Wednesday, July 27, 2016

Doctors and nurses are battling (again), but does it have to be this way?

The Department of Veterans’ Affairs proposal to allow Advanced Practice Registered Nurses (APRNs) to have full and independent practice authority, preempting state laws that hold them back, has triggered another ugly fight between the medical and nursing professions.  The American Nurses Association supports it, the AMA opposes it.

The fight over the VA’s proposal continues a long-standing battle that plays out regularly in state legislatures, as nurses have sought to expand their “scope of practice” and eliminate existing “physician supervision” requirements, while state medical societies have battled back. 

Both sides, of course, frame the issue as being about quality and access, not about who is in control.  Physicians argue that being licensed as an MD or DO requires a higher level of education and patient care experience (four years of medical school and at least 3 years of supervised direct patient care training in residency and fellowship positions) that makes them uniquely qualified to take care of patients, especially those with more advanced conditions, while nurses argue that their different but unique  training and skills—especially those that have been trained as Advanced Practice Registered Nurses—make them at least as qualified to treat most patients, with equal or better outcomes.  Both cite conflicting studies to support their positions. 

I have personal experience in how hard it is to find common ground between the two professions or, for that matter, within the medical profession itself.   Three years ago, the American College of Physicians published a position paper in the Annals of Internal Medicine, Principles Supporting Dynamic Clinical Care Teams: A Position Paper of the American College of Physicians, which I co-wrote with my colleague Ryan Crowley on behalf of ACP’s Health and Public Policy Committee.  I know Ryan would agree with me that it was one of the more challenging papers we have written.  Throughout the two years of research and writing the document, we struggled to find positions that would enjoy the support of ACP’s own membership, which were themselves not entirely on the same page on how hard to push back against efforts to expand nurses’ scope of practice, but also to move closer to finding common ground with the nursing profession.

There was almost universal agreement among ACP’s leadership that physicians have unique training and skills that make them especially qualified to exercise advanced clinical leadership responsibilities for team-based care.  But there was also recognition that APRNs, NPs, and other non-physician professionals are essential members of the team, and, in some cases, they may have been held back from practicing to the full extent of their training and skills by overly restrictive internal supervision requirements and overly restrictive state laws.  Some of ACP’s members favored a more hard-line, physicians-should-always-be-in-charge stance, while others were open to a more nuanced approach that emphasized collaboration and sharing of clinical responsibilities within teams, putting less emphasis on who should run the show.  During the process of writing the paper, we engaged in a constructive dialogue with respected members of the nursing profession, seeking to find common ground where possible or, at least, to avoid using words (like physician “supervision”) that we learned from them were viewed as offensive, creating rhetorical barriers to achieving agreement. 

In the end, I think the paper struck exactly the right balance, affirming that physicians do have unique and more advanced training and skills that make them especially  qualified to exercise clinical leadership responsibilities for a team, while supporting the important and essential contributions of highly trained APRNs, NPs, PAs, clinical pharmacists and others in sharing patient care responsibilities, with all members of the team being allowed to practice to the full extent of their training.  In other words, we came up with a nuanced approach to the issues of clinical leadership responsibilities within a team rather than defining the issue as being about who is in charge.

The problem is that the VA’s proposal is anything but nuanced, because it frames the issue as a binary choice: are you for or are you against allowing APRNs to practice independently, pre-empting any state law licensure laws that hold them back? Presented this way, is it any surprise that it has led to another divisive fight between the medical and nursing professionals?

ACP, for its part, thinks there is a better way.  In our comments on the VA proposal, submitted Monday, we offered an alternative to the VA’s proposal that tries to move the discussion away from considerations of “independence” and “hierarchy” to how to organize high-functioning, patient-centered clinical care teams that use everyone’s skills to the maximum extent of their clinical training and skills, based on the principles in our 2013 paper.  Our alternative offered the following key points:

