to DHFS website “Consumer Guide to Health Care”

6. APN On-line Directory • Access through WNA website home page: http://www.wisconsinnurses.org, then within the APN Forum section • Free to WNA members; $50 annually for non-members • Needs to be updated annually • Promote your practice! Help patients find you!

7. Mary Barker Scholarships • Two $2000 annual scholarships sponsored by the APN Forum • WNA members pursuing graduate study in nursing may apply • Access guidelines/application form through WNA website home page: http://www.wisconsinnurses.org, then within the APN Forum section • First scholarships to be awarded June 1, 2007

8. Wisconsin Chapter of National Association of Clinical Nurse Specialists • Introductory meeting in Milwaukee in 3/07 • 26 attendees • Goals: networking, support, education, idea generation, sharing outcomes, increase political influence, role advocacy and differentiation, mentoring • Link to colleges of nursing for resources/ program development • Liason with WNA, other APN groups • Develop email list, prioritize list of ideas • Next meeting 4/27/07 theyse@wi.rr.com

9. Survey of Wisconsin’s Third Party Payors • 2005 APN Forum Reimbursement Survey and • 2005 article in the American Journal for Nurse Practitioners showed that reimbursement for APN services is a major practice barrier for Wisconsin APNs. • Wing, P., O’Grady, E. & Langelier, M. (2005). Changes in the Legal Practice Environment of NPs, 1992 to 2000. The American Journal for Nurse Practitioners, 9(2), 25-37.

10. Reimbursement from Private Payors • Generally accepted practice to bill NP services under collaborating physician’s group or facility provider number (legal unless insurer has policy stating otherwise). • Each individual insurer has right to set their own policies. • Many insurers do not have policies for APN reimbursement in place, and are not prepared to deal with issue until pressured by state law, insurance commissioners, NP organizations or consumers demanding access to APN services. Linda Carlson, CPNP & Colleen Kochman, CPNP, NAPNAP

11. Strategic Goal: Survey of Wisconsin’s Largest Third Party Payors • Systematically survey of the 33 companies comprising Wisconsin’s top 20 group & top 20 individual health insurance payors • Compile this data in spreadsheet format • Data can be used to identify problem payors across the state • Help us know which companies and their subscribers to target with campaigns

12. Survey of Wisconsin’s Largest Third Party Payors • Surprisingly hard to find/contact the individual within each company who knows company’s policy about APN reimbursement. • Time and labor-intensive! • Will require dedicated staff who can log phone time 9-5, make multiple follow-up calls, pursue answers to our questions through multiple contacts at the companies.

13. Survey of Wisconsin’s Largest Third Party Payors • APN Forum will fund part-time salary of nursing graduate student/intern to assist us in this data collection in 2007-’08 • Intern will assist WNA staff with other work at their discretion • Compile data in spreadsheet format to share with APN Forum members at 2008 Pharmacology Conference

14. Strategies to Address Problem Payors • Meetings with problem payors to present facts about APNs: we can improve access to high quality care for subscribers. • Pilot studies? We can prove our worth. • Meet with larger groups of subscribers to enlist their help in requesting ability to see APNs for needed health care services

15. Legislative Fix? • Any Willing Provider • Almost half the states have laws prohibiting health insurers from excluding participation of willing and qualified health care providers in their geographic coverage areas. Several states have adopted broad provisions applying to hospitals, physicians, chiropractors, pharmacists, podiatrists, therapists and nurses. • Typical Provisions • A typical any willing provider law requires all health insurers to be ready and willing at all times to enter into service contracts with all health care providers who are qualified under state law, who practice within the general geographic area served by the insurance company, and who are willing to meet the terms and the conditions set forth by the insurer.

16. APN Reimbursement: a National Issue • The APN Multi-State Alliance representatives from 20 APN state organizations and 3 national APN organizations discuss ways to address reimbursement barriers that currently result in limited access to quality health care provided by APNs. Health care provided by APNs is often to the neediest of health care consumers such as those who are uninsured or underinsured. APNs often have markedly reduced reimbursement for the health services they provide, even though they may be the primary provider of health care services. The multi state group looks specifically at commercial insurers but also discusses problems with Medicare and Medicaid reimbursement.

17. National Provider Identifier • Under the National Provider Identifier Regulation that was published in the Federal Register on Jan. 23, 2004, a health care provider who is a covered entity, as defined at 45 C.F.R. & 160.103, is required to obtain a National Provider Identifier by May 23, 2007. To apply online, visit: https://nppes.cms.hhs.gov/

18. NPI • Medicare could reject NPI noncompliers as soon as JulyMedicare could begin rejecting fee-for-service claims that don't have national provider identifiers for the primary provider as soon as July 1, according to the CMS. The deadline for providers to comply with the NPI requirement is May 23, but the agency says it will not bring enforcement action after that date if entities are acting in good faith to become compliant. Health Data Management

19. NPI • Likely to be used by other payors besides Medicare; universal= reduced paperwork • Can be used to track an individual provider’s outcomes and demographic information • The end of billing under collaborating physician’s number?

