AJN, American Journal of Nursing:
In the News
Recognition by reimbursement and insurance companies remain key issues.
NPs are the primary care providers (PCPs) of choice for many Americans, but some insurance companies are refusing to “credential” or “empanel” them—the recognition required under state law for reimbursement. In Colorado, for example, two of the state's largest insurance carriers, Anthem Blue Cross and Blue Shield of Colorado and Rocky Mountain Health Plans, have refused to empanel independent advanced practice nurses (APNs) in urban areas. That decision, which the carriers defend by claiming that there isn't a need for additional providers in those areas, has meant that huge out-of-pocket fees must be paid by patients who prefer NP-provided care over care provided by physicians or in local health clinics. Efforts by independent NPs to become recognized by these companies, which together insure more than 1.2 million people in the state, have so far been ineffective.
The battle in Colorado is hardly unique, however; the National Nursing Centers Consortium found that in 2009, nearly half of the major U.S. managed care organizations didn't credential NPs as PCPs. But the tide may be turning. The shortage of primary care physicians is growing: the Health Resources and Services Administration estimates that more than 15,000 additional practitioners are needed to care for people in underserved areas, and that number will rise with the increased insurance coverage mandated by the Patient Protection and Affordable Care Act (ACA). NPs are in a position to help fill the gap quickly. But Susan King, executive director of the Oregon Nurses Association, notes, “By thinking that this is all about need, the carriers are missing the other issue. If we're moving to a system that's supposed to be consumer or patient focused, we have to think about [providing a] choice.”
Choice is less of a problem in Oregon than in some states because scope of practice laws permit NPs there to practice independently of physicians, something only 18 states and the District of Columbia currently allow, according to the October 25, 2012, issue of Health Affairs' Health Policy Brief, and a state statute requires that insurance companies recognize them as providers. Rather, the issues that arise there are matters of equal compensation, wherein insurance carriers have reduced reimbursements drastically for nonphysician providers. Efforts now are being made within the state to guarantee pay parity for NPs doing the same work as physicians, according to Oregon's Lund Report.
Progress is being made nationally on scope of practice laws, albeit slowly; in 2012 alone, 50 bills related to nurses' scope of practice were introduced in state legislatures. As Tay Kopanos, director of health care policy for state government affairs at the American Association of Nurse Practitioners, points out, section 2706 of the ACA will go into effect in January 2014, barring insurance companies from discriminating against health care providers who are working within the limits of their licenses under current state law. And there's some good news for independent NPs like those in Colorado and elsewhere (see An NP-Led Model That Works).
Box. An NP-Led Model...Image Tools
“Now is a good time for NPs to begin the application process if they're interested in credentialing,” Kopanos says. If they run into barriers, she says, they can ask insurance companies when they're going to incorporate section 2706 into their policies.
Even though section 2706 doesn't specifically apply to nursing but to health care professionals across the board, Kopanos explains, “The point is to give patients better access to the providers of their choice.”—Laura Wallis
© 2013 Lippincott Williams & Wilkins, Inc.