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Nurse practitioners would get a significant boost from legislation now pending in Congress. U.S. Rep Allyson Schwartz (D-Pa.) and Sens. Maria Cantwell (D-Wash.) and Susan Collins (R-Maine) recently introduced the "Preserving Patient Access to Primary Care Act of 2009" (H.R. 2350/S. 1174) to address the shortage of primary care providers. The bill would create scholarships and loans for primary care providers who serve in critical shortage areas and support an interdisciplinary "medical home" model in which many types of providers would be able to practice collaboratively and to the full extent of their education and licensure.
The bill aims to increase primary care access for patients and includes nurse practitioners as leaders of patient-centered medical homes. Read the full text of the bill at www.opencongress.org/bill/111-h2350/text.
Turf Wars
The bill is currently being reviewed by several committees, and no formal testimony has been scheduled. "This has the potential to be monumental legislation for our nation," wrote Stephen Ferrara, NP, on his blog, A Nurse Practitioner's View (www.npview.blogspot.com). He also pointed out that many physician groups are supporting this bill, but he warned that "the American Academy of Family Practice is begrudgingly 'putting up' with the inclusion of NPs."
"These guys continue to play the turf war, and it is getting so very tired," Ferrara wrote. "Nurse practitioners want to partner and collaborate with physicians."
The Patient Access to Primary Care Act defines a primary care provider as a physician or "(A) a nurse practitioner; or (B) a physician assistant practicing as a member of a physician-directed or nurse-practitioner-directed team; who provides first contact, continuous, and comprehensive care to patients."
Nurse practitioner leaders have expressed hopes that the term "medical home" will be changed to "healthcare home." Loretta Ford, NP, cofounder of the NP role, remarked similarly when she spoke with ADVANCE in May: "I don't think we're going to be part of a medical home, we're going to be part of a health home."
Promoting NPs
National nurse practitioner organizations are working collaboratively in Washington under an umbrella called the NP Roundtable. This coalition brings together the National Association of Pediatric Nurse Practitioners (NAPNAP), the American College of Nurse Practitioners, the American Academy of Nurse Practitioners and the National Organization of Nurse Practitioner Faculties.
"The NP Roundtable worked tirelessly with staff to influence the language of H.R. Bill 2350," explained Ann Sheehan, NP, health policy chairwoman for NAPNAP. The NP Roundtable issued a call to action to its members in May, asking them send letters of thanks to bill sponsors and to ask other members to consider cosponsoring the bill if they had not already done so. These letters to Congress included information about how this legislation would affect NP practice.
"To serve the full U.S. population, every provider must work to the full legal scope of practice. Barriers to full NP practice exist in many bills federally and in state healthcare reform," Sheehan told ADVANCE.
The NP Roundtable's goal is to consistently convey the message that nurse practitioners are proficient providers and care coordinators in healthcare homes; that they are qualified to lead healthcare homes; and that they are qualified to provide direct healthcare, to make appropriate referrals, and to advocate for children, families and vulnerable populations.
Hurdles
Sheehan listed several hurdles that NPs might experience in relation to this bill. The following challenges make constant contact with legislators all the more urgent:
Misunderstanding of the Institute of Medicine's definition of primary care. This definition states that primary care is the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community. This definition is provider-inclusive and acceptable to NPs.
Use of physician-exclusive language in all legislation and health policy. This is true of medical home legislation as well as other healthcare reform proposals. The NP Roundtable is advocating for the use of terms such as "healthcare provider" or "clinician" or simply listing providers by their profession.
Instances in which NPs cannot practice to the full extent of their education, certification and licensure. Safety nets already are in place to regulate the practice of nurse practitioners in the same way there are safety nets to regulate the practice of physicians, Sheehan noted.
Barriers to patients' ability to choose NPs as providers if exclusive physician-focused language is passed.
Nurse practitioners should be eligible to lead medical homes, Sheehan said, noting that 14 states already have no requirement for physician supervision. She added that the goal of the APRN Consensus Model is for NPs to be licensed independent providers in all states. Federal legislation that is physician-focused will create barriers to NPs' ability to provide high-quality primary care consistent with the standards for the medical home.
"NPs will definitely end up providing care within the healthcare/medical home model if this legislation passes," Sheehan said. "Without provider-inclusive language, there is the danger that NPs will be invisible and not directly receive reimbursement for their services in this type of reimbursement system."
Any legislation that creates a medical home benefit that authorizes demonstration programs, revises reimbursement structures for primary care or sets incentives for participation in medical homes or coordinated primary care practices must be applicable to nurse practitioners.
"Medical" vs. "Healthcare"
Some states, such as Minnesota, have passed legislation that uses the term "healthcare home," not "medical home." NAPNAP's recent position statement uses the term "healthcare/medical home." However, the accepted term for the last two legislative sessions has been "medical home."
The original concept of medical home was developed by pediatricians many years ago for providing comprehensive care to children with special needs, according to NAPNAP president Linda Lindeke, NP. The concept has evolved over time to other terminology such as "patient-centered medical home," a term typically used by internal medicine groups.
The NP Roundtable has been collaborating with a large and growing organization called the Patient-Centered Primary Care Collaborative (PCPCC; www.pcpcc.net). A result of that collaboration is an extensive position paper by the American College of Physicians about NP practice that has been helpful in lobbying Congress for inclusive language (www.acponline.org/advocacy/where_we_stand/policy/np_pc.pdf).
"NPs must be aware that there has never been a time when their support of their professional organization of choice was more important," Lindeke told ADVANCE. "Nurses are working collaboratively in Washington as never before, and the stakes have never been higher."
In many bills, the concept of the medical home is inclusive of all healthcare. Because it is so broadly defined, NPs must be positioned as autonomous providers with full access to leadership roles and reimbursement. The opportunities, challenges and risks are considerable, and NPs are urged to respond to all calls for their involvement during this unprecedented time of reform. The evidence that NPs are safe, effective and well accepted by the public is plentiful. However, interprofessional turf issues may be at an all-time high. The voice of each nurse practitioner is essential. Contact your lawmakers today!
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