Nurses Raise Battle Cry Over Reimbursement

Their rates fell statewide without Legislative fix last year

January 23, 2012 -- Kathy Moon, a nurse practitioner at Dunes Family Health Care, is one of the lucky ones whose practice hasn’t closed down or had to slash services because nurses now make less for performing the same functions as physicians.

Not that her patients wouldn’t notice the strain on her practice, she points out. But while it doesn’t affect her personally, being on a salary, it does affect the clinic’s ability to hire help in the office.

“My overhead is the same—we don’t pay medical assistants less if they’re in our office than if they were in a physician’s office,” Moon said.

Hundreds of other nurse practitioners in Oregon have fallen into the same trap so far without a legislative fix. Reimbursement parity for nurse practitioners became a concern after insurance companies in 2009 started sending newsletter emails (rather than official documents) saying that they were reducing reimbursement rates for services rendered by “non-physician” providers.

“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,” Moon said. “Nurse practitioners provide care that’s been shown to be just as high quality and sometimes even better than their physician counterparts.”

During last year’s legislative session, she and other members of the Oregon Nurses Association worked on reversing cuts of reimbursement rates by 40-55 percent for psychiatric and primary nurse practitioners. With sponsorship from Reps. Tina Kotek (D-Portland) and Bill Kennemer (R-Oregon City), they introduced legislation that would require insurers to reimburse providers at equal rates when they perform equal services.

But House Bill 3028 stalled before coming to a vote, and those cuts remain intact. When the Legislature meets again in February, the ONA plans to introduce similar legislation, and dozens of nurses converged at the Capitol on Jan. 18 for Payment Parity Lobby Day.

After a full day of talking with elected representatives, ONA Executive Director Susan King was hopeful they were being heard.

“It’s a significant problem that needs to be solved, and I think the legislators understand the problems associated with a lack of reimbursement parity,” King said. “There’s no current law that speaks to payment for services in the private insurance business, and so they can just set the numbers wherever they want.”

Moon argues the stakes for success are especially high in the large area of the state outside of the Willamette Valley.

“Oregon is comprised of a lot of rural and frontier areas where access to services is a paramount problem,” said Moon, who works in the small south coast town of Reedsport. “The idea that we should be paid less for whatever reason is a big disincentive to nurse practitioners to enter practice, especially in rural areas where clinics are run on a shoestring to begin with.”

King said that more than 10 ONA members are reporting “significant changes” such as limiting their practice or firing staff, and at least two have closed down as a result of the recent changes in reimbursement rates compared to physicians.

Physicians must co-sign?

That’s not all that’s ailing Oregon nurses at the moment.

Like physicians, nurse practitioners are trained to perform physical assessments and treat their patients’ illnesses, including helping their elderly patients find home healthcare. But language in Medicare regulations prevent nurse practitioners from ordering home care services, and they must get their orders co-signed by physicians, which causes delays in their patients obtaining timely care.

This rule makes little sense particularly for nurses in Oregon, where their practices can function with their own licenses and can be completely separate under their own roofs from physicians.

That’s why the ONA supports the Home Health Planning Improvement Act introduced by Congressman Greg Walden (R-Oregon) and Congresswoman Allyson Schwarz (D-Pennsylvania) to allow physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives to order home health services.

“It’s an obstacle for me to get an order for home health through if everything needs to be co-signed because of antiquated language in Medicare,” Moon said. “It makes my work a lot harder to do, and it’s unfair that my patients have to wait a lot longer to get the same service.”

Advocates don’t know how reimbursement policies would change as a result of medical homes, but the ONA does have hope for the new coordinated care organizations getting under way in July, assuming the Legislature approves the plan submitted by the Oregon Health Authority. They believe it’s essential that nurse practitioners get a seat at the table in discussions on the formation of medical homes and that nurses are recognized as a key part of the team.

“It’s important to know that the bill we’re proposing is a fix for the current system, and we’re hopeful that sometime in the future, when we have a more global system, hopefully we’ll fix some of these other problems that happen when one piece of Medicare gets changed and the rest of the statutes don’t move along,” King said.

