Reimbursements of Advanced Practice Nurses - Research Paper Example

Reimbursements of Advanced Practice Nurses The role of advanced practice nurses in the health industry has been a rising topic for debates on legislation about health care programs and policies. Consequently, Medicare services have been a source of significant interest for citizens, the states, and the federal government. People put prime significance in Medicare services because these services are integral in having a healthy and prosperous society. According to Frakes and Evans (2006), in 2003, the federal government spent 13% of its budget on Medicare services. This means that the federal government spent as much as $271 billion on providing health care services to the needy citizens (Frakes and Evans, 2006). As a result of the increasing allocation on health care programs and policies, the federal government has put significant interest in managing and controlling its costs on implementing these health care programs. In doing so, the federal government has used the legislation to control health care costs by creating a regulatory structure that will regulate resultant costs and prevent fraud within the health industry (Frakes and Evans, 2006). Because of these regulatory policies and programs, health care providers in both patient care and practice are affected (Frakes and Evans, 2006). Of the health care providers that are very much affected of the regulatory efforts set by the federal government, the advanced practice nurses (APN) are among them. Nurse practitioners (NPs) and clinical nurse specialists (CNSs) make up APNs (Frakes and Evans, 2006). According to (Hamric, Spross, and Hanson, 2009), the roles of APNs include nurse practitioners (NPs), certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNSs), and ), certified nurse-midwives (CNMs). Frakes and Evans (2006) assert that payers reimbursing hospitals for the costs for providing services has forced the federal government to implement prospective payment systems. These reimbursements have become financially unbearable; hence, in 1983, “Prospective Payments for Medicare Inpatient Hospital Services” was created (Frakes and Evans, 2006). Consequently, health providers such as physicians and registered nurses are reimbursed under the Current Procedural Terminology system which is created by the American Medical Association (Frakes and Evans, 2006). In this system, which was developed in 1966, reimbursements for a service are determined through the individual provider’s relative value scale (Frakes and Evans, 2006). Subsequently, the value scale, according to Richmond, Thompson, & Sullivan-Marx (2000), is thereby established based on the professional liability insurance cost, practice expense, and work done of the provider, and then multiplied by a geographic expense adjustment modifier. Incidentally, under the reimbursement system, APNs can receive reimbursements from the government’s Medicare and Medicaid programs, commercial insurers, self-insured institutions, and managed care organizations for the services they provide (Frakes and Evans, 2006). With the Omnibus Budget Reconciliation Acts of 1989 and 1990, APNs are able to receive reimbursements; however, Richmond, Thompson, & Sullivan-Marx (2000) maintain that the limitation of this Act is that reimbursements are confined to those who practice inside skilled nursing facilities and rural areas. Another restriction to the reimbursement rights of APNs is that APNS can reimburse only for services billed as “incident to” a physician’s care but requires that the APN be employed or contracted with the physician (Frakes and Evans, 2006). Through this set-up, physicians enjoy reimbursements at 100% of their rates. Clearly, the disparity between APNs and physicians is manifested through these reimbursement policies. In a study of Ruchlin, Levey, and Muller (1975), they define the function of reimbursement programs. In their study, they utilize the incentive reimbursement model in which aims to recognize and adequately compensate health care providers for the physical, psychological, and social care they provide for their patients (Ruchlin, Levey, and Muller, 1975). Another aim of the reimbursement program is to encourage the development of health care services and maintain the effectiveness of health care programs in the long run (Ruchlin, Levey, and Muller, 1975). With this reimbursement model, it is asserted that emphasis is given to the effectiveness of care given by health providers rather than the services they offer. This is the main argument why many groups lobby for the delineation of the reimbursement policy toward APNs. According to Weiland (2008), many factors, such as physicians’ enjoyment of full reimbursements and state regulations to health care providers, have been detrimental to the full acknowledgment of APNs as independent health care providers. With the work and contributions of APNs being unrecognized, Weiland (2008) argues that APNs’ role can be utilized well only with their full professional recognition as independent providers. Consequently, Weiland (2008) maintains that APNs’ roles and performance should not be juxtaposed with those of the physicians’ because APNs are not substitutes to physicians, but rather they are autonomous health care providers who have a