Healing Arts-Scope of Practice Task Force APRN PRESENTATIONS OCTOBER 13, 2016
Issues we face in Tennessee Poor health outcomes despite high costs Inadequate access to primary care providers Tennessee is one of the 12 most restrictive practice environments for APRNs Yet 40+ years of evidence has shown that APRNs can provide access to cost-effective care with comparable outcomes to that of physicians
Tennessee: Overall Rank 46 45 45 44 43 42 41 41 42 42 43 40 39 2011 2012 2013 2014 2015 Source: United Health Foundation, 2015, America s Health Rankings.
Health outcomes Metric Rank Diabetes 48 Poor mental health days 50 Poor physical health days 46 Disparity in health status 6 Infant mortality 36 Cardiovascular deaths 44 Cancer deaths 44 Premature deaths 43 OVERALL 45 Source: United Health Foundation, 2015, America s Health Rankings.
Advanced Practice Registered Nurses (APRNs) APRNs are educated in one of the four roles: Nurse Practitioner Certified Nurse Midwife Certified Registered Nurse Anesthetist Clinical Nurse Specialist and in at least one of six population foci: Family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women s health/gender-related or psych/mental health
Nurse Practitioners (NPs)
Who are NPs? Advanced Practice Registered Nurses who: Assess patients Order & interpret diagnostic tests Make diagnoses Initiate & manage treatment plans (including prescribing) 49.9% hold hospital privileges; 11.3% LTC privileges Nearly 3 in 4 are accepting new Medicare patients & 77.9% new Medicaid patients Hold state RN license, APRN certificate, & national certification
NPs by the numbers 12,315 APRNs in Tennessee 9,442 (76.7%) are NPs 9,394 (99.5%) have authority to prescribe
Inadequate access to primary care providers in Tennessee Substantial shortages of primary care providers exist in Tennessee; especially in rural counties. 95 counties in Tennessee 3 counties (3.2%)-No primary care physicians 23 counties (24.2%)-Low Adequate Supply 45 counties (47.3%)-Moderately Adequate Supply 24 counties (25.3%)-Adequate Supply Only one rural county has Adequate Supply Low inadequate >3500 residents/primary care physician Moderately inadequate 1501-3500 residents/primary care physician Adequate < 1500 residents/primary care physician Source: US Department of Health & Human Services-Health Resources & Services Administration (2014-5), Area Resource File.
Current primary care physician supply inadequate; demand is growing Demand Drivers 23% 13% 64% To maintain current rates of utilization, Tennessee needs 1,107 additional primary care physicians by 2030; (27% increase) (Petterson, Cai, Moore, & Bazemore, 2013) Increased population Increased utilization Expanded health care coverage
NPs offer option for meeting growing primary care demands Majority of primary care services can be provided by NPs Reduced interest in primary care among medical school graduates: Specialty care is more lucrative Physicians may be over-qualified for majority of primary care which includes routine assessment & ongoing care, not diagnosis & treatment of complex conditions NPs & other nurses well-suited for emerging models of primary care emphasizing comprehensive, patient-centered care & ACOs because of experience & expertise in care coordination, health promotion & holistic disciplinary perspective
Primary care workforce challenges in Tennessee 15,500 active Tennessee physicians 5,500 (35.5%) are primary care physicians 16% of primary care physicians are age 40 or younger 26% of primary care physicians are at least 60 years old (Source: Legislative presentation in 2014 by representatives from the Tennessee Medical Association, Quillen College of Medicine, and the University of Tennessee Health Sciences Center)
Supply of NPs is growing 89% of NP workforce prepared in primary care; 75% actively practicing NPs working in primary care (AANP, 2013 Metric Time period Growth Actual growth in NP graduates (Salsberg, May 26, 2015) Projected increase in NP graduates (Bureau of Labor statistics, 2015) Growth in ratio NPs to primary care physicians (IOM, 2010) 2001-2014 +18,484 graduates (+150%) 2012-2022 +34% 1996-2009 From 0.23 NPs/PCP to 0.48 NPs/PCP )
Expanded primary care reduces costs & improves outcomes Primary care associated with: More preventive services Better health outcomes Decreased hospitalization & ED visits (Shi, 2012) States with a higher ratio of primary care providers have lower Medicare expenditures and lower rates of disease-specific deaths (Kuo, 2013)
A substantial body of research examining the quality of NP primary care shows that these clinicians perform as well as physicians on important clinical outcome measures, such as mortality, improvement in pathological condition, reduction of symptoms, health status, and functional status (Kaiser Commission on Medicaid & the Uninsured, 2011 March). Studies cited include: Horocks, 2001; Laurant et al., 2009; Laurant et al., 2004; Lenz et al, 2004; Naylor & Kutzman, 2010; Mundinger et al., 2000.