  •  While ACP does not support the VA's proposal to broadly preempt state licensing laws to grant full independent practice authority to APRNs, we propose an alternative that matches patients with the health care professionals on the team who have the training and skills needed to meet their care needs, modeled on the recommendations in ACP’s 2013 position paper.
  • We express support for veterans being able to have access to a personal physician who accepts clinical responsibilities for care of the “whole person,” consistent with the Patient-Centered Medical Home model.  In a press release that summarizes our recommendations to the VA, ACP’s President, Dr. Nitin S. Damle observed that “While internal medicine physicians have unique training to exercise clinical leadership responsibilities for the team and to care for adults with complex illnesses and diagnostic challenges, patients might appropriately be seen by other members of the clinical care team -- including nurses -- depending on their specific clinical needs and circumstances with physicians being available for referral or consultation as needed."
  • Because primary care encompasses various activities and responsibilities, it is simplistic to view primary care as a single type of care that is uniformly best provided by a particular health care professional.  To illustrate, our letter observes that an advanced practice registered nurse providing primary care commensurate with his or her training may consult with or make a referral to an internal medicine physician, a family physician, or another physician specialist when presented with a patient with significantly complex medical conditions.
  • Effective clinical care teams allow each member of the team to practice to the full extent of their training and experience, ACP observed.  While ACP does not support pre-emption of state licensing laws, it strongly encourages states to examine their laws to ensure that all clinicians are able to practice the full extent of their training and skill while practicing within a dynamic clinical care team.
  • Our letter notes that especially in physician shortage areas, it may be infeasible for patients to have “an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.  They may also be unable to have immediate on-site access to other team members who may be located some distance from where the patient lives and accesses medical care. In such cases, collaboration, consultation, and communication between the primary care clinician or clinicians who are available on site and other out-of-area team members who may have additional and distinct training and skills needed to meet the patient's health care needs are imperative. We suggested the even if a physician and APRN are not physically co-located, the patient should have access to a 'virtual' clinical care team through use of telemedicine, electronic health records, regular telephone consultations, and other technology to enable the on-site primary care clinician and all members of the health care team to effectively collaborate and share patient information. Telemedicine and telehealth technologies can help virtual clinical care teams provide clinical consultation and decision support as well as patient education, remote monitoring, and other services.”

I am under no illusion that ACP’s approach will be the basis for a truce between the medical and nursing professions on the VA’s proposal or, more broadly, over the other raging battles over preserving, changing, or superseding state laws that set limits on what nurses can do independently.  These fights will go on, precisely because they present the issue as “either/or” choices.  I am hopeful that ACP’s nuanced approach of trying to move the discussion towards how both professions can work together, rather than fighting against each other, will eventually bridge some of the differences over leadership, supervision, and scope, especially at the level where care is actually delivered, when teams of clinicians, highly trained in their own disciplines, work closely and collaboratively together while focused solely on what is best for their patients.

Today’s question: What do you think of the VA proposal and ACP’s alternative?

Monday, July 18, 2016

Primary Care Resurgence

By most accounts, primary care physicians are a pretty beleaguered lot these days, especially those in smaller independent practices.  Years of being undervalued and over-hassled have taken their toll, leading many established primary care physicians (PCPs) to look for an exit ramp from practice, while discouraging medical students from considering careers in primary care. burnout  is rampant. To borrow a line from the Rolling Stones, it’s enough to make a grown doctor cry.

Yet there may be reason for optimism that things will get better for primary care—even leading to its resurgence.  Writing in the New England Journal of Medicine, Dr. Bob Kocher predicts that “As health care reimbursement shifts from fee-for-service to risk-based payments, PCPs are well positioned economically and strategically. Their incomes are likely to grow substantially over the next decade, at the expense of hospitals and specialists. Specialists who fail to expand their role and develop the capabilities and relationships to drive value improvement will face a threat to their incomes and practices.”  He explains that as Medicare and other payers increasingly adopt primary care based alternative payment models (APMs) that hold clinicians accountable for achieving shared savings,  dollars will flow to primary care physicians and away from other specialists:

“These APMs assign to organizations that employ primary care physicians (PCPs) accountability for achieving quality goals and saving money relative to benchmarks. As a result, PCPs must practice differently to reduce the total cost of care and improve its quality, invest in tools such as population health management software, and often add staff such as care coordinators. PCPs assume risk and incur costs in hopes of achieving economic windfalls later from shared-savings payments or low medical costs relative to Medicare Advantage capitated payments. Many organizations, particularly large physician-led groups focusing on Medicare Advantage, have demonstrated that large and recurring savings can be achieved. Since sharing savings from beating benchmarks is predicated on reducing spending from somewhere in the health care value chain, these models create economic winners and losers. Future incomes for both PCPs and specialists depend on the “sources” and “uses” of savings: whose revenue is lost to create savings, who receives reduced expenses or proceeds, and who controls the flow of funds in these models. Early experience suggests that the sources of savings will be reducing hospital days, emergency department visits, lengths of stay in skilled nursing facilities, referrals to specialists, and the intensity of diagnostic testing by specialists. Some of the medical conditions whose costs are most modifiable are congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes, back pain, and arthritis. Reductions in volume and treatment intensity will most affect hospitals, skilled nursing facilities, and specialists — particularly emergency medicine physicians, cardiologists, pulmonologists, endocrinologists, orthopedists, and radiologists.”