20. President’s FY 2008 Budget • 30% cut in funds for nursing education, practice, retention • 100% cut in funds for advanced nursing education! • No increase in nurse faculty loan program • Steep cuts to funding of Title VII health professions programs • State Children’s Health Insurance Program (SCHIP) would not be renewed

21. FY 2008 Budget • The 2008 budget resolution approved by congressional appropriations committees on 5/2/07 specifically rejects the President's cuts to education, including his plan to eliminate many education programs. • Budget resolution makes a down payment towards addressing long-standing needs in education, training, and social services. To that end, the resolution provides an appropriated program level for health programs that is $7.9 billion above the 2008 level in the President's budget. • SCHIP program renewed

22. CMS Physician Quality Reporting Initiative • “Pay for Performance” – financial incentive for APNs to participate in voluntary quality reporting program http://www.cms.hhs.gov/pqri/ • 74 quality measures • Can earn 1.5% bonus on all allowed charges for covered professional services • Reporting period 7/1/07 through 12/31/07 • Can participate individually, without physician collaborator

23. Transmittal 1168- Clarification of Balanced Budget Act of 1997 • Calls for direct reimbursement for NPs and CNSs providing Medicare Part B services regardless of setting; not restricted by site or geographical location. • “Incident to” billing is no longer needed; NPs and CNSs are classified as Part B providers • Dropped the “MD needs to be on-site” to receive reimbursement • Can still bill “incident to” at 100% if office setting, not new patient or old pt. with new problem, physician on-site

24. CMS Transmittal 1168- • Calls for NPs to be reimbursed for assisting in surgery • NPs now authorized to receive reimbursement for serving as “attending physicians” in hospice and home health care, although we still cannot order hospice or home health care independently. • Physician co-signature for hospital admitting physicals by NPs has been eliminated.

25. Federal Legislation • Improving Access to Worker’s Compensation for Injured Federal Workers Act (S 11149) -amendment to add NPs to list of providers authorized to provide services • Family Smoking Prevention & Tobacco Control Act (S 625 and HR 1108) • Medicaid Advanced Practice Nurses & Physician Assistants Access Act of 2007 (S 59)

26. Threat to Nursing’s Scope of Practice • 31 states and D.C. faced scope-of-practice legislation involving >22 groups of health professionals in 2006 • Training & skills of all health professionals has increased dramatically in the past 30 years, but their ability to practice to the full extent of knowledge & expertise is limited by regulation restricting their scopes of practice • Knowledge explosion/ greater understanding of effective treatments for illnesses, injuries, prevention and health promotion strategies.

27. Who is the Threat? • Advanced Practice Nurses-NPs, CNSs, CRNAs, CNMs • Physician Assistants Clinical Psychologists • Pharmacists Massage Therapists • Practitioners of Chinese Medicine Doctors of Optometry • Hair Removal Operators Professional Midwives • Podiatric Physicians Doctors of Chiropractic • Naturopathic Physicians Accupuncturists • Estheticians Physical Therapists

28. Historical Context • In early 1900s physicians were first HCP to secure licensure • Legally defined any kind of medical or health intervention as their exclusive domain • All health interventions and patient care done by anyone other than a physician is a “delegated medical act”

29. Scope of Medical Practice • Only profession with state practice acts that cover all of health care services • “Overly inclusive, undifferentiated, universal, timeless”- “It can’t be yours because it’s mine” mentality • No one health profession’s educational program is comprehensive enough to own all health knowledge. • Physicians have a huge vested interest in maintaining scope of practice monopolies, income, control, status, and excluding other equally capable groups from providing services.

30. Restrictive Scopes of Practice • Lag behind what HCPs are trained and able to do; waste skills that could relieve unmet health needs of millions of Americans • Stifle new technologies, practice models, ideas to provide high quality care at a lower cost • Promote an antiquated model of health care delivery. New model is an integrated, interdisciplinary, collaborative model of care delivered by various members of a team.

31. AMA Scope of Practice Partnership • AMA & other physician groups have formed the SOPP to study “qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review of all ‘limited licensure’ providers. • SOPP will serve as national clearinghouse for physicians, legislators, courts & regulatory agencies in states dealing with scope of practice legislation • Significant $$$ are being directed toward this initiative

32. Scope of Practice Partnership • Stated goals:”public protection/ensure quality care for patients…it is important that our patients know & receive care that only physicians are uniquely qualified to provide.” • Organized medicine wants to oppose any legislative changes that “jeopardize the health & safety of the public” & “keep others from straying into the realm of medicine.”

