Scope of Practice: Colorado and the Current Debate Impact Conversation

Scope of Practice: Colorado and the Current Debate Impact Conversation Series October 5, 2011

Today’s Discussion Primary Care: A booming market The National Conversation State of the Debate in Colorado APN & PA Survey Findings Planning now for new solutions Training Regulator y Financial Cultural 2

Primary Care: A booming market

On the Horizon: Primary Care Need In Colorado 500k more “newly insured” How much care will they seek? Where will they seek care? 214,00 0 153,00 0 175,00 0 4

Gaps in Primary Care 5

Who Can Practice Primary Care? Medicine Physicians Physician assistants (PAs) Nursing Nurse Practitioners (NPs) Clinical Nurse Midwives (CNMs) 6

Scope of Practice Training & complexity of care MAs CNAs LPNs RNs PAs APNs Generali stMDs Specialis t MDs Subspecialist MDs Cost-effective care & providers, access 7

Progression of the Debate Training Regulatory Financial Curriculum Certification Licensing Statutes Insurance empanelment Reimburseme nt Billing Cultural 8

The National Conversation

The Importance of Frame of Reference Nursing Perspective Physician Perspective IOM Perspective Growing literature: plenty for everyone 10

National-level reform Federal role Mid-tolong range change State role Immediate term change 11

The Promise of Medical Homes Reduced costs Improved care quality Reduced medical errors Higher patient satisfaction Fewer health disparities 12

The Promise Deferred Not today or tomorrow – Require transformation – Workforce as members of “care teams” – Technology is not “plug and play” – Health care neighborhoods – Payment reform 13

Accountable Care Organizations A model for reforming health care delivery and payment Integrated care delivery Payments linked to cost-reducing quality benchmarks Performance measurement 14

Scope of Practice: Market Dynamics Cost/Value Efficiency Reimburseme nt Payment reform Medical homes Delivery models Access & Choice Mal-distribution Educational capacity 15

State of The Debate in Colorado

Our Primary Care Workforce Primary Care Providers per 100,000 population US Colorado* 90 65 30 28 15 8 Physicians NPs NOTES: Estimates do not include non-primary care practitioners. *Colorado providers include practicing/working providers only. SOURCES: GAO, Peregrine, DORA, Colorado Office of Demography, PAs 17

State Role: Leverage Points Practice Acts (legislative decisions) Medicaid payment structure Insurance regulation 18

CO 19

Scope of Practice: APNs Pre-2008 2008 Education program OR certification 2009 Graduate degree required Prescriptive authority for APNs Medicaid reimbursemen t for all APNs 2010 2011 National certificati on required APN physician collaborative agreement dropped APN insurance empanelm ent? 20

APN & PA Workforce Surveys

Colorado NPs Primar y care special ty 1 No primar y care special ty 0 NOTE: The total of all specialties sums to more than 100% because each respondent could select more than one specialty. SOURCE: 2010 Colorado Advanced Practice Nurse Workforce Survey, Colorado Health Institute, Q14, Q15, Q24

NPs: Many recent graduates Year of graduation 46% 31% 14% 9% 1980 or before 1981-1990 1991-2000 2001 or after 23

NPs: A homogenous profession Gender Male 0 Female 1 Race-ethnicity Hispanic/ Latino 0 White, not Hispanic 94% OTE: The total of all specialties sums to more than 100% because each respondent could select more than one specialty. OURCE: 2010 Colorado Advanced Practice Nurse Workforce Survey, Colorado Health Institute, Q14, Q15, Q24 24

NPs: Age and career cycle 36% 21% 19% 18% 5% 34 ye s ar or y n u o r e g 35 - 44 ye s r a 45 - 54 ye s r a 55 - 64 ye s r a 65 ye s r a or ol r e d 25

NPs: Policy opinions Enforceable policies establishing reimbursement commensurate with clinical services provided 95% Institutional policies that reflect APN scope of practice under law 95% Physician-APN convenings on issues of scope of practice and collaborative models of care 92% 26

Colorado PAs Specialty & gender Number of PAs 1200 1000 800 600 400 200 0 Primary Care 43% of PAs Specialty Care 57% of PAs *PAs were classified as primary care if they practiced family/general medicine, general internal medicine, general pediatrics or prevention/wellness at least 50% of their practice time during a typical work week. SOURCE: CHI: 2011 Physician Assistant Workforce Survey, Q24, Q17, Q1. 27

PAs: Increasingly educated 29 Education and age 3039 60% 43% 29%27% 31% 0% As so ci 's e at 9% re g e D 1% e l e h c Ba 58% o s r' re g e D 36%33%31% 13% 0% e r e C te a c it fi M a 's r e st 16%13% re g e D SOURCE: CHI: 2011 Physician Assistant Workforce Survey, Q24, Q2, Q13 e 28

PAs: Policy opinions State/federal loan forgiveness for those PAs practicing in underserved areas of Colorado Private reimbursement that reflects equal pay for equal work Allow home health, SNF and hospice care ordering to be delegated to PAs under Medicare 98% 90% 85% 29

What the surveys tell us: Important primary care providers Meeting higher education standards Some of the same issues as physicians NP issues: Reimbursement, institutional policies, physician convenings PA issues: Reimbursement and Medicare scope 30

Planning now for new solutions

The late stages of the debate Training Interdisciplinary education Regulato ry Monitor mentor/preceptor availability Insurance empanelment DORA Data Bill Financial Reimbursement, billing Payment reform/health exchange policy Nurse-led health centers 32

Are the Changes Enough? Calls for Disruptive Innovation Clinician-led teams, practices Telehealth Leveraging new practitioners: Community health workers/patient navigators/care managers? Training Regulato ry Financial Innovati on 33

Options Moving Forward Aligning financial structures & institutional policies Paying for value Building consensus: NPATCH Support for loan forgiveness Evaluate Community health worker models 34