This isn’t just theoretical, Kocher notes, it’s already happening. “The uses of savings will be divided between lower medical claims for payers and new revenue paid as shared savings to provider organizations that achieve savings. This potentially large magnitude of revenue gains for PCPs provides strong motivation. PCPs have an average annual income of $195,000 — significantly less than the specialist average of $284,000 — and account directly for a small percentage of health care costs. Yet they substantially influence the total cost of care through referrals and directing of their patients’ subsequent care. For example, a PCP could earn an extra $80,000 by achieving the savings rates attained in the fourth year of the Alternative Quality Contract program. This figure amounts to a 10% reduction in the total cost of care for a 1500-patient panel (assuming that payers keep half the savings and that physicians must use three fourths of their savings to pay for additional staff and tools).”

Soon, Medicare will be launching the Primary Care Plus Program that will allow up to 5,000 primary care practices (with an estimated 20,000 clinicians in those practices) in 20 states/regions--the sites will be announced later this summer--to receive risk adjusted per beneficiary per month (PBPM) care coordination payments.  Two different tracks will be offered; track one will pay these practices an average of $15 PBPM for every Medicare patient they see, track two will pay them an average of $27 PBPM.  They can also earn additional PBPB incentive payments, $2.50 in track one, $4.00 in track two for achieving savings to Medicare; these would have to be paid back to Medicare if the savings aren’t achieved.  I explained more about the program in a blog I posted in April.  And, under the proposed rule for the Medicare Access and CHIP Reauthorization Act (MACRA), Comprehensive Primary Care Plus practices will also be eligible to receive 5% Medicare fee-for-service bonus payments from 2019 through 2024, plus their PBPM payments.

But there also good news for primary care physicians in more traditional practices who aren’t quite ready to go the APM route.  Last month, Medicare published another proposed rule updating the Medicare Physician Fee Schedule, proposing a number of new codes and payment policies that will redistribute dollars from specialty care to primary care.  As ACP noted in a statement applauding  the proposed rule, Medicare proposes to:

Improve payments for Care Coordination by Primary Care Physicians: The proposed rule includes revisions to the billing requirements for the existing chronic care management (CCM) codes to address the administrative burdens of electronic access, use of certified EHRs, and documentation.  CMS is also proposing payment for two additional codes to address the amount of time patients with complex needs require for extra care management.

Increased payment for prolonged services: The Agency also proposes to recognize payment for codes related to non-face-to-face prolonged evaluation and management (E/M) services and increase payment rates for face-to-face prolonged E/M services. These codes provide a means to recognize the additional resource costs incurred by physicians when they spend significant time outside of the in-person office visit.

Integrating Mental and Behavioral Health into Team-based Primary Care: CMS is proposing to pay for specific behavioral health services furnished using the Collaborative Care Model; in this model, patients are cared for through a team approach, involving a primary care practitioner, behavioral health care manager, and psychiatric consultant. CMS is also proposing to pay more broadly for other approaches to behavioral health integration services.

Cognitive Impairment Care Assessment and Planning: CMS is proposing a new code to pay for cognitive and functional assessment and care planning for patients with cognitive impairment (e.g., for patients with Alzheimer’s). This is a major step forward in care planning for these populations.

Payment for Care of Patients with Mobility-Related Impairments: CMS is proposing to pay physicians more accurately for furnishing services to beneficiaries with mobility-related impairments. This increase in payment will improve quality and access for this vulnerable population.

Expansion of Diabetes Prevention Program (DPP) Model: The proposed rule would expand to eligible patients and physician practices in all states this CMMI model, now available in only eight states, which provides counseling and other support services to help prevent diabetes in patients that have been found to be at a greater risk of becoming diabetic.  Physicians and other clinicians who participate in the program would receive additional payments for providing such support services to their eligible patients.  ACP strongly supports CMS’s expansion of this prevention model and is pleased that it met the legal Actuarial requirements required for CMMI to expand it nationwide, and will be providing comments on the basic framework outlined in the proposed rule.

Addressing Undervaluation of Primary Care Services:  CMS notes in the proposed rule that the current set of codes for primary care evaluation and management services, like office visits, do not adequately reflect the resources involved in providing such services, and seeks comments on improving the relative value units assigned to such codes to more accurately reflect their resource costs.

These and other improvements proposed by CMS would increase aggregate payments to physicians, especially those who practice in primary care specialties including internal medicine, by approximately $900 million said Acting CMS Administrator Andy Slavitt in a blog post.

So, to our beleaguered primary care doctors, take heart, things are moving in the right direction.  It’s long been understood that patients having a relationship with a primary care physician results in better care at lower cost, the definition of high value care.  Now, finally, Medicare and other payers are beginning to put real money back into strengthening primary care; looking ahead, primary care physicians “are well positioned economically and strategically. . . Their incomes are likely to grow substantially over the next decade, at the expense of hospitals and specialists,” as Dr. Kocher predicts.

Today’s question: how does the future of primary care look to you?