different approach to health care. Subsequently, in a study of Salkever, Skinner, Steinwachs, and Katz (1982), they assert that while nurse practitioners' care is less costly, approximately 20% below than that of the physicians’, it is not less effective. Reimbursement Legislation and Policies The introduction of the Balanced Budget Act of 1997, and more importantly, the Primary Care Health Practitioner Incentive Act changed the manner in which Medicare program reimburses the services of APNs. Prior to January 1, 1998, Miller, Snyder, and Lindeke (2005) assert that APNs who were serving in rural areas or health care facilities were the few ones who were able to reimburse for their services. During this period, APNs could only reimburse for their health care services if they were working in certain health care facilities or they were providing health care in rural areas. With the legislation of the Balanced Budget Act of 1997, APNs in all geographic areas and all health care units are able to reimburse for their services (Miller, Snyder, and Lindeke, 2005). This Act removed practice and setting restrictions for APNs allowing for direct Medicare reimbursement at 80% of the physicians’ reimbursement fees (Miller, Snyder, and Lindeke, 2005). However, despite the reimbursements for APNs, the legislation still permits the 100% reimbursement of physician rates if the APN provided services under the physician’s direct on-site supervision (Miller, Snyder, and Lindeke, 2005). There are four prerequisites so that APNs will be able to reimburse Medicare directly: they must be registered professional nurses; they must hold a master’s degree in nursing as of January 1, 2003; they must be authorized to perform services in the state where they practice; and they must be certified by the American Nurses Credentialing Center or other certifying agencies (Miller, Snyder, and Lindeke, 2005). Given these prerequisites, Frakes and Evans (2006) posit that several nuances thereby exist in the Medicare regulations. One of these is that an APN cannot reimburse for his or her services that are included in the surgeon’s global rates like pain or wound management, pre- or post-op outpatient visits, or suture or drain removal (Frakes and Evans, 2006). Another restriction is that federal law requires physician supervision condition for APN practice (Frakes and Evans, 2006). Likewise, federal law requires that APN should provide services within the state’s defined scope of nurse practice; thus, when a service is not addressed in a scope, it cannot be assumed that a non-physician provider cannot provide that service (Miller, Snyder, and Lindeke, 2005). Facing Reimbursement Challenges Assessing the history and literature about APN reimbursements, I believe that APNs are integral in providing efficient health care system in our country. The main role of APNs in our country’s health care program is that they provide care and support that cannot be given by physicians. By neglecting them in our health care legislation and policies, we also neglect the important roles they play in our health system. Analyzing the means in which to address the issues surrounding APN reimbursements entails looking at the legislation policies that seek to improve their situation, within the local and federal levels. I shall contact legislators both on the state and federal levels. First, I shall look for legislators in the federal system that advocate APN rights and support their reimbursement lobbies. Incidentally, one of those legislators in the federal legislative system is Congresswoman Louis Capps of the 23rd district of California. I will work with Congresswoman Capps and be of service to her advocacies and lobbies on the improvement of the reimbursement policy toward APNs. Congresswoman Capps has been an advocate of health reform laws and health care legislation policies. One of the nursing legislations that is supported by Rep. Capps is the Nurses’ Higher Education Loan Repayment Act of 2008. This Act was sponsored by Rep. Capps alongside Reps. Tom Latham, Tammy Baldwin, Madeleine Bordallo, G.K. Butterfield, Corrine Brown, Phil English, Luis Gutierrez, Ron Kind, Raul Grijalya, Michael McNulty, John Sarbanes, and Christopher Smith. This legislation aims to give students and graduates of nursing graduate and post-graduate programs reimbursement for their student loans (Nursing Legislation in the 110 the Congress Amending Title VIII). Another initiative of Rep. Capps is the American Affordable Health Choices Act which clarifies that nurse-managed health clinics are eligible for grants, and which promotes improvements to nurse education, among many others. Incidentally, Rep. Capps is a registered nurse and one of the leading voices in Congress on health care programs and debates, especially those concerning nursing practices. To reach her, I will first call her office in Washington (202 225-3601); and I will send a formal letter of intent to join her volunteers through fax (202 225-5632). Afterwards, I shall wait for the instructions that would come from the office of Rep. Capps and subsequently shall work for her even if it entails going to her office in Washington DC located at 2231 Rayburn House Office. Likewise I shall also tie up with Congressman Tom Cole in the US House of Representatives. He is a member of the