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July 2013



Volume 10, Issue 4


President's Budget Proposes Increase for Title VIII Nursing Programs
HRSA to Collect New Grant Project Data
Better Reimbursement for APRNs and PAs Discussed by MedPAC


NLN Government Affairs Action Center
NLN Public Policy

President's Budget Proposes Increase for Title VIII Nursing Programs

President Obama released his FY 2014 budget on April 10, 2013. The specific breakdown for Title VIII Nursing Workforce Development Programs follows. Please note that the additional $20 million for the Advanced Education Nursing Program is actually coming from the Public Health Service Evaluation Fund.

Title VIII - Nursing Workforce Development Programs

(In Millions)

Program FY 2012 FY 2013 Sequestration President's FY14 Request
Advanced Education Nursing $63.469 $60.665 $83.469
Nurse Education, Practice, and Retention $39.638 $37.184 $39.638
Nursing Workforce Diversity $15.819 $15.012 $15.819
NURSE Corps (formally Nurse Loan Repayment and Scholarship Program) $83.135 $78.895 $83.135
Comprehensive Geriatric Education $4.485 $4.256 $4.485
Nursing Faculty Loan Program $24.553 $23.3 $24.553
Total, Title VIII $231.099 $219.312 $251.099

HRSA to Collect New Grant Project Data

More than 40 programs administered by the Health Resources and Services Administration's (HRSA) Bureau of Health Professions (BHPr) award grants to health professions schools and training programs across the United States. These grants are aimed at developing, expanding, and enhancing training and strengthening the distribution of the US health care workforce. Many of these programs are governed by the Public Health Service Act, specifically Titles III, VII, and VIII (the Nursing Workforce Development Programs).

Health care reform, the Patient Protection and Affordable Care Act (PPACA), affected a broad range of BHPr health care workforce grant programs. The law reauthorized most of these programs and, in some cases, expanded eligibility, modified program activities, and/or established new requirements. Also, because PPACA created new health professions programs, it was necessary to reexamine BHPr's existing performance measures to ensure that these programs address the changes, meet evolving program management needs, and respond to emerging workforce concerns.

In the coming months, HRSA BHPr will issue revised data collection to enhance analysis and reporting of grantee training and education activities, outcomes, and intended practice locations. Data collected from these grant programs will provide a description of the program activities of more than 1,600 reporting grantees to better inform policymakers on the barriers, opportunities, and outcomes involved in health care workforce development. The proposed measures will focus on five key outcomes:

  1. Increasing the workforce supply of diverse well-educated practitioners
  2. Influencing the distribution of practitioners to practice in underserved and rural areas
  3. Enhancing the quality of education
  4. Diversifying the pipeline for new health professionals
  5. Supporting educational infrastructure to increase the capacity to train more health professionals

Revisions to the current reporting will require the collection of baseline data at the grant application and award stages and will include performance reporting semi-annually by the type of programs: direct financial support programs, infrastructure programs, and multipurpose or hybrid programs (could be direct financial support, infrastructure, or both within the same grant program). Measures will be reported at the individual, program-specific, and/or program cluster-levels.

At present, the federal government is examining the burden to grantees to undertake the revised data collection. The burden in this context means the time expended by persons to generate, maintain, retain, disclose, or provide the information requested. This includes the time needed to review instructions; to develop, acquire, install, and use technology and systems for the purpose of collecting, validating and verifying information, processing, and maintaining information, and disclosing and providing information; to train personnel and to be able to respond to a collection of information; to search data sources; to complete and review the collection of information; and to transmit or otherwise disclose the information.

Better Reimbursement for APRNs and PAs Discussed by MedPAC

At its April meeting, some members of the Medicare Payment Advisory Commission (MedPAC) suggested Medicare take stronger steps to reward the work of APRNs and physician assistants (PAs). Medicare reimbursement generally follows state scope-of-practice laws for APRNs and PAs. These laws vary widely and affect what APRNs and PAs can bill Medicare.

If a particular state allows an APRN to operate independently of a physician, Medicare will pay the APRN 85 percent of what a doctor would receive for providing that service. But if the APRN must work under a physician, that doctor receives 100 percent of the payment for that service even if the doctor did not provide it. That practice drew criticism during the MedPAC meeting.

Mary Naylor, PhD, RN, from the University of Pennsylvania School of Nursing and a MedPAC member, stated, "I would really wonder whether or not we couldn't create the conditions of participation that say you can't restrict the use of people." Naylor continued that Medicare payment principles, such as equity in payment for comparable services and use of efficient providers, can apply to APRNs and PAs. She added that Medicare should work on eliminating barriers that restrict APRNs and PAs from practicing more freely in some cases, such as determining which patients are suited for home health care.

Craig Samitt, MD, MBA, president and chief executive of the Dean Health System in Madison, WI, suggested that Medicare pay doctors for services best left to APRNs and PAs at 85 percent of the rate it pays physicians now. He noted that Medicare also should pay those APRNs and PAs the same as what physicians receive for performing higher-level services. He also stated that Medicare should provide higher payments to APRNs and PAs who serve in rural and underserved areas to incentivize their practices there. "Instead of trying to recruit physicians, do we try to recruit advanced practitioners for some functions?" Samitt asked.

Some medical societies have spoken against the use of independent nurse practitioners, saying they should work under a physician who has many more years of education and training. However, though use of the mid-level providers is seen by their advocates as being able to solve at least part of the physician shortage, Rita Redberg, MD, professor of clinical medicine at the University of California at San Francisco, cautioned against wide use of these providers. Comparing her 11 years of postgraduate training and education and APRNs' two years, the cardiologist noted that experience cannot be understated in the clinic.

The MedPAC commissioners ended their meeting only offering their views for staff to develop more policy recommendations; they took no official action. The next MedPAC meeting is in September.


us-map-smAlabama Senate Passes NP Prescription Authority Bill

The Alabama Senate recently passed a bill that would allow certified nurse practitioners to prescribe some drugs they cannot prescribe now — a move that the sponsor of the bill — state Senator Greg Reed (R-Jasper) — said would expand access to health care in some Alabama areas. The bill would allow the practitioners, operating under the supervision of a collaborating physician, to prescribe certain controlled substances that they cannot under current law.

Reed said patients in rural areas sometimes depend on nurse practitioners as their first option for health care because they have to drive some distance to see a physician. He said that while practitioners can prescribe certain medicines now, the limitations on prescription-writing can be a problem. For example, a nurse practitioner can sew up a cut for a patient, but might not be able to provide the level of painkiller the patient might need.

The bill passed by a vote of 27 to 1 and now moves to the Alabama House of Representatives, which has passed a similar measure.

Expanding Learning in Iowa

The Iowa Action Coalition, formed a year ago to further nursing statewide based on recommendations from the Institute of Medicine's Future of Nursing report, has released a set of goals. The list includes getting nurse residency programs in every hospital in the state and increasing the proportion of registered nurses with at least a BSN from 26 percent to 50 percent by 2020.

The Robert Wood Johnson Foundation last month announced that the Iowa Action Coalition is one of 20 "future of nursing" groups chosen to be part of a $3 million initiative to further nursing. The initiative aims to help states prepare the nursing profession to address today's three primary health care challenges — access, quality, and cost.

The push to use nurse residency programs statewide addresses the need for a better transition from academic preparations to actual practice. The residency program helps hospitals because it increases nurse retention, which ups staff members' experience and knowledge with each hospital's procedures and practices. About seven Iowa hospitals currently have nurse residency programs, but the idea is to establish a statewide program that's accessible to all nurse employers. For example, if a smaller organization doesn't have the resources to implement its own program, it could tap the state enterprise.