Advanced practice registered nurses (APRNs) continue to provide critical access to healthcare throughout the US. Multiple studies have shown that the outcomes for patients who see APRNs are equivalent to those who see physicians.1,2 In addition, APRNs are more likely to practice in rural areas compared with physicians.3 More individuals have access to health insurance since the implementation of the 2010 Patient Protection and Affordable Care Act (PPACA), which has in turn increased the demand for healthcare providers.
APRNs or their employers bill for the services they provide. Medicare reimburses NPs, certified registered nurse anesthetists, and clinical nurse specialists at a rate of 85% of the physician fee schedule, whereas certified nurse midwives are reimbursed at the same rate as physicians since the PPACA was passed.4 Medicaid and private insurance reimbursement varies widely based on state regulations and health plan policies.5
Oregon is the only state with legislation requiring private insurers to reimburse NPs and physician assistants in primary and behavioral healthcare at 100% of the physician rate.6 APRNs are expected to achieve the same quality of care for patient outcomes and assume full responsibility and liability for the care they provide compared with physicians, yet payment for their services is not always equivalent. This article describes efforts in Washington State to achieve reimbursement parity.
ARNPs in Washington State
All APRNs in Washington State are licensed as advanced registered nurse practitioners (ARNPs).7 ARNPs have full practice authority in Washington State, and Medicaid and the Department of Labor and Industries reimburse ARNPs at 100% of the physician rate.8,9 The reimbursement practices of private insurance companies are difficult to track because of the proprietary nature of reimbursement contracts.10 Nonetheless, two of the state's largest insurers, Premera Blue Cross and Regence Blue Shield, announced in memos to ARNPs their plans to reduce NP reimbursement to 85% of the physician rate in 2013 and 2015, respectively.11-13 Regence Blue Shield reimbursed NPs at 95% of the physician fee schedule for nearly 2 decades before reducing reimbursement again to 85%.
Efforts to achieve the same pay for the same service
Prior to the reduction of NP reimbursement to 85%, a complaint was filed by an NP with the Washington Office of the Insurance Commissioner in 2002, citing a section of Washington law that seemed to indicate that parity reimbursement was required. The complaint was initially upheld as valid but was overturned on appeal in 2004.14 A lawsuit filed by the Washington State Nurses Association to argue in support of payment parity for ARNPs was rejected in King County Superior Court.15 In order to achieve reimbursement parity, legislation will be required to mandate that private insurers pay ARNPs the same rate as physicians for the same service.
ARNPs United of Washington State
ARNPs United of Washington State (AUWS) is a statewide professional organization that has historically advocated for reimbursement parity. In 2016, after several attempts, AUWS worked successfully with the Department of Labor & Industries through the regulatory process to increase NP reimbursement from 90% to 100% of the physician rate. Legislative efforts to require parity reimbursement were stalled for over a decade for several reasons, including lack of support from an influential lawmaker.
In 2018, AUWS developed a multipronged strategy to garner support for the introduction of a bill. This advocacy strategy included a statewide survey to identify the effects of reduced health plan reimbursement, a political endorsement process, engagement with AUWS membership, meetings and communication with legislators, and identifying legislative champions.
AUWS political endorsement process
Washington State law allows organizations to provide political endorsements without forming a political action committee, which would be required if money were to be raised and donated to candidates. The political endorsement process used by AUWS included developing a candidate questionnaire, developing rating criteria, communicating with candidates, organizing responses for review, and holding meetings to determine which candidates to endorse.
The 231 candidates for the state Senate and House races were contacted after the primary election results were certified by the Washington Secretary of State on August 24, 2018. Responses were received from 75 candidates. In addition to the candidate's responses, factors considered for endorsement included the political lean of the district, party, incumbency status, leadership role, and whether the candidate was endorsed by other nursing organizations.
Thirty-three House candidates and 13 Senate candidates were endorsed. AUWS announced the endorsements on the organization's website and Facebook page. Many of the candidates promoted the endorsement using their campaign media. Among those endorsed, 22 of 33 (66.7%) House candidates and 10 of 13 (76.9%) Senate candidates were elected. AUWS sent a congratulatory message to the newly elected officials.
Communication with membership
In addition to the announcements on the AUWS website and Facebook page, endorsements were discussed during the AUWS annual meeting in October 2018. Current and prospective AUWS members received updates on the political endorsement process and efforts to promote legislation.
2019 legislative session
In Washington state, this year's regular legislative session occurred from January 14 to April 28. A leadership team of AUWS met with a key committee chairperson in November 2018. A briefing packet with workforce data, the 2018 ARNP survey results, and health plan reimbursement information was presented to the legislator. After the meeting, the legislator gave permission to submit a bill that was drafted by committee staff using the Oregon law as a model. Preparation for the legislative session included organizing talking points, identifying and collaborating with a new contract lobbyist, and outlining a strategy for bill sponsorship and introduction. Part of this process involved discussions with other organizations and professions, such as the physician assistant group, the medical association, and other nursing organizations.
Knowing the health insurance companies would oppose the bill, understanding the positions of these organizations on reimbursement parity was necessary to strategize for the legislative session. House Bill (HB) 1433 and Senate Bill (SB) 5647 were introduced in the Washington State Legislature in January 2019. In all, 11 representatives served as sponsors for HB 1433, and 12 senators served as bipartisan sponsors for SB 5647.
In the 2019 session, HB 1433 and SB 5647 did not receive a hearing by their respective committees, which effectively killed the bills for the 2019 session. The efforts to promote the bills during the 2019 session were the groundwork for securing a hearing in the 2020 legislative session. In the interim, AUWS will work with its membership and coalition partners to lobby legislators, collect stories from ARNP practice owners, and meet with key committee chairs before the next session to promote a hearing.
Bills often take several years to pass. The Oregon pay parity bill required three sessions for passage. Advocates in Washington State are undeterred and will be back in 2020.
1. Swan M, Ferguson S, Chang A, Larson E, Smaldone A. Quality of primary care by advanced practice nurses: a systematic review. Int J Qual Health Care
2. Kurtzman ET, Barnow BS. A comparison of nurse practitioners, physician assistants, and primary care physicians' patterns of practice and quality of care in health centers. Med Care
3. Graves JA, Mishra P, Dittus RS, Parikh R, Perloff J, Buerhaus PI. Role of geography and nurse practitioner scope-of-practice in efforts to expand primary care system capacity: Health Reform and the Primary Care Workforce. Med Care
5. Barnes H, Maier CB, Altares Sarik D, Germack HD, Aiken LH, McHugh MD. Effects of regulation and payment policies on nurse practitioners' clinical practices. Med Care Res Rev
13. Kaplan L, Gill J. 2018 Washington State advanced registered nurse practitioner survey data report. Unpublished report. 2018.