Dear NNPEN Colleague and Friend: Our comments back to CMS Scope of Practice both 1) congratulates the Trump Administration for putting Full Practice Authority at stage center, recognizing it as the bipartisan issue it is; and 2) suggests ways CMS can uniquely contribute to value-based payment reform for advanced practitioners by encouraging advanced practitioners to accept the challenge of becoming informed risk-takers. Happy reading to start out 2020!
Re: Scope of Practice response to a request for feedback from CMS regarding President Trump’s Executive Order 10/3/2019
January 16, 2020
Ladies and Gentlemen of the Patients Over Paperwork Initiative:
- My name is Sandra Berkowitz and I am the CEO of NNPEN, a national network of Nurse Practitioners (NPs) who are owners of, and employees within, nurse-led clinical practices. These NPs are included within MACRA’s QPP definition of “eligible clinician” and CPC+’s definition of “practitioner”.
- My comments relate to Executive Order #13890 specifically, but also more broadly to how CMS can take the lead withother payers in the construction of infrastructure that facilitates the quickest uptake of, and access to, advanced practitioners into the Medicare provider network. Build outcomes and claims data set specifications, ensuring CMS actuaries will have the ability to compare longitudinal data quality and cost for physician and other advanced practitioners practicing at the top of their license. If CMS makes participation in databases mandatory the cost calculations are run on a leveled playing field. The metaphor when Medicare sneezes everyone gets a cold is trite but true here. Think of this as the encore to our government’s funding technology development in early years by supplying the expensive hardware.
- As a general statement, NNPEN agrees that replacing a legislative/prescriptive definition of scope of practice with one that defers to the education and training of the designated practitioner’s license is a good thing.
- Expecting that AANP and many other friends of NPs will also be responding, NNPEN restricts our other comments to preparing NPs to be informed risk-takers in Value Based Payment risk programs—a skillset that is not part of the NP’s cautious nature—and in fact, is not part of any practitioner’s training.
- NP Scope of Practice success is a pyrrhic victory without NP access to Value-Based Payment arrangements that we know can reliably reward the NP outcomes that flow from the Nursing Process. Executive Order #13890 gives this conversation—i.e., NP risk-taking skills required to succeed in Value Based Payment programs --new and significant urgency.
- Here are our comments detailing opportunities for CMS to level the SOP playing field short and long term:
#1—Preserve/extend the cost and quality benefits of the Nursing Process
- Uncontroverted literature of >100 peer-reviewed studies finds that NPs produce quality and cost outcomes as good or better than those of physician PCPs. Why? because of the integrated view of the patient that is the backbone of the Nursing Process. This hard-wired Nursing Process also explains why nurses are consistently viewed as the most trusted profession
- Yet the Nursing Process is desecrated by the dominant medical model pressure to “see”25-30 patients per day, squeezing patient office visits into 15 -minute segments
- To preserve the benefits of nurse-led care, NPs need many more sustainable independent practice options, that give consumers access to healthcare and preserve the benefits of the Nursing Process in all fifty states. This Executive Order does that.
#2—Full Practice Authority (aka Independent Scope of Practice) will generate a much-needed NP primary care outcomes database
- As long as the NP is not the independent Primary Care Provider, no performance data is being separately attributed to the NP--- both syphoning NP value off to benefit the billing physician and allowing payers to resist exploration of VBP with NPs for “lack of credible data”. CMS can require collection of the longitudinal data that is essential to measuring and documenting the NP’s (and all other PCPs’) management of population health risk
#3--Without NPs delivering primary care access across the nation, CMS will fail to meet its Triple Aim Goals
- We are losing primary care physicians at an unprecedented rate across the U.S., especially in rural areas where the needs are extremely high and opioid addiction/deaths are skyrocketing. Many doctors are moving to "concierge" care models which leave out the poorest/sickest in the U.S.
- NPs are the fastest growing health care professional group by a lot. The American Association of Nurse Practitioners’ website reports there are 270,000 NPs in America in 2019. According to the New England Journal of Medicine, “Between 2010 and 2016… growth in the NP supply accelerated to nearly 10% per year, whereas growth in the PA supply slowed to 2.5% and growth in physician supply slowed to 1.1%.” n engl j med 378;25 nejm.org June 21, 2018
Armed with EO #13890, CMS has the power and gravitas with a top- of -license SOP vision to overcome the payer resistance and physician stonewalling that still confounds SOP progress in more than half of our 50 states. The marketplace and the workforce are ready for SOP change that is refreshingly bipartisan. The timing of EO #13890 couldn’t be better!
We applaud President Trump and CMS for moving SOP to center-stage and look forward to working with CMS as it is rolled out. Please let us know if NNPEN can be of any assistance.
On behalf of our NP entrepreneur membership and an America filled with consumers without access to primary care, NNPEN thanks you for our opportunity to comment on SOP today.
/s/Sandy Berkowitz, RN, JD