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While I very much sympathize with the nurses plight against unfair, unilateral cuts to their reimbursement by commercial insurance companies, their proposed solution to mandate payment equal to physicians creates more problems than it solves. First, this bill could dramatically and unnecessarily increase the cost of health care. The bill applies to all physicians in all specialties and sub-specialties. Why are we going to start mandating that a nurse with 2/9ths the training of a physician receive the same pay? To the contrary, the economic advantage of having physician-extenders is in increasing the numbers of our nurse practitioners to see more primary care patients doing preventative care, routine care and less complex specialty care. There is no need to have so many of these patients seeing our costliest providers (physicians). We as a society can provide more care to more people at lower costs if we use practitioners who are functioning at the "top of their license" and not using overqualified providers to do the bulk of the health care. But if we mandate equal pay to those nurses, then we not only eliminate cost savings, but we will increase costs from where they are now. Secondly, physicians do have much, much more invested in their training than nurses. For example, a psychiatric mental health nurse practitioner (PMHNP) need only complete a 2 year masters program to become a licensed medical provider (LMP). By state statute, they have been given the authority to see any age psychiatric patient with any psychiatric disorder and code the same service codes (CPT codes) as a board certified child psychiatrist who has 9 years of post-graduate training (4 years of medical school, 3 years of residency and 2 years of fellowship). This physician has an additional 7 years of education before entering the workplace. The opportunity costs are significantly higher for the physician who has spent years deferring income and incurring more debt in loans. For example, the average indebtedness of a physician attending a public medical school is $150,000 and a private school is over $300,000. Plus, physicians are held to a higher standard of care and frequently see more complex patients. This is reflected in significantly higher malpractice insurance premiums and increased accountability with courts and juries. So when nurses say they have the same costs as physicians, this simply isn't true. Finally, the nurses' lobby has previously insisted that Bachelors in Science of Nursing (BSN) be reimbursed more than those RNs without bachelor degrees even though they do the exact same work. So why do they find themselves arguing that the amount and quality of education suddenly doesn't matter? Third, this legislation would greatly dis-incentivize anyone from going into the practice of medicine. Once again, why become a physician if you can get the same reimbursement with 2/9ths the training? We will make Oregon a much less attractive state for recruiting physicians and no doubt will see some of our physicians leave the state if the government mandates that they be paid the same as a nurse. I think this would be worrisome to anyone concerned with having the most expert and qualified medical workforce available to the population. We would be substituting the practice of nursing for the practice of medicine. Fourth, there is no way to code for complexity in many cases. For example, a nurse practitioner is going to be reimbursed the same for seeing a 35 year old with mild anxiety as a child psychiatrist would be for seeing a 5 year old with autism, fetal alcohol effects, severe trauma and complex medical co-morbidities. We need to fix coding issues before we claim all work is the same. Fifth, the nurses claim that there are studies suggesting they broadly provide equivalent or better outcomes. However, if you look at the studies they reference, you find that there are no studies in mental health outcomes. Furthermore, most of the studies support nurses working together with physicians to improve care and not necessarily as solo practitioners of care. In summary, the insurance companies overreached big time when they drastically cut the nurses reimbursement. This should not stand. But the solution to mandate 100% pay as if they were physicians is misguided. We might want to look to the example of Medicare reimbursement as a possible solution. Medicare reimburses advance practice nurses at 85% of physician reimbursement nation wide. This appears reasonable and has been upheld upon scrutinization by various commissions through the years. It would raise the nurses current reimbursement to sustainable levels and prohibit future unfair reductions. This solves the nurses problem as they say it only became an issue after the recent cuts. Let's not rush to a major and unprecedented mandate that is likely to increase costs and decrease the expertise of our workforce. The state and the larger health care community needs to examine the impact of this legislation much more thoroughly and make appropriate amendments before it moves any further.

