Attempts to Amend Nurse Practitioner Bill Failed

In the end, the Oregon Nurses Association was unwilling to budge
The Lund Report

February 24, 2012—Some legislators, including Rep. Alissa Keny-Guyer (D-Portland), hoped that the referral of a bill reimbursing nurse practitioners at the same rate as physicians to the House Rules Committee wouldn’t mean that the bill would die, but that it could be amended to address the concerns of various constituencies.

But with the Oregon Nurses Association unwilling to submit a new amendment to House Bill 4010, and with the amount of time left for this month’s short session, it appears that the bill truly is dead.

Keny-Guyer told the Lund Report yesterday that there were attempts made to amend the bill, including using language suggested by the Oregon Medical Association, and supported by the American Academy of Physicians, that would have brought the reimbursement rate of nurse practitioners to the level they were before 2009. At that time their reimbursement rates were not always on par with primary care physicians, according to Betsy Boyd-Flynn, executive vice president of the Oregon Medical Association.   

One of many problems the Oregon Medical Association had with House Bill 4010 was that it “sought to unilaterally increase all nurse practitioner reimbursement rates to 100 percent of physicians, regardless of specialty or past reimbursement history.”

Keny-Guyer, who was one of two votes in the House Health Care Committee opposing the bill, agreed. “If you have a physician and a nurse practitioner suturing, there should be nurse parity,” she said.

But there are complex medical cases that a psychiatrist, who has nine years of training, is more able to treat as opposed to a psychiatrist nurse practitioner, who has only two years of training. Those sorts of cases, she said, do not warrant equal pay.

When they do a diagnosis, and someone with two years does a diagnosis, is it really equal work?” Keny-Guyer asked during the healthcare committee’s vote on February 3. “That is something that has really plagued me. I think nurses have a fairness issue, and I think people with nine years [of training] have a fairness issue.

There was another amendment that would have changed the reimbursement rates only for nurse practitioners in rural areas.

Jack Dempsey, the lobbyist for the Oregon Nurses Association, said that none of those concepts would have received a hearing in the Rules Committee.

“It would have depended on the amendment,” said Rep. Tina Kotek (D-Portland), who co-chairs the Rules Committee and is a staunch advocate of changing the reimbursement rates for nurse practitioners.

Dempsey said the Oregon Medical Association amendment would not achieve reimbursement parity because it would not reimburse nurse practitioners at the current rate. Dempsey adamantly opposed the amendment which would have only impacted the rates of nurse practitioners in rural areas, saying it would have discriminated against nurse practitioners doing the same work elsewhere such as Portland.

“The bill died when it got sent back to the Rules Committee,” he said. “I don’t think there’s any amendment that we could write to get the bill out of the Rules Committee.”

Numerous groups opposed the bill, including the Oregon Medical Association, the Oregon Academy of Family Physicians, the Oregon Psychiatric Association and the Oregon Society of Clinical Social Workers, the National Federation of Independent Businesses, the Taxpayer Association of Oregon and Regence BlueCross Blue Shield.

Among their concerns were that insurance companies would decrease the reimbursement rate of physicians and psychiatrists rather than increase the rates paid to nurse practitioners; that reimbursing nurse practitioners at an equal rate would increase healthcare costs, and that reforming a reimbursement structure based in the fee-for-service model ran counter to the state’s efforts transform the Oregon Health Plan’s delivery system, and moving away from a fee-for-service payment system to a global budget focused on providing more efficient care.

“Every business group, insurer, and provider group opposed the bill,” Dempsey said.

The bill, which was one of five bills sponsored by the entire House Healthcare committee, was vetted numerous times before the current session. But an interim hearing in November only invited the testimony of the Oregon Nurses Association, and not any opposition groups. When asked why the association did not pursue a consensus bill, Dempsey said that he wasn’t sure that could have happened.  

But, he said, the Oregon Nurses Association will be back next session for what will be their third attempt at changing reimbursement rates. “This issue isn’t going away,” he said.

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Where are the psychiatric nurse practitioner, "who has only two years of training" being trained. Why are they counting the Psychiatrists full education and not considering the Masters level work that the nurse practitioner has completed?

Psychiatric Mental Health Nurse Practitioners (PMHNPs) are trained at nursing schools such as OHSU's School of Nursing. They complete a 2 years masters program after receiving their bachelor's degree. Thus, formal training after college = 2 years. Physicians specializing in psychiatry have 8 to 10 years of formal training after completing college and earning their bachelor's degree. This is composed of 4 years of medical school (MD or DO degree) followed by 4 years of full time residency training plus 1 to 2 years of full time fellowship training if one sub-specializes (e.g. child and adolescent psychiatry, forensic psychiatry, geriatric psychiatry, addictions psychiatry, etc). Thus, formal training after college = 8 - 10 years.

As a PMHNP I was not trained to deliver babies, or do surgery. It is this type of over training that increases health care cost.

Come to think of it, NPs are over trained as well. They had to learn how to draw blood, change bed pans, and bandage wounds. What a waste of money. I'm sure we could devise an associates degree program to train the workforce responsible for the care of our patients suffering from complex neuropsychiatric disorders. So much unnecessary education ...

Amazingly, many physicians who hire NPs bill under their ID number to get the higher reimbursement but if an NP is independent and does the same work they will be paid less. More complicated cases require a more complicated code which would give the MD the higher rate for their expert work. There is much more to this than what is being stated.

What is not told is that NPs really have as much education and training as MDs. ONLY difference is that the NPs don't get it recognized as it is called "on the job training" (OJT) and the MDs get a residency PAID for by the Federal Government!! After the new grad MD and the new grad NP have been OTJ their skills are equal in primary care--at least equal. The NP may actually have more skill due to the past experience as a nurse--surely this experience more than equates whatever experience the MD got in medical school training. The fact that the NP can do what the MD does is all that should matter in primary care. You do not need a cardiac surgeon to see you for your primary care issues. The cardiac surgeon has more training and expertise and so should get paid more--but not if he is working in primary care, only if he is working to the full capacity of his training in an area in which it is required. This is apples and oranges to compare MDs in general to NPs. We need to look at scope of practice, training, responsibility and outcomes. Do not punish the NP for being smarter and paying less for their education. We should be rewarding that. If MDs continue to think they can claim primary care for themselves and continue to rip off NPs every step of the way we are going to be in a world of hurt come 2014

As a medical student considering primary care, I hope this bill does not pass. It would sound the resounding message that society does not value our extra education and skills that come from going through medical school and residency. Yes I agree that there is overlap between what a MD and NP can do in primary care and the quality of that overlap is probably comparable. Last time I checked NPs are not trained in OB to deliver babies or do C-sections, or manage patients with multiple chronic illnesses with high risk of complications. The tenant of the medical home model of primary care is that everyone works at the top of their license. The top of a family physician's license is higher than that of an NP, there is no doubt about that. I this was not the case then we should just staff the entire US primary care workforce with NPs. That would not be logical.