33. The Docs were busy at their 2006 convention • Resolution 211-”Need to Expose and Counter Nurse Doctoral Programs” • Resolution 716- “Health Clinics in Retail Stores” • Resolution 814- “Limited Licensure Health Care Provider Training & Certification Standards” • Resolution 902- “Need for Active Medical Board Insight of Medical Scopes-of-Practice Activities of Mid-level Providers”

34. And finally…HR 5688“The Healthcare Truth & Transparency Act of 2006” • “Protect” the public from HCPs who are not physicians; makes unsubstantiated claims of “numerous” instances of HCPs intentionally deceiving public by misrepresenting themselves as physicians • Targets those with a DNP degree as misleading & confusing patients that they are “true physicians” • States consumers think that complex medical issues, procedures, and prescribing medicines should only be performed by medical doctors • Charges the FTC with enforcement of violation of “prohibited conduct”

35. HR 5688 An unnecessary, misleading, inflammatory waste of taxpayer dollars to fix a problem that doesn’t exist!

36. HR 5688 • Challenges states’ ability to regulate and determine scopes of practice. HCPs are well-regulated by state boards in all 50 states. We already have legislation making it illegal to hold one’s self out to the public as a physician. • Would expand the authority of the FTC to intervene if it should believe a scope is “fraudulent”; ultimately would limit the government’s ability to restructure the health care system • Would allow non-nurses to determine if the scope is consistent with state law • Thinly veiled attempt to limit competition

37. Coalition for Patients’ Rights • Loud, united response from 33 organizations representing over 3 million healthcare professionals calling on SOPP to “cease their divisive efforts and instead work with us to advance the well-being of patients.” • Called for a balanced study of whether physician practice is overly broad; evaluate implications of state laws that allow MDs to practice in any specialty, regardless of individual qualifications • Addressed pejorative terminology used by AMA; “We are NOT physician adjuncts. We are independently responsible for our actions, regardless of whether MDs are involved.”

38. Collaborative Health Care Scope of Practice Document • Reps from national boards of social work, physical therapy, medicine, pharmacy, occupational therapy and nursing created a practical document to help legislators & regulatory bodies in their decisions about changes to HCP’s scopes of practice • Most HCPs today share some skills and procedures with other professions. No longer reasonable to expect each profession to have a completely unique scope of practice • Describes when a health care profession is capable of delivering the proposed care in a safe and effective manner • www.ncsbn.org

39. HR 5688 • Died before even making it to committee; no companion senate bill • A calculated move by the AMA, but could not gather bipartisan support

40. It’s not about skill, patient safety and “medical acts”. It’s about statute, politics, money, power, control. MDs don’t own diagnosing, prescribing, or delivering care; they are “medical” acts because the AMA made them so in statute. The AMA is a trade union dedicated to protecting physicians’ interests and maintaining the status quo. They are economically motivated. These attacks by AMA are not representative of mainstream physicians, are not improving access to health care for patients, & lead to wasted time, energy & use of limited financial resources to fight them.

41. Administrative Law Judge Rules on CRNA Scope of Practice • Wisconsin Society of Anesthesiologists petitioned the Board of Medicine to decide if the administration of anesthesia by a CRNA requires physician supervision. • WANA filed a ($15,000) brief with the court detailing how delivery of anesthesia is the practice of nursing as far back as the civil war. Affidavits of support filed by WNA, Rural Healthcare Hospital Association, others • Administrative law judge ruled 1/07 that CRNA must be APNP, but that anesthesia administration was within the scope of nursing, and did not need physician supervision. • Anesthesiologists appealed the decision.

42. Decriminalization of Medical Errors • High profile medication error of Madison RN causing the death of a patient 10/06 • Department of Justice made unprecedented move by filing criminal charges • Massive outpouring of support for RN from nursing and medical community, WNA • Coalition of interested HCPs and payors, employers, patient safety organizations, attorneys met to prepare recommendations that HCPs, in the absence of criminal intent, should not be held criminally liable for act or omission related to rendering care or failure to render care.

43. Surveyor causing trouble? • Psych/Mental Health CNS APNPs providing outpatient psychotherapy services have been asked to document every episode of physician collaboration. • Clarification sought

44. “We must be the change we want to see in the world.” Mahatma Ghandi

45. Save the date! 2008 Pharmacology & Clinical Update Thursday April 17- Saturday April 19, 2008 Kalahari Resort & Convention Center Wisconsin Dells