Effective and Compliant Utilization of Nurse Practitioners and Physician Assistants

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1 Effective and Compliant Utilization of Nurse Practitioners and Physician Assistants Alex Krouse, JD, MHA 4101 Edison Lakes Parkway, Ste. 100 Mishawaka, IN

2 Disclaimer This is an educational program. This program is not intended as legal advice. Please engage competent legal counsel and other professionals, as necessary, before taking any action in reliance on the content presented or provided during today s program. 2

3 Practitioner Landscape 205,000 Nurse Practitioners Indiana 83,466 Physician Assistants Indiana 834,769 Active Physicians 397,130 Primary Care Physicians Pediatrics 70,967 OBGYN 45,043 Family Medicine 116,933 Internal Medicine - 164,187 Source: Kaiser Family Foundation 2020: Shortage of 91,500 Physicians Including 45,000 Primary Care Physicians Source: Assoc. of American Medical Colleges 3

4 Demand for NP and PA Services Consumer Demand Immediate Care From NP or PA vs. Waiting for a Physician 4

5 Questions About Quality Nurse Practitioners Quality of Care 80% to 90% of Care Study 2000 Study Published in the Journal of the American Medical Association Systematic Review of 26 Studies Published Since Study Impact level of practice of NPs has on outcomes of Medicare and Medicaid patients Physician Assistants 2004 Journal of American Geriatrics Society 2004 American Surgeon Published Study 5

6 NP and PA Education Prerequisite Education Category Nurse Practitioner Physician Assistant Physician Bachelor s Required Clinical Experience Bachelor s Curriculum Post-Baccalaureate Clinical Experience Bachelor s Degree in Nursing Bachelor s Degree in PA Studies or Bachelor s Degree 500 to 1000 Hours 0 Hours if Non-PA Bachelor s Degree or 2,000 Hours if Bachelor s Trained Medical-Nursing- Science 8 to 13 Years on Average Medical-Science or Science N/A Bachelor s Degree 0 Hours Science Graduate Degree MSN or DNP Master s Degree MD or DO Classroom Hours 500 Hours 1000 Hours Two Years Clinical Hours 500 to 1600 Hours 2000 Hours Two Years Graduate Degree Focus Family, Women s Health, Acute, Psychiatric, or Pediatrics General Medical N/A General Medical Residency Not Required Not Required Three Year Minimum Total Years of 6 to 8 Years 4 to 6 Years 8 Years Education 6

7 Nurse Practitioner Prescriptive Indiana Authority Prescribing Authority Contingent on Collaboration Schedule II - V 5% Random Sampling of Charts and Medications Prescribed for Patients Authority to Prescribe if within Scope of Practice No Prescriptions for Weight Loss or Obesity Changes in 2015 July 1,

8 Physician Assistant Prescriptive Indiana Authority Requirement that PA practice for at least 1,800 hours This is not required for non-controlled substances. Schedule II - V Limitations related to prescribing, administering, and monitoring general anesthesia. Prescriptive Authority is Delegated from Physician to PA No Prescriptions for Weight Loss or Obesity Changes in 2015 July 1,

9 Supervision vs. Collaboration Physician Assistants Supervision Required What is Supervision? Legal Responsibility Nurse Practitioners No Supervision Required What is Collaboration? Independent Members of the Healthcare Team 9

10 NP and PA Scope of Practice Nurse Practitioner Federal Delegated to states. Indiana Patient Assessment Identify conditions Diagnose Develop treatment plans Evaluate patient outcomes and Collaborate or refer in managing plan of care. Advanced Knowledge Educate patients and health team members Independent Decisions Plan, Implement, and Develop Plan of Care Physician Assistant Federal Delegated to states. Indiana Prohibited from Independent Practice The Indiana code specifically prohibits this Scope is Limited to Supervising Physician Identify conditions Diagnose Develop treatment plans Evaluate patient outcomes and Collaborate or refer in managing plan of care. Delegation to Plan, Implement, and Develop Plan of Care 10

11 Medicare and Medicaid Reimbursement Nurse Practitioners Medicaid Can enroll as billing, group, dual or rendering providers 75% Reimbursement if Not in a Group vs. 100% if in Group Medicare Can enroll and receive reimbursement directly 85% or 100% if Incident To Physician Assistants Medicaid Cannot Independently Enroll in Medicaid Must Bill Incident To a Physician s Services Medicare Can enroll but cannot receive reimbursement directly (must go to employer) 85% or 100% if Incident To 11

12 Reimbursement and Practice Settings Incident To Billing Requirements Shared Service Billing Requirements Direct Billing Option NPs Only Inpatient Settings NP and PA Can Order Inpatient Admissions Physician Must Certify Order Critical Access Issues Hospice NPs can be attending physician PAs cannot 12

13 Questions? 13

14 Medication Therapy Management and Associated New Law Update John B. Hertig, PharmD, MS, CPPS Associate Director Center for Medication Safety Advancement Purdue University College of Pharmacy Indianapolis, IN

15 Current Issue Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008: 16; CD

16 What is MTM? Medication Therapy Management (MTM) means a distinct service or group of services that optimize therapeutic outcomes for individuals that are independent of, but may occur in conjunction with, the provision of a medication or medical device SEA 358; Indiana statute

