Payers, not states, often dictate non-physicians’ authority, reimbursement

This article is part of an ongoing series from the American Association of Clinical Urologists (AACU), based on a partnership between the AACU and Urology Times. Articles are designed to provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions about topics for future articles. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information.

The aging population and an expected influx of 30 million newly insured Americans have raised concerns about provider shortages and bolstered efforts to expand the role of advanced practice practitioners (APPs) in the delivery of patient care. Unsatisfied with collaborative teams led by physicians that empower APPs and promote patient safety, organizations representing nurse practitioners, for one, are seizing this opportunity to increase the number of states where they practice without supervision.

The vast expansion of legal authority required to achieve this end has already been granted in 18 states and the District of Columbia, where nurse practitioner scope of practice laws permit independent practice. Legislators in California, Michigan, and Nevada have considered bills in recent months to similarly allow non-physicians to provide care without any oversight, essentially removing the doctor from the doctor-patient relationship.

Policymakers and the health care community would be wise to urge restraint.

A growing body of evidence suggests that scope of practice laws, in and of themselves, do not prevent APPs from practicing to the full extent of their education and training. Rather, public and private payers’ reimbursement policies are more often cited as the reason that APPs have not attained personal and professional goals, according to an article in the National Institute for Health Care Reform’s Research Brief (Feb. 2013; www.nihcr.org/PCP-Workforce-NPs). Both “independent” and “supervised” nurse practitioners seeking credentialing as primary care providers are growing frustrated by insurers’ inaction. A recent American Journal of Nursingarticle cites a National Nursing Centers Consortium study that found nearly half of major U.S. managed care organizations didn't credential nurse practitioners as primary care providers (Am J Nurs 2013; 113:16-7).

APPs argue that patients deserve to choose whether to receive health care from a physician or non-physician provider in the interest of cost savings. Therefore, states and payers should amend laws and policies to make it possible for them to achieve practice independence and success in the marketplace. As of today, however, a significant majority of Americans qualified to participate in health insurance marketplaces are not willing to see a nurse practitioner instead of a physician just to save money. Management consulting firm Accenture found that barely 41% of retail health care consumers would chose a limited license provider for routine care to cut costs.

What’s more, any immediate savings achieved by states authorizing APPs to practice independently and to run their own medical practices will be mitigated by the inevitable next step-payment equality. Some states already pay nurses the same rates as they pay physicians for Medicaid services and the Institute of Medicine recommended that Congress apply enhanced primary care payments mandated by the Affordable Care Act equally, irrespective of training and education. Legislators in Oregon are considering a bill (House Bill 2902) that requires private insurers to pay independent nurse practitioners and physician assistants at the same rate they would pay doctors for the same services. The measure is on the verge of passage in the Beaver State, having failed the past three times it was considered.

A one-size-fits-all mentality pervades both the scope of practice expansion and pay equity issues. Physicians must be prepared to add nuance to these discussions in a sensitive manner. After all, APPs who specialize in urologic care require different skills and supervision, perhaps, than those in primary care. Amid cries of “equal pay for equal work,” one must gently remind equally dedicated colleagues that a physician’s “work” includes more than 10,000 hours of medical education and training, compared to less than 1,000 hours mandated for nurses.

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