Legislation Giving Nurse Practitioners Equal Pay Appears Dead

Although the bill sailed through the House Healthcare Committee, Rep, Jason Conger succeeded in getting the bill sent to the House Rules Committee, where bills usually die

February 17, 2012—Legislation that would reimburse nurse practitioners at the same rate as primary care doctors failed to pass on the House floor last week as expected, and instead was sent to the Rules Committee where such bills usually die.

The motion made by Rep. Jason Conger (R-Bend) seemed to catch people off guard, yet had bipartisan support with a 33-26 vote. Conger said House Bill 4010 needed to go to the Rules Committee because he was concerned about the definition of a nurse practitioner’s “service area.”

By that, he didn’t mean the specialty of a nurse practitioner, but the geographic area where that person worked. Conger said he was concerned because a nurse practitioner could negotiate a reimbursement rate with an insurance company that was different than the rate paid to another provider in the same town.

“As it stands, the bill would not be specific as to what an ‘area’ would be used in determining what reimbursement rate should be applied to nurse practitioners,” Conger said.

He fumbled multiple times through his explanation, and Co-Speaker Arnie Roblan (D-Coos Bay) admonished Conger more than once to be clear.

“I’m not sure I can actually claim to be clear,” Conger said at one point.

Sources also say there was a burst of last-minute lobbying last week opposing the bill after it passed the House Healthcare Committee by the Oregon Medical Association, the Oregon Academy of Family Physicians, the Oregon Psychiatric Association and the Oregon Society of Clinical Social Workers.

If the bill passed, they claimed, insurance companies would decrease the reimbursement rate of primary care physicians rather than increase the rates paid to nurse practitioners.

Those organizations also argued that it was inappropriate to change the reimbursement rates for one provider group at the same time Oregon is transforming 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.

“Any dialogue about reforming payment and realigning incentives should occur in tandem with health delivery system reforms and must include input from all physicians and other healthcare providers as the system is redesigned to be meaningful,” according to testimony submitted by the Oregon Academy of Family Physicians.

Other opposition came from the National Federation of Independent Businesses and the Taxpayer Association of Oregon, a conservative watchdog group that advocates for taxpayers. They claimed reimbursing nurse practitioners at an equal rate would increase healthcare costs.

Regence BlueCross BlueShield used that same argument. “The bill ties our hands to be fully engaged in the reform efforts that I think we all support to attempt to bend the cost curve,” said Tom Holt, director of legislative and regulatory affairs. “We don’t think it’s productive to enshrine in statute something that is really attached to a fee-for-service system that everyone hates, and that we know is [the reason for] a very severe increase in the affordability of [insurance].”

Before the bill was sent to the Rules Committee, lawmakers on both sides of the aisle urged their colleagues to oppose Conger’s motion. Rep. Mitch Greenlick (D-Portland), who co-chairs the House Healthcare Committee, said that the definition of a service area was not “properly” raised in committee, where the bill could have been amended.

Rep. Peter Buckley (D-Ashland) argued that the bill should be passed, stating that Conger’s concerns could be dealt with by the Senate’s Healthcare Committee

“To refer a bill to another committee in this short session, if we’re not careful, is about killing the bill,” said Rep. Bill Kennemer (R-Oregon City).

He went onto to say that the bill would impact 200 to 300 nurse practitioners who might have to close their practices because of the lower reimbursement payments. “It is a crisis,” Kennemer said. “The opportunity to kill this bill would damage them and our healthcare delivery system.”

Rep. Julie Parrish (R-Tualatin), who freely admitted that House Bill 4010 was “not the type of bill I would normally support and get behind,” shared that concern.

But Parrish supported the bill because she knows people in rural areas who rely on nurse practitioners as their only healthcare provider. “It’s an access issue,” she said. “They’re (nurse practitioners) in high demand.”

Until 2009, nurse practitioners were paid the same rate as primary care physicians. Then, insurers began reducing the payment rates for psychiatric and primary nurse practitioners by as much as 55 percent, despite the fact that they performed the same functions as a physician.

The bill, Greenlick said on the House floor is about “equal pay for equal work.”

“Nurse practitioners have the same scope of service that physicians have,” he said. “[They] do, generally speaking, the same things as doctors in the same specialty.”

Legislation to achieve payment parity appeared in the 2009 and 2011 legislative sessions, but failed to gain momentum.

Now the legislation waits in the Rules Committee, co-chaired by Rep. Tina Kotek (D-Portland), who sponsored a similar bill in 2011, and Rep. Andy Olsen (R-Albany). Both legislators must agree to give it a public hearing before the bill can pass out of their committee. Thus far, no hearing has been scheduled.

“At this point, we're running out of time,” Parrish said. “I hope we get it solved in this session.”

The Oregon Nurses Association is more pessimistic, believing the bill is dead. “Unfortunately, the short February session, Oregon's difficult economic issues, the powerful influence of health insurance providers, physician groups and business associations all combined to make passing this important legislation impossible this session,” the association told The Lund Report. “ONA and our partners are committed to returning to this issue in the future and working hard to ensure that nurse practitioners receive the payment parity that they deserve.”

