Short Takes On News & Events

Nurse Practitioners Say How They’re Paid Affects Care They Can Provide

By Alvin Tran

March 1st, 2013, 1:06 PM

Many nurse practitioners say restrictive payment policies impact how they care for patients more than state laws governing what care they can give, according to a new study.

In the study, published Thursday by the National Institute for Health Care Reform, researchers found that while so-called “scope of practice” laws did not appear to restrict the primary care services nurse practitioners can provide to patients, they do affect how the advanced nurses are paid.

Researchers at the Center for Studying Health System Change conducted telephone interviews with 30 nurse practitioners, practice managers, and physicians working in a variety of clinical settings — all of which employed nurse practitioners. The researchers focused on six states representing a range of legal scope-of-practice restrictions: Maryland, Arizona, Michigan, Indiana, Massachusetts, and Arkansas.

Based on the interviews, Dr. Tracy Yee and her colleagues found that nurse practitioners — registered nurses with advanced degrees — faced greater challenges in the states with more restrictions on how they practice. In states such as Arkansas and Indiana where they cannot practice without a doctor’s supervision, nurse practitioners are not recognized as primary care providers by the traditional Medicaid program, and that affects how they deliver care to patients as well as how they are paid.

Other challenges in more restrictive states include disentangling the billing system involving public and private payers, ordering tests and procedures, and establishing independent primary care practices. And though private and public payers must adhere to scope-of-practice laws, they often impose additional restrictions on how these nurse practitioners practice, the study found.

Many nurse practitioners told researchers that restrictive payment policies had a much greater impact on their day-to-day practice than the current scope-of-practice laws enacted in their states. “Payers are in a position to determine what services NPs are paid for, their payment rates, whether NPs are designated as primary care providers and assigned their own patient panels, and whether NPs can be paid directly,” the authors of the study wrote.

Such policies “might hamper the efficiency of our provider capacity,” Yee said. “NPs can be doing more; they could be seeing more patients; they could be reaching communities that are underserved more often.”

States might consider making clearer what nurse practitioners can and can’t bill for — particularly in Medicaid and from other private payers, Yee added.

Dr. Angela Golden, president of the American Association of Nurse Practitioners, says she wasn’t surprised by the study’s findings on scope-of-practice laws. “It’s really important for people to recognize that removing those outdated laws will especially help people in medically underserved areas,” she said. “Fifty-five million people live in medically underserved areas.”

But Dr. Reid Blackwelder, the president-elect of the American Academy of Family Physicians, said he believes a more collaborative approach among physicians, advanced practice nurses, and physician assistants would pay dividends. “This discussion is often tied to the concept that an [advanced practice nurse] does what a family physician does or takes the place of a family physician. … What’s really important is that these roles are not interchangeable — they’re different,” he said during an interview.  “Each is critical and each has a role to play. You can’t just take one and make due if you can’t have the other.”

17 Responses to “Nurse Practitioners Say How They’re Paid Affects Care They Can Provide”

  1. JC says:

    I appreciate the sentiment of the study and it has some valid points. I am afraid, however, that the characterization of Arkansas’s environment for practicing NPs in the study rest on a flawed legal assumption. In Arkansas, Registered Nurse Practitioners (who are required by law to be supervised by physicians) are truly a relic and were largely replaced by those with the title Advanced Practice Nurses in the late 1990s (who do not require physician supervision to diagnose and treat but must have a collaborative practice agreement to prescribe). It seems the study relied on the Pearson Report, which describes both, but the study went with the more restrictive yet far less prevalent of the two. Arkansas is actually among the 7-8 states between complete supervision and no supervision, and the collaborative practice agreement is just that–a collaboration. It requires the physician to be available and accessible but does not dictate the means for doing so. In a sense, we are in what some would call the sweet spot: we have retained a formal mechanism for team-based care with the agreement but have not restricted where or how APNs practice.

  2. Chris Porter says:

    While I appreciate the response and clarification of the role of the advanced practice nurse is Arkansas, I have only one question: Can a Nurse Practitioner practice in that state without a collaboration agreement? If the amswer is no, then it is a level of restriction the prohibits that provider from practicing to the the fullest potenttial of their training and experience. The “sweet spot” is that the physicians get what they want and the Nurse Practitioners are left to make due with whatever is left over. Removing the barriers to independent practice for Nurse Practitioners is the only way to unleash the greatest potential for primary and specialty care in all states. Nurse Practitoners will never replace doctors, but the choice and availability of high quality care is strenghtened with them. THis can cannot be denied and should not be ignored – even if there is assumed to be a “sweet spot” in the face of less than independent practice.

