WASHINGTON -- Can advanced practice nurses and physician assistants practice at the top of their licenses, unsupervised by physicians, without endangering their patients?
Physicians and other healthcare professionals continue to debate the question, and it appears that one of the best sources of U.S. healthcare outcomes data -- the Medicare system -- is poorly equipped to help settle it.
That was the message from a Politico Pro healthcare panel held here Tuesday, focused on the scope of practice furor currently raging.
The shortage of primary care physicians, the aging of baby boomers, the expansion of coverage under the Affordable Care Act, and the increased drive towards value-based care, would suggest that allowing nonphysicians to practice at the top of their license would be a good thing, yet tempers flare whenever such a change is proposed.
Take the recent proposal from the Department of Veterans Affairs. The VA announced a few weeks ago a potential policy change that would allow advanced practice nurses to work independently within the VA healthcare system, overriding any state or local laws that might restrict such a practice.
Physicians and specialty groups were outraged.
The American Medical Association slammed the VA for robbing patients of physician expertise, and the American Society of Anesthesiologists argued that such a change "lowers standards of care and jeopardizes Veterans' lives."
Nurses and their advocates unsurprisingly disagreed. But they face a continuing challenge in trying to prove their worth.
The way Medicare is currently billed makes it difficult for researchers trying to determine who's really responsible for patient outcomes.
Lisa Summers, MSN, DrPH, a senior policy fellow with American Nurses Association, who attended the panel, explained that nurse practitioners who bill under their own National Provider Identifier (NPI) are reimbursed at 85% of the physician rate -- rates may differ depending on location -- though when an NP bills "incident to" -- under their physician -- the practice is reimbursed at 100% of that physician rate.
The problem with team-based care is tracking who's responsible for performance measures.
Summers continued, "So if the diabetic's A1c improves dramatically, who do you attribute that to? Is that the PA who provided the primary care? Or the physician who maybe never saw that patient but under whose name [services are] billed?"
"It's essentially incentivizing gaming," said Patricia "Polly" Pittman, PhD, professor and co-director of the Health Workforce Institute at George Washington University here, who also spoke on the panel.
With such a foggy method of accountability giving credit where credit is due is next to impossible. And under the new payment system, the Medicare Access and CHIP Reauthorization Act (MACRA), as more alternative payment models -- many focused on team-based care -- emerge, such accountability remains problematic for nonphysicians.
"Right now we are invisible providers in many instances. Hopefully, as [payment reform] evolves we will become more visible," said Jeffrey Katz, PA-C, president and chair of the board of the American Academy of Physician Assistants.
If the VA's proposal does succeed, said Tammi Damas, PhD, MBA, RN, associate dean at the College of Nursing and Allied Health Sciences at Howard University here, the culture of opposition from physicians is unlikely to change, until the data can convince them otherwise.
"For an institution like the VA to allow advance practice registered nurses to have full authority, I'm hoping that's a trend that other institutions will follow," Damas said at Tuesday's briefing.
"I do believe, and there are studies that show, that patient satisfaction and patient outcomes are equally as good, if not better, [with] advanced practice nurses in comparison to physicians," she told MedPage Today.
"[Advanced practice nurses] spend more time with the patients. The patients are treated holistically. They look at all aspects of their care," she continued.
Summers also took the opportunity to respond qualitatively to critics of the VA proposal.
She blamed biased reporting -- mentioning Fox News specifically -- for some of the most bruising criticism the new proposal encountered.
"It's been scare tactics. It's been painting the care of advanced practice nurses as dangerous and unsafe, and I don't get where that comes from," she said.
"When you're out in the world and you talk to the physician assistants and the nurse practitioners and the obstetrician they work with, the vast majority of these people, they all get along ... They've got a waiting room full of patients and they've got to figure out how to take care of them."
Summers reserved some blame for state medical societies whose attacks she called "disconcerting."
"I'm just tired of it. We need to be spending our time on how do we improve outcomes, how do we truly pay for value."