Appropriations Committee which has jurisdiction over the annual appropriations bills that are used to fund all government agencies. Consequently, he can be of big help in the fight for the health care reform because he is a member of the Labor/Health & Human Services/Education subcommittee that oversees the budget allocation for health care services. Moreover, he is the only Member of Congress from Oklahoma to currently serve on the Appropriations Committee. To reach Rep. Tom Cole, I shall personally visit his district office in Norman located at 424 Springer Dr., Ste. 201 Norman, Oaklahoma. Consequently, I shall also fax my letters, suggestions, and intent to be a volunteer to 405 321-7369 (Norman district office). I shall wait for the instructions that would come from his office and shall volunteer for him even if it entails going to his office in Washington DC located at 2458 Rayburn HOB. Both Reps. Capps and Cole espouse health care bills geared to protect citizens, one of which is HR 847 (Roll #664) or the Health and Compensation Act. Consequently, both are supporters of the Health care reform. On the other hand, the limitations of the proposed measures of contacting legislators to lobby, offer service, and ultimately bring about change are the following. First, reaching the legislators through their phones entail bureaucratic procedures. Their secretaries will only ask you to fax a letter about your concerns and suggestions. Consequently, they will ask you to forward your concerns to their online portals. Another limitation is that personally going to their offices is costly and entails much time. Another perspective on confronting the reimbursement issue is to strengthen the education of our APNs. It is asserted by different studies (Salkever, Skinner, Steinwachs, & Katz, 1982; Lacey & Minarik, 2000; Phillips, 2006; and Nursing Resource, 2010) that APNs have little knowledge on reimbursements policies and regulations, let alone the role they play vis-à-vis physicians. With the strengthening of the education of our APNs in terms of the reimbursement regulations, federal laws, and rules concerning nursing practices, I believe that our APNs will be able to understand their integral role in the health care of our country. As an individual, I will join the cause by supporting legislative agenda about APN reimbursements. Consequently, I shall volunteer myself to maintain information portals such as websites or blogs to educate and inform not only our APNs but also the citizenry in general about the importance and significance of APNs in our heath care system and how it is important to advance health care reforms and legislations. In confronting the challenges regarding APN reimbursements and other health care reforms and legislations, I shall continue to be in constant vigilance about the latest news, debates, and legislations on these pertinent issues. I give importance to health care policies and programs; thus, I believe that even if I am just an individual, I will still bring about change. Just by being watchful of the recent developments in legislation and by using the technology of the Web to disseminate information, I shall be able to use myself and be a catalyst of change. Bringing about change entails facing different challenges ahead; and I believe that the limitations of contacting are just one of the many roadblocks that I will face to bring about transformation. However, I believe that as soon as I have established my contact with the legislators, I shall have no more worries because these legislators are firm and supportive of the fight for health care. Bibliography Frakes, M. A. & Evans, T. (2006). An Overview of Medicare Reimbursement Regulations for Advanced Practice Nurses. Nursing Economics, Vol. 24 (2), 59-66. Hamric, A. B., Spross, J. A., & Hanson, C. M. (2009). Advanced practice nursing: An integrative approach (4th ed.). St. Louis, MO: Elsevier. Knight, P. (2010). Current Issues for Advanced Practice Nurses. Accessed from . Lacey, K. O. & Minarik, P. A. (2000). Medicare Reimbursement of APNs. The American Journal of Nursing, Vol. 100 (5), pp.24AAA+24BBB+24CCC+24DDD. Miller, M., Snyder, M., & Lindeke, L. L. (2005). Nurse Practitioners: Current Status and Future Challenges. Clinical Excellence for Nurse Practitioners, Vol. 9 (3), 162-169. Nursing Legislation in the 110 the Congress Amending Title VIII Accessed from . Nursing Resource. (2010). 2010 ANA-PAC Election Endorsements. Accessed from . Phillips, S. J. (2006). A Comprehensive Look at the Legislative Issues Affecting Advanced Nursing Practice. The Nurse Practitioner, Vol. 31 (1), 6-38. Richmond, T.S., Thompson, H.J., & Sullivan-Marx, E.M. (2000). Reimbursement for acute care nurse practitioner services. American Journal of Critical Care, 9(1), 52-61. Ruchlin, H. S., Levey, S., & Muller, C. (1975). The Long-Term Care Marketplace: An Analysis of Deficiencies and Potential Reform by Means of Incentive Reimbursement. Medical Care, Vol. 13 (12), 979-991. Salkever, D. S, Skinner, E. A., Steinwachs, D. M., & Katz, H. (1982). Episode-Based Efficiency Comparisons for Physicians and Nurse Practitioners. Medical Care, Vol. 20 (2), 143-153. Weiland, S. A. (2008). Reflection on Independence in Nurse Practitioner Practice. Journal of the American Academy of Nurse Practitioners, 20, 345-352. Read More