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boy, this is as ridiculous as it gets. We're trying to reduce healthcare costs, not increase them. Here's a friendly amendment to HB 4010: let's pay physicians what we pay nurse-practitioners. Equal pay for equal work.

not passing this bill is about continuing to ensure that Regence has their pockets adequately lined. Its lying, cheating and stealing plain and clear. Not paying NPs what they have always been paid does not control costs. Do you think that Regence will now ask for a rate reduction because they have now save 15% of their primary care costs since primary care is delivered by about 50% NPs in this state? Of course not. We will see them asking for yet another 22% increase in premiums next year--one way or another, they continue to profit at the expense of everyone but themselves.

There are several critical reporting errors in this article: 1. "Legislation that would reimburse nurse practitioners at the same rate as primary care doctors ..." Fact: This was NOT a primary care bill. This legislation was extremely broad and could be applied to any physician and nurse practitioners practicing in any specialty. 2. "Until 2009, nurse practitioners were paid the same rate as primary care physicians." Fact: Commercial insurance has always reimbursed NPs at various percentages of physician pay across multiple specialties. Some were reimbursed at 100%, some less. There was never any assumed "parity" in reimbursement. In 2009 some commercial insurance companies significantly reduced psychiatric mental health nurse practitioner reimbursement (PMHNP) and then followed with reductions to NPs in primary care. 3. There is no mention of the fact that amendments were offered to the House Health Committee that would have reinstated the NPs to the pre-2009 rates, reversing the unilateral reductions that prompted the legislation in the first place. This has been the stated goal of the nurses since the outset. Please see the earlier Lund Report article on this issue in which the NP's representative, Kathy Moon, says, “We’re not asking to be paid more than we have in the past—we’re asking for the same that we had been receiving.” 4. While this is not a reporting error, it is a factual error when Rep Greenlick states, " “Nurse practitioners have the same scope of service that physicians have,” he said. “[They] do, generally speaking, the same things as doctors in the same specialty.” While Oregon NPs have the broadest scope of practice in the nation, they are not interchangeable with physicians in all specialties. If they were, why on earth would we continue to invest so much in the training of medical doctors, including our most highly trained specialists and sub-specialists? And why would anyone choose to go to 9 years of training when they could demand the same reimbursement for 2 years of training? As has been stated many times before, the nurses have a very legitimate complaint with the insurance industry. Their rates were unjustifiably and drastically reduced in a unilateral manner with no warning and no recourse. This must be fixed. Amendments have been offered that would fix it and prohibit future similar behavior by the insurance companies. But this legislation was a major overreach. Let's get this amended appropriately in the Rules Committee this session.

Not all nurse practitioners do what all MDs do - obviously, NPs don't do major surgeries or similar things, but in areas where they do do what MDs do, such as primary care, they should be paid the same amount of money. Nurse practitioners take call on weekends for entire practices, including MDs and other NPs, for example. They cover for physicians in their practices when they are ill or on vacation. Providence medical practices, for example, have NPs doing exactly what their primary care docs do! Why should they be paid less? It just makes no sense. Equal pay for equal work. Its basic.

If only it were that simple. One would think that a nurse practitioners scope would be more limited. But Oregon has the most liberal scope of practice laws for NPs in the nation. They function entirely independently and code almost any procedure except for some of the surgical and highly procedural specialties. By Oregon law, there really isn't much of a limit on what they are legally allowed to do -- although whether or not that's good medicine is another question. Let me give you another example: Take a board certified child psychiatrist who went through 9 years of formal training AFTER graduating from college: 4 years of medical school, 3 years of residency and 2 years of fellowship. This is extremely rigorous training, much of it focused on a wide array of neuropsychiatric diagnoses and treatment. In contrast, a psychiatric mental health nurse practitioner (PMHNP) completes a 2 years master's nursing program. By statute and regulations, both the NP and MD must use exactly the same CPT codes when seing patients. For example, a 90801 is a comprehensive psychiatric evaluation. There is no coding to differentiate complexity of acuity. So, might there be more value in a child psychiatrist's assessment of a 5 year old child with Asperger's, severe sexual trauma, co-morbid medical illness, etc versus that of a PMHNP with no formal training in pediatric psychiatry? Both allowed to "evaluate" this patient. Both must use the same CPT code. Should both be reimbursed the same? Are the services really the same? I think not. Why on earth is anyone going to go to medical school plus 3-6 years of residency if our society says that this provides no more value to patient care than a nurse with a master's degree? With this legislation we will be shifting the training of our most expert workforce from medical school to nursing school. Plus, physicians continue to be held to a higher standard of care (as they should be) which results in significantly higher malpractice insurance. Educational debt is on the order of a magnitude more for a physician than a nurse. Plus there is the opportunity cost of not being in the workforce for a decade after college. This is very short-sighted legislation. It is bad policy. Let's fix the cut in the nurses' reimbursement but let's not equate NPs with our most highly trained specialists. Yes, we need to look at economics and workforce issues. But let's make reforms through a thoughtful, rational process inclusive of all stakeholders. HB 4010 is not that.

Because the NP is not so full of herself and will most likely spend much more time with the child I suspect that the evaluation may be more indepth and comprehensive than that of the MD.

The ERA does not take into account the educational level, if the Practitioners provide the same services the have the right to the same reimbursement.