This is not an issue of Nurse Practitioner versus physician. Nurses value their physician colleagues and acknowledge that our education is different. However, we reject the assertion that the issue of parity when the services provided are the same - and that is the important point - will raise the cost of health care. Insurance companies do not give their insureds a discount when they reduce rates for the provider. Further, for the majority of NPs in the state, the reimbursement is the same for the same service. This most often is true when they are a part of a group practice that has the resources to negotiate with and pressure the insurance company to pay the same. Why should payment to a solo NP practice be penalized for not having a business manager who can spend time to negotiate with carriers? When insurance carriers are questioned about their reimbursement practices, their responses are all over the map. One asserted that they were 'above market" for NPs therefore justified in their fee reduction. Another pays the same for credentialed NPs. Others have a range of answers none of which have anything to do with the service provided. Now, lets talk outcomes. Decades of data show that the outcomes of NP care are equal to and in some cases better than that provide by physicians. Again, this is not about one provide versus another but rather fairness from an industry that lacks transparency, makes spurious decisions and itself contributes rising cost of our health care services. All providers should support efforts to reform state policy while our transformation is proceeding. Maybe in the very near future the parity proposal will be unnecessary. I look forward to spending time building a stronger system rather than trying to fix what should be an obvious problem NP supporter

If we are going to design a new way to deliver care (and we HAVE to) we will depend on NPs and PAs to provide care at all levels and in all specialties. While physician education is more extensive, IT IS NOT MORE EXTENSIVE AT DOING WHAT WE ALL DO DAILY. I suspect the poster above will not believe this, but when I examine your throat, or your bruise or look into your ear, or write a prescription I am providing care that is AT LEAST the equal of anyone else doing it. I could argue I listen more and take a bit more time. My 35 years in practice plus great schooling on how to look, listen, touch and hear is what makes the diagnosis. As much have things have changed over these many years, my continuing education after graduation determines much of how I decide to treat. As a PA I have been taught to get a second opinion when I am unsure, which I believe is the best way for anyone to practice, MD, DO, NP or PA. That all being said, no one can live on 85% of what Medicare pays. So, NPs and PAs are saying pay us for the care we provide. If you need to, up some of the primary care fees as there is already a huge primary care shortage and specialties recruit us as much as our physician colleagues. So if I see a sore throat, or a sprained ankle or a hypertensive, or someone who is feeling depressed pay me or my practice on the service provided. Or let's turn the tables, prove to me that my outcomes are inferior. They are not. PS. Good luck in proving outcomes in psychiatry-that may be the hardest thing ever. Even many psychiatrists do not believe it can be done. Dave Mittman, PA

Primary Care is going to the dogs--the underdogs that is--as in NPs. We are the only providers who can work as primary care providers independent of MDs. The fact that a MD chooses to go to school longer to learn the same thing and practice the same way that I do does not mean he/she is "worth" more. A primary care issue is a primary care issue. Who is the "smarter" provider? The one who is saddled with $180,000 in school debt or the one who is perhaps at most $100,000 in debt? The only leg that the physicians who think they are superior to NPs have to stand on is the fact that they have a paid residency program. This is the only difference in the way care is delivered when the rubber hits the road in the primary care office. It takes a good 2 or 3 years to develop the skills to be a good primary care provider, capable of standing on one’s own 2 feet with regards to primary care--which, coincidentally, is the same amount of time as a Family Practice residency program. We need NP residencies, and not the kind that the DNP programs think are satisfactory. We need government sponsored real residency programs and we ought to follow the medical model in this regard. Why re-invent the wheel? Regarding payment--it has only been recently that NPs (aside from Medicare) have been getting a lower re-imbursement from private insurance carriers. So the fact that this will drive up the cost is ridiculous. In another article today I see that blue cross is sponsoring a golf tournament for $900,000. All one has to do it to look at the perpetual profit of the private insurance companies to realize this is hooey. It’s all about greed and taking whatever they think they can get away with. Primary care is totally broken. We have a system that is burning every single primary care provider out. Less than 1% of new graduate physicians are entering primary care. The pay differential between MD PCPs and NP PCPs is narrowing. The average visit is 7 minutes and re-imbursement rates are on the decline for everyone. Over the past 10 years specialty referrals have doubled in the past 10 years ( due to the fact that we have less time to spend with the patient to diagnose the issue ourselves. We have become a revolving gate--we can't get paid unless we have an office visit, so we drag people in who could just as easily be treated by phone, email or otherwise--in fact research proves that 70-90% of most primary care issues can be handled in ways other than a face to face primary care visit. All of this has resulted in per capita medical spending of nearly $8,200 in the USA and still we rank 31st in world health. We cannot work harder, or faster. We have to work smarter. We have to stop the insanity and do things different. Just as an astute clinician would not add another sulfonaurea to the treatment regime of a diabetic whose pancreas has been whipped to death, the answer is not to pile more patients onto our already insane schedules, or to do it defacto by decreasing payment to primary care providers such as NPs as it will have the same affect-- increased costs and burn out. Burn out of primary care providers is a huge issue and one we are going to be slapped in the face with in a major way come 2014. Just look at what happend to Mass. when they rolled out universal health care. Lastly, since most NPs are employed by MDs this is a defacto reduction to MDs. As such, they ought to be as enraged as NPs over this practice. Teri Bunker, FNP Bridge City Family Medical Clinic