17 Pharmacist-Provided MTM Performing or obtaining assessments of the patient's health status and formulating a medication treatment plan Selecting, initiating, modifying, or administering medication therapy Documenting the care delivered and communicating essential information to the patient's other health care providers Providing education and training designed to enhance patient understanding and appropriate use of medications

18 MTM Examples Targeted disease state education Medication adherence assessment Monitoring for chronic renal insufficiency and dose adjustment Pharmacogeneticmonitoring and dose adjustment

19 Benefits Isetts BJ, Schondelmeyer SW, Artz MB, Lenarz LA, Heaton AH, Wadd WB, et al. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. JAPhA 2008 Mar;48(2):

20 State Success Stories Care Source. Ohio Medicaid Basics. Iowa Medicaid Pharmaceutical Case Management. Iowa Pharmacy Association. Available at:

21 Senate Enrolled Act 358 Signed by Governor Pence on April 30, 2015 Effective July 1, 2015 Two key changes related to providing MTM services in Indiana Standard definition of MTM services Inclusion of NPs and PAs to act as supervising providers

22 Standard Definition Change Brings Indiana s current definition of medication therapy management in line with the national best practice standard Does not change the scope of pharmacy practice Provides a clear definition and offers flexibility for providing services to patients MTM included in the the practice of pharmacy" or "the practice of the profession of pharmacy As defined in the law

23 Supervisory Expansion Includes nurse practitioners and physician assistants as supervising practitioners for pharmacists who enter in to a collaborative practice agreements (CPA) Allows pharmacists to continue to provide care to patients when the physician is out of clinic Allowing NPs and PAs to supervise per an approved CPAs in a physician s absence provides flexibility and improves access Especially valuable in extending care to rural and other underserved areas

24 Takeaways The challenge to provide safe medication-related care has never been more difficult Increased medication complexity MTM has been proven to improve the quality and safety of medication-related care SEA 358 Lends clarity to defining medication therapy management, ensuring Indiana is aligned with national standards Enhances access to proven pharmacist-provided care

25 Acknowledgments Veronica Vernon Gloria Sachdev Denise Fields Many others

26 Questions?

27 Pharmacists and Provider Status with CMS A Legislative Overview Daniel D. Degnan, PharmD, MS, CPHQ, CPPS Senior Project Manager Center for Medication Safety Advancement Purdue University College of Pharmacy Indianapolis, IN

28 Current Legislation Two bills currently in front of US Congress HR 592 and S 314 Same as bill introduced last session Garnered bipartisan support More than 100 cosponsors What do these bills do and what do they not do? How might this affect rural health provision in Indiana?

29 Current Legislation HR 592 and S 314 Pharmacy and Medically Underserved Areas Enhancement Act Also known as Provider Status bill among pharmacy organizations Broad support from pharmacy organizations Patient Access to Pharmacists Care Coalition Roughly 25 organizations representing patients, pharmacists and pharmacies

30 Patient Access to Pharmacists Care Coalition Partial listing of PAPCC Members American Association of Colleges of Pharmacy American Society of Consultant Pharmacists American Society of Health-system Pharmacists American Pharmacists Association National Alliance of State Pharmacy Associations CVS Health WalMart Target Kroger Walgreens Cardinal Health Amerisource Bergen National Center for Farmworker Health Food Marketing Institute

31 Other Support Studies of pharmacists providing MTM services to Under Medicare Part B, improve therapeutic pharmacists are not included outcomes indicate that such in the statutory definition of services improve outcomes providers.... and reduce costs NGA Center for Best Practices. Expanding the Role of Pharmacists.

32 What do HR 592 and S 314 do? Enables pharmacists to serve Medicare beneficiaries in medically underserved areas Services provided by pharmacists determined by state scope of practice In Indiana... SEA 358 signed by Governor Pence on April 30, 2015 Clarity to scope not necessarily expansion

33 What do HR 592 and S 314 do?

34 What do HR 592 and S 314 do? Amends Part B of the Social Security Act to compensate for pharmacy services Why? Fee for services are going away Modifies widely used reference standard Indiana State Department of Health.

35 Pharmacist Qualifications as a Provider Doctor of Pharmacy degree Residencies and Fellowships Equivalent to other non-physician providers currently listed in the act Practicing at the top of a license

36 Pharmacist Qualifications as a Provider The Education of a Pharmacist Pharmacist Licensure Minimum 2 years of pre-pharmacy 4 to 5 years of pharmacy school 1 year of general residency 1 year of specialty residency Board Certification *after completion of pharmacy school, pharmacist may complete a 2 year fellowship Specialty Certification Diabetes Anticoagulation Immunization MTM Specialty Residency Primary care Cardiology Critical care Pediatrics Oncology Board Certification Ambulatory Critical care Oncology Pediatrics Psychiatry

37 Are pharmacists filling the role of physicians? In short.... No! Medically underserved areas addressed in the legislation No change in scope of practice delineated by states Pharmacists often serve on care teams similar to Physician Assistants and Nurse Practitioners

38 Are pharmacists filling the role of physicians? AAMC. Complexities of Physician Supply and Demand: Projections from 2013 to 2025

39 Acknowledgments Nick Gentile and Joe Hill from the American Society of Health-system Pharmacists (ASHP)

40

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