joanne m. pohl phd, anp -bc, faan, faanp professor emerita ... · u.s. primary care physician...
TRANSCRIPT
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Joanne M. Pohl PhD, ANP-BC, FAAN, FAANP Professor Emerita,
The University of Michigan School of Nursing
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Compare NP workforce data with PA and Physician data
Discuss regulatory scope of practice issues Discuss reimbursement issues
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Improving Access and Overall Health System Performance
Macrosystems • Policies, regulations,
organizations and environmental forces that support or provide barriers to microsystems – Federal/State regulations – Reimbursement policies – Educational
standards/policies – Accreditation – National boards
Microsystems • People, processes and
practices that interact directly with patients or support patient care at the local level
• Primary care practices • ED • ICU
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*Federation of State Medical Boards Data 2012 **Kaiser Foundation: http://kff.org/other/state-indicator/total-nurse-practitioners/ ***AAPAs Vital Statistics 2012 National Commission on Certification of Physician Assistants
AHRQ (2012) . Primary care workforce facts and stats #1, 2. http://www.ahrq.gov/research/pcworkforce.htm
Total (2013 data) Percent primary care
(AHRQ (2012). Primary care workforce facts and stats #2.)
http://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html
# Practicing primary care
Physicians (878,194) Federation of State Medical Boards Data
33% 208,807 (2010) 289,804 (2013)
NPs 106,073 180,233 Kaiser Foundation: http://kff.org/other/state-indicator/total-nurse-practitioners/
52% - 66% (AHRQ-AANP)
55,625 (2010) 93,721-108,000 (2013)
PAs 86,500 AAPAs Vital Statistics 2012 National Commission on Certification of Physician Assistants
43.4% 30,402 (2010) 37,541 (2013)
Total 1,144,927 294,834 (2010) 421,070 + (2013)
http://kff.org/other/state-indicator/total-nurse-practitioners/http://kff.org/other/state-indicator/total-nurse-practitioners/http://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.htmlhttp://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.htmlhttp://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.htmlhttp://kff.org/other/state-indicator/total-nurse-practitioners/http://kff.org/other/state-indicator/total-nurse-practitioners/
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Geo-graphy
NP PA Family physicians
Gen Internal Med
General Peds
US Population
Urban 72.2% 75.1% 77.5% 89.8% 91.2% 80%
Large Rural
11.0% 11.7% 11.1% 6.7% 6.2% 10%
Small Rural
7.7% 6.9% 7.2% 2.4% 1.8% 5%
Remote Rural/ Frontier
9.1% 6.3% 4.2% 1.1% 0.8% 5%
http://www.ahrq.gov/research/pcwork3.htmhttp://www.ahrq.gov/research/pcwork3.htm
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Only 92 additional U.S. graduates matched to primary care specialties compared to 2012 ◦ Family Medicine match by U.S. medical students: 1,374
(an increase of 39 from 2012) ◦ General Internal Medicine Primary Care matches by U.S.
medical students: 200 (an increase of 14 from 2012). ◦ Primary Care Pediatrics match by U.S. medical students :
30 (an increase of 3 from 2012) ◦ Internal Medicine Pediatrics match by U.S. medical
students: 312 (an increase of 36 from 2012)
Total of 1,916 U.S. medical school graduates matched to primary care residency programs
Including international graduates, 3,715 primary care matches
http://www.nrmp.org/data/resultsanddata2013.pdfhttp://www.nrmp.org/data/resultsanddata2013.pdf
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●14,401 graduates from all NP programs in 2012 ●11,936 (82%) prepared in primary
care roles an increase of about 2,000 from
2011 graduates ◦ Enrollment rates continue to
grow ◦ Currently a total of about
180,000 NPs nationally
American Association of Colleges of Nursing (AACN) and National Organization of Nurse Practitioner Faculties (NONPF)(2013). Enrollment & Graduation Annual survey.