Wow. Just wow. You REALLY think MDs go to school longer for no particular reason? You truly think that those extra years of education and training make no difference in diagnostic acumen? Seriously? You are correct that everyone's reimbursement is declining - and in the face of increasing overhead. This has to do with budget deficits and increased utilization. The HealthCare Industrial Complex and the bureaucrats who hold the purse strings will look for any reason they can to cut costs. And that includes all health care providers, including physicians. I don't think it was "personal."

This Bill just highlights the broken reimbursement system. The NP's claim that a bill for an E&M service is equivalent regardless of the illness burden of the patient. If nurses care for patients with the same health status, have the same quality, and consume the same resources- they deserve the same pay. However, if they admit to a more limited scope of services and need to refer more complex patients to physicians, physicians should be compensated. We need a reimbursement system that provides much greater resources to the 20% of patients that consume more than 80% of the resources. Those patients tend to be cared for by physicians.We don't need legislative mandates that require higher pay for lower acuity primary care (regardless of provider)

Will the Anonymous poster please stand up and announce who they are? I refuse to take seriously comments and criticisms of people who will not sign their name to their postings. In general I am saying this about NP training. 1. The reason it takes 2 or 3 years for a Family NP to become as profecient as a newly minted Family practice MD is because this is the length of time spend in OJT (on the job training, aka, residency). The sad part is that NPs are not getting paid for this OJT. I would "put up" a 4th year medical student against a new graduate FNP any day with regards to primary care--they are equally as green. However the MD may be a tad more green if the new graduate NP has not been an expert RN. Since we can no longer guarantee that all nurses are experts before they go on to become a NP this is almost a moot point anymore. 2. Regarding primary care. We--all PCPs--need to stand together. A cut for anyone is a cut for everyone. As has been pointed out--most NPs work for MDs. MDs are taking a 15% cut when the NP working for them gets a 15% cut in re-imbursement. 3. I have hung out my own "shingle" and I do make as much as (or as little as) my fellow MDs who have opened their own practice. 4. I do not refer my complicated 20%'ers to a physician. In fact, at my office my MD colleagues--who are also my employees-- consult with ME about difficult patients. 5. The biggest factor driving cost is the devaluation of primary care. Teri Bunker, FNP

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: I am a board certified child psychiatrist. I went through 9 years of formal training AFTER I graduated from college: 4 years of medical school, 3 years of residency and 2 years of fellowship. This was 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, we both must use exactly the same CPT codes when we see patients. For example, a 90801 is a comprehensive psychiatric evaluation. There is no coding to differentiate complexity of acuity. So, I ask you, might there be more value in my 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? We are both allowed to "evaluate" this patient. We both must use the same CPT code. Should we both be reimbursed the same? Are we providing the same service? 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.

"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? " Why indeed would you do this?? Good question. Over education does not make your skills worth more. Just because you get paid for your OJT (ie residency) doesn't mean it is any "better" after the first 3 years of practice a new grad NP is just as "smart" and capable as your new grad MD--and has cost the whole system a hell of a lot less money!!

So you are advocating to close down all the medical schools and residency programs in all specialties and replace them with nursing school? Is there no role for our most highly educated and trained physicians in health care? Is there no role that a nurse can't perform equal to a physician? Where's the data?