  3. With regard to the MD-NP scenario, I’m reminded of a little rhyme my dad told me came from the Swiss-German neighborhood in Chicago in which he grew up after his birth in 1908…

    “Yes you may swim my darling daughter,
    just don’t go near the water.”

  4. With regard to the MD-NP scenario, I’m reminded of a little rhyme my dad told me came from the Swiss-German neighborhood in Chicago in which he grew up after his birth in 1908…

    “Yes you may swim my darling daughter,
    just don’t go near the water.”

  5. Regarding the two posts above by D Morf, the 10:47 am post has a bad reference link when one hovers over the name field, while the 10:49 am post has a corrected good reference link when one hovers over the name field. Regrets for the 10:47 entry error.

  6. This makes me laugh. They have no clue what’s ahead for them. They have no clue why they make what they do now (sometimes 70% of what the M.D. takes home; they should be happy!). Wait until you (NP’s) get your “Autonomy” from Physicians (which you are lobbying for ), begin opening your own Practices, pay your own Malpractice Insurance premiums, realize the crappy reimbursement that has been going on for years (especially in Primary Care; PPACA or not), and then no longer have your nice 1/2 hour to spend with your Patient because you have to book 5-6 Patients an hour to meet your overhead and pay your mortgage. Then let me hear you moaning about how much you are making. Short-sighted and clueless; as usual.

  7. Sandie Bock says:

    SHAME on the NPs who say the care they give is affected by how they are paid. SHAME ON THEM. I am a PA-C and feel that we(NPs and PAs) are paid well and MUST remember we are not MDs. I feel we should be compensated(or the practice we work for) but not at the same rate as the doctor. There are patients that NPs or PAs are not qualfied to care for, those who have very complicated conditions and that we would refer to the physician and so why should we be paid the same and not have to perform in the same way. AND how about malpractice insurance, for practicing MEDICINE instead of Nursing when you take on an independent practice without having the comprehensive schooling and training. Lets be truthful, an NP is anyone with an RN, who then goes and gets their NP which can take about another year. PAs are with 4 year at least college education and then another 2 years of college, Masters Degree and most had to have some experience in healthcare before going to PA school. NEITHER should be able to seen as Primary Care Provider without any MD supervision and YES I do believe we do not deserve the same pay as the MDs. Talk about being Delusional!!

  8. YaleNP says:

    I think the article is talking about the payment schemes being reimbursed for different types of services and tests being ordered, not NP’s salary or that NPs will provide you a “mid-level” type of care as they’re being paid a “mid-level” salary. I’m in a community health center working along side the pediatrician as a colleague and we’re always stumped with what we can and cannot order as PCP period since some insurance will not reimburse us for the care being provided or needed to be provided. And we’re in CA! We often have to negotiate with the insurance or most of the time provide FREE care without charging anyone because of this. The opportunity cost is high and is paid by our own tax dollars and health centers in other ways obviously. Please read the article before shaming anyone Sandie Bock and Logicaldoc.

  9. With all due respect YALENP (did you go to Yale?; I did); I believe Sandie Bock and I completely get the bigger picture here and appear to understand the evolution of Healthcare in this Country (I have over 20 years experience); rather than concentrating on superficial specific issues that, in the end, are in fact consequences (symptoms) of this “bigger picture”. Kudos to Sandie Bock for truly “getting it”! However, there’s more to the story; to the mere fact that a market for NP’s and PA’s was even created in the first place. Not sure how “seasoned” you (YALENP) are, but if you’d like to learn how it all developed, why Healthcare Delivery is in chaos now due to the dynamics of the last 25-30 years, and why the things you (and the article) brings up are superficial non-issues (when you break it down), consider this:

  10. BTW; I don’t think I ever shamed anyone in my statements. However, I would agree with the “delusional” reference by Sandie Bock.

  11. Gianetta Norwood says:

    It frightens me to really read these comments. A MD who has made it evident that he is clueless to what Nurse Practitioners really want and a PA who has minimize the education of a NP. Nurse Practitioner’s goals are to make healthcare accessible. Somewhere specialization of practices only care for smaller populations that require healthcare services and do not supply healthcare to the general population the has majority need. The current number of family/primary care practitioners (MD) numbers are not sufficient to care for the general population. Nurse Practitioner’s have 4 years training as an RN then additional 2-4 years in graduate studies (2015 the title will require a doctorate to all those who have returned) totaling a 6-8 year education. Most RN have an average of 6 years experience before returning to graduate. No we are not trying to replace Doctors (as they think); we are trying to deliver care. As was mentioned if you don’t have revenue and support you cannot deliver in the areas that so need them. Yes Nurse Practitioners are willing to work with physicians because we are not able to manage the more complicated cases. However, with more independent practices more ground is able to be covered.