Specific Primary Care NP Rates • Family NP: 8,107 • Adult NP: 1,867 • Peds NP: 888 • Gero NP: 81 • Adult/GNP: 398 • Women’s Health: 423
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NPs choose and practice in primary care to a larger degree (by %) than either physicians, or PAs U.S. Primary Care Physician numbers are basically stagnant based on 2013 Match data while Primary Care Physicians continue to choose specialty practices over primary care for very complex reasons PAs tend to follow physician practice decisions; although numbers are increasing, fewer PAs are practicing in primary care. ›Need for more accurate workforce data
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22 states and DC allow independent practice with some prescriptive limits National State Boards of Nursing https://www.ncsbn.org/2567.htm
•17 states and DC allow NPs to practice fully under their own license (full plenary authority) including prescriptive authority •12 states considered restricted
AANPhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf
•Five states have legislation in process (California, Massachusetts, Michigan, New Jersey, Pennsylvania)
•Substantial evidence to support NPs practicing to their full extent of educational preparation (Macy Foundation Report, IOM reports, National Governors Association Report, )
https://www.ncsbn.org/2567.htmhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttps://www.ncsbn.org/2567.htmhttps://www.ncsbn.org/2567.htm
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Green: Full Authority Yellow: Limited Authority Red: Restricted practice
http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf
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Education
Certification
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Medicaid Reimbursement Rate*
75% 4 States 80% 3 States 83% 1 State 85% 4 States 90% 7 States 92% 1 State (for “some”
services) 95% 1 State 100% Remainder &
DC *http://kff.org/medicaid/state-
indicator/nurse-practitioner-services/#table
Medicare: NPs reimbursed directly at 85% physician rate with collaborative agreement ◦ 100% if billed “incident
to”/under physician
Medicaid: State by state policies ranging from 75%- 100% rate of physicians
Commercial insurers: vary, some using Medicare policy and others at 100%
http://kff.org/medicaid/state-indicator/nurse-practitioner-services/http://kff.org/medicaid/state-indicator/nurse-practitioner-services/http://kff.org/medicaid/state-indicator/nurse-practitioner-services/
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About 12,000 NP new graduates per year prepared as primary care providers
Substantial evidence over 40 years that NPs provide quality, cost efficient care, high patient satisfaction
NPs well positioned to be part of the solution to issues of access to primary care
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Auerbach, D.I. Will the NP workforce grow in the future? Hew forecasts and implications for healthcare delivery. Medical Care, 50(7), 606-610, 2012. (AHRQ. Primary care workforce facts and stats #2. and #3, 2012. ttp://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html a http://www.ahrq.gov/research/pcwork3.htm American Association of Colleges of Nursing (AACN) and National Organization of Nurse Practitioner Faculties (NONPF). Enrollment & Graduation Annual survey., 2013. AANP, 2013: http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf. Cronenwett, L.. & Dzau, V.J. Chairman’s summary of the conference. In Culliton, B., (Ed.), Who will provide primary care and how will they be trained? Durham, NC: Josiah Macy Jr. Foundation, 2010. Iglehart, J.K. Expanding the Role of Advanced Nurse Practitioners--Risks and Rewards. NEJM, 368;20, 1935-1941, 2013. IOM. The Future of Nursing: Leading Change, Advancing Health. National Academies Press, 2011. IOM. Geographic Adjustment in Medicare Payment Phase II: Implications for Access, Quality, and Efficiency. National Academies Press, 2012. National Governors Association. The role of nurse practitioners in meeting increasing demand f or primary care. 2012. http://www.nga.org/cms/home/nga-
center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.html National Residence Match Program, 2013. http://www.nrmp.org/data/resultsanddata2013.pdf. National Council of State Boards of Nursing (NCSBN), Association of Social Work Boards, Federation of State Boards of Physical Therapy, Federation of State
Medical Boards, National Association of Boards of Pharmacy, & National Board for Certification in Occupational Therapy, eds. Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations. Chicago: NCSBN. 2006.
Naylor, M.,D., & Kurtzman, E.T. The role of nurse practitioners in reinventing primary care. Health Affairs, 29 :893-899. doi: 10.1377/hlthaff.2010.0440., 2010.
Newhouse, RP, Stanik-Hutt, J, White, KM, Johantgen, M., Bass, EB., Zangaro G, et al. Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing Economics, 29, 1-21, 2011.
Pohl, J.M., Hanson, C., Newland, J., Cronenwett, L. Unleashing the full potential of nurse practitioners to deliver primary care and lead health care teams. Health Affairs,29, 900-905, 2010.
Pohl, J.M., Barksdale, D.J. ,Werner, K. Primary Care Nurse Practitioner and Physician Workforce: The Latest Data-Can We Afford to Waste our Workforce? Health Affairs Blog, June 18, 2013. http://healthaffairs.org/blog/author/pohlbarksdalewerner/
Safriet, B.J. Federal options for maximizing the value of advanced practice nurses in providing quality, cost-effective health care. In Institute of Medicine (Ed.), The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press., 2011.
Traczynski, J. & Udalova, V. Nurse Practitioner Independence, Health Care Utilization, and Health Outcomes. Presented at the Fourth Annual Midwest Health Economics Conference, April 4-5, 2013, in Madison, Wisconsin.
References
http://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.htmlhttp://www.ahrq.gov/research/pcwork3.htmhttp://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdfhttp://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.htmlhttp://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.htmlhttp://www.nrmp.org/data/resultsanddata2013.pdfhttp://www.ncbi.nlm.nih.gov/pubmed?term=Zangaro%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22372080http://healthaffairs.org/blog/author/pohlbarksdalewerner/
Role of Nurse Practitioners in Meeting the Nation’s Primary Care Needs�National Health Policy Forum�Reconsidering Scope of Practice�November 15, 2013Presentation Focus�Improving Access and Overall Health System PerformanceIs The Number of Primary Care Providers in U.S. Over 400,000?Geographic Distribution of Health Care Professionals in Primary Care, 2010 �AHRQ (2012). Primary care workforce facts and stats #3. http://www.ahrq.gov/research/pcwork3.htm �2013 Primary Care Workforce Data�2013 Physician Match Data�http://www.nrmp.org/data/resultsanddata2013.pdf��2013 Primary Care Workforce Data�2012 NP Graduation Rates Summary of Data TrendsState Scope of Practice Regulations� https://www.ncsbn.org/2567.htm ; AANP, 2012State by State Regulation�(AANP, 2013: http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf)Scope & Regulation: Macrosystem �Four “Legs” of Regulation� Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations, 2007.Current Reimbursement PolicyNPs Are Part of the Solution to the Critical Primary Care Workforce IssuesReferences