Wisconsin Nurses Association
Advanced Practice Nurse Forum
Mary Beck, MSN, APRN, BC, APNP,
President
Business Meeting Address
Pharmacology & Clinical Update
Radisson Hotel & La Crosse Center
May 5, 2007
2006-’07 APN Forum
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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
WNA Staff
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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
APN Forum Mission
Provide a forum for APNs to organize and
act on
 professional
 educational
 economic
 legislative
issues
APN On-line Directory
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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”
APN On-line Directory
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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!
Mary Barker Scholarships
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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
Wisconsin Chapter of National
Association of Clinical Nurse Specialists
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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
Survey of Wisconsin’s Third Party
Payors
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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.
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Reimbursement from Private Payors
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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
Strategic Goal: Survey of
Wisconsin’s Largest Third Party
Payors
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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
Survey of Wisconsin’s Largest Third
Party Payors
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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.
Survey of Wisconsin’s Largest Third
Party Payors
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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
Strategies to Address Problem
Payors
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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
Legislative Fix?
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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.
APN Reimbursement: a National
Issue
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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.
National Provider Identifier
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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/
NPI
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Medicare could reject NPI noncompliers as soon
as July
Medicare 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
NPI
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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?
President’s FY 2008 Budget
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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
FY 2008 Budget
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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
CMS Physician Quality Reporting
Initiative
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“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
Transmittal 1168- Clarification of
Balanced Budget Act of 1997
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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 onsite
CMS Transmittal 1168
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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.
Federal Legislation
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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)
Threat to Nursing’s Scope of
Practice
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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.
Who is the Threat?
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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
Historical Context
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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”
Scope of Medical Practice
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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.
Restrictive Scopes of Practice
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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.
AMA Scope of Practice Partnership
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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
Scope of Practice Partnership
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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.”
The Docs were busy at their
2006 convention
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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”
And finally…HR 5688
“The Healthcare Truth & Transparency
Act of 2006”
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“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”
HR 5688
An unnecessary, misleading,
inflammatory waste of taxpayer
dollars to fix a problem that
doesn’t exist!
HR 5688
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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
Coalition for Patients’ Rights
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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.”
Collaborative Health Care Scope
of Practice Document
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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
HR 5688
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Died before even making it to committee;
no companion senate bill
A calculated move by the AMA, but could
not gather bipartisan support
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.
Administrative Law Judge Rules on
CRNA Scope of Practice
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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.
Decriminalization of Medical
Errors
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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.
Surveyor causing trouble?
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Psych/Mental Health CNS APNPs providing
outpatient psychotherapy services have
been asked to document every episode of
physician collaboration.
Clarification sought
“We must be the change
we want to see in the
world.”
Mahatma Ghandi
Save the date!
2008 Pharmacology & Clinical Update
Thursday April 17- Saturday April 19,
2008
Kalahari Resort & Convention Center
Wisconsin Dells