  12. ProudOkie says:

    Speak for yourself Sandie Bock…I’ve been practicing independently for over 10 years without issue or lawsuit. Who do you think takes care of all those complicatefd cases that many of the MDs won’t because of Medicaid or “other” issues? You need to get out of your supervising physician’s kingdom more often. You make yourself look foolish. Your supervising physician should be proud of you….good PA! gooooood PA!

  13. UNCNP says:

    The bottom line is that there has never been a single study indicating that care by NPs is of lesser quality or safety than that of MDs. In fact, some studies have indicated that patients prefer the care provided by NPs. Yes, there are some cases that are more complicated than an NP in Primary Care can or should handle. And NPs do exactly what Family Physicians do in such cases–refer to a specialist. NPs are also sued for malpractice far less often and have far fewer complaints to their Boards than MDs per capita. In states where there are no restrictions on NP practice and NPs are able to work completely without MD involvement, this remains true (Pearson Report). This proves that NPs are able to independently provide safe, high quality care.

  14. Bridget McKinley says:

    Just let us practice to our full scope of practice– let the patients decide if they want care by an MD or an NP– keep it simple. We are safe and cost effective: that is the bottom line– but we should get paid equal pay for the services we provide as well– AGAIN EQUAL PAY FOR THE SERVICES WE PROVIDE.

  15. Deborah says:

    It is not in the patients best interest for the patients when a Nurse Practitioner is abruptly removed from practice due to physician retirement, illness, or unprofessional demeanors of demoralizing an NP/swearing at NPs/ruining the reputation of NPs. A patient builds a trusting relationship with a healthcare provider and takes the medication from that provider based on trust. I have patients who will not see another provider and are not on their medications because they want my services. Politicians are bought by the medical profession and will not voluntarily remove the barriers or unlock the shackles the physicians hold the keys to unless nursing joins together to vote out the health committee politicians in a state refusing to pass legislation freeing us from our bondage. Michigan has had legislation in committee for almost 2 years; the head of the health committees husband is a cardiologist and participates at a very well known hospital. At her campaign fund raiser physician donations were the primary source of funding. Remember, history has taught us the enemy will iniltrate to destroy the good plans in order to keep power.

    Physicians want to keep NPs under their thumbs for money, not patient interest. To pay a NP $40-$50 an hour while the payment schedule is $123 tells us alot. All you have to do is look up the billing code from Medicare and then look at your wages. Buying malpractice is not too hard for an individual as physicians seem to think “an employer must provide it”.

    There is a distinct difference between an employee mentality and a professional mentality. The PAs comments are inappropriate, are of an employee mentality, and are out of place. This is a Nurse Practitioner issue not a PA/NP issue. A Nurse Pracitioner is not a PA (physician ASSISTANT). Nurses have a long history of providing quality care. Historically, physicians were males and as males they were able to legislate nurses out of work in the 1800′s or to be submissive as “good women should be”. I, like many colleagues, would prefer the PA keep their opinions to their PA model of practice and let the Nurse Practitioners delve into their own issues. Again, a PA and NP are not one in the same.

    I pray daily to ask God to free me from my bondage. I need to answer for my own diagnostic decisions and prescribing orders. There are legal methods for every profession to handle the compentency of its membership.

    Our politicians are concerned with votes and money buys votes. That is what they care about. Money and power. Physicians also are concerned with money – taking over 1/2 the NPs reimbursement to pay their mortgages. Neither the politician nor the physician have the patients best interest in mind – the obtaining of high quality, compassionate care.

  16. Continue on with your discussion about all the superficial non-issues (symptoms) these days; as it is evident that no one appears to understand the history and evolution of the Healthcare Industry over the last 30 years. Rationalize all you want because only those that understand this evolution will understand the more important core issues that laid the foundation of the mess we are in today.
    ” The bottom line is that there has never been a single study indicating that care by NPs is of lesser quality or safety than that of MDs.”
    There will be many in the future when the M.D. becomes extinct and the N.P. has to deal with the “reality” a Physician’s practice has been dealing with, and must deal with now. Good luck! Get your crystal balls out because you will need them.

  17. Reading these commentaries compelled me to reply. What difference does it make whether you are a Yale graduate or a GW grad (myself) or a lesser known school? I’m happy I’ve never experienced this elitist view in practice. The bottom line is that we are all concerned with giving the best care we are capable of. Time constraints will always be an issue. If we stoop to the pettiness of type and years of schooling, the number and years of experience etc. and terms like “bondage”, we demean who we are. If I as an NP treat a strep throat, and my colleague who is an MD does the same…then why do I deserve a lesser payment? Let’s respect one another, and practice the golden rule.