NP quality of care equivalent 2010 review of 26 studies comparing primary care provided by physicians & NPs found: Patients both groups had comparable outcomes NPs found to outperform physicians on measures of consultation time, patient follow-up, & patient satisfaction (Laurant, et al., 2010).
NP quality of care equivalent Randomized trial with 1316 adult patients (Mundinger, 2000) showed: No significant differences in patient health status, diseasespecific physiological measures, & health services utilization among patients randomized to NP & physician provider groups Significantly lower diastolic pressure among NP patients Follow-up studywith 406 adult patients (Lenz et al, 2004) showed: No significant differences health status; physiological measures; satisfaction; & use specialist, ER, & inpatient services Patients assigned to physician group averaged more primary care visits than NP patients
National Governor s Association 2012 report: NPs provided at least equal quality of care to patients (metrics included patient satisfaction, time spent with patients, prescribing accuracy, & the provision of preventive care)
Supervision of NPs impedes access In rural & other underserved areas physician collaborators in short supply Contractual costs & complying with statutory requirements costly for both physicians & NPs Physician productivity increases when physician supervision of NPs is deleted; physicians spend approximately 8% more time on patient care with no increase in hours spent on all medical activities (Traczynski & Udalova, 2014).
Supervision of NPs impedes innovation Inhibits innovation in health care delivery that may reduce costs (Federal Trade Commission, 2014). While strengthening the workforce involves strategies for increasing the quantity of providers in rural areas, states & localities are demonstrating that innovations in technology (i.e., telehealth or redefined roles for primary care providers & care extenders can expand the reach of the current workforce & improve access to care (National Council of State Legislatures, 2013 November)
Conclusion Removing out-of-date & unnecessary practice authority recommendations will: Help to meet growing demand for primary care services (NGA, 2012) Increase competition & innovation in the delivery of health care services (FTC, 2014), including collaboration & team-based care (IOM, 2013)
Certified Nurse Midwives (CNMs)
Practice of Nurse-Midwifery Primary health care services for women Adolescents to seniors Gynecologic & family planning care Preconception & prenatal care Childbirth & postpartum care Newborn care Male partners for sexually transmitted infections Collaborate, consult, & refer
Certified Nurse-Midwife education & credentials Educated in two disciplines: nursing & midwifery Master s degree or higher Education accreditation: Accreditation Commission for Midwifery Education National certification: American Midwifery Certification Board Recertified every 5 years RN & APRN Licenses TN Board of Nursing Renewed every 2 years
CNM Health workforce in the United States & Tennessee Attend 9% of births; rate varies by state CNMs attend 5.7% of all Tennessee births Sources: http://ahrf.hrsa.gov/arfdashboard/arfgeo.aspx; http://www.midwife.org/acnm/files/cclibraryfiles/filename/000000005600/acnmstatefactsheets8-21-15.pdf
Tennessee maternity care workforce 47 counties currently without hospitals with obstetric services (THA) Source: http://ahrf.hrsa.gov/arfdashboard/arfgeo.aspx
Tennessee women & access to healthcare Number of obstetricians retiring will soon equal the number of obstetric residents who will graduate (nationally) Anticipated shortage of obstetricians will be 18% by 2030 & 25% by 2050 Female population is expected to increase by 19.6%, higher than the national average The number of women over 65 years of age will double in the next 20 years Source: 2014 ACOG Workforce Fact Sheet: Tennessee
Health outcomes of Tennessee s pregnant women in 2013 Infant mortality rate 6.8 per 1,000 live births (544 babies per year) Third highest in the US Preterm birth rate 12.6% (10,076 babies) Low birth rate 9.1% (7,307 babies) Lower prenatal care rate Higher rate of smoking (27% vs 19% in US) Source: http://www.marchofdimes.org/peristats/pdflib/999/pds_47_all.pdf
Health outcomes of Tennessee s pregnant women in 2013 cont d. Geographic differences & racial differences Between 2003 & 2013, the percent of cesarean births increased nearly 17% Rate of vaginal birth after previous cesarean birth only 10% Source: http://www.marchofdimes.org/peristats/pdflib/999/pds_47_all.pdf
Prematurity report card for Tennessee (2015) = D (March of Dimes) Average preterm birth rate = 10.8 (state rank #44) African-American preterm birth rate = 14.3 Source: http://www.marchofdimes.org/peristats/pdflib/998/premature-birth-report-card-tennessee.pdf
Cost of preterm birth Societal cost of preterm birth in the US annually estimated at $26 billion (Institute of Medicine, 2005) Individual child cost varies depending on gestational age Less than 28 weeks - $6 million 32-36 weeks $4.8 million Additional lifetime costs hard to quantify Ongoing medical needs Transportation Accommodations Childcare for other siblings Effect employment loss of family income Family stresses Source: http://www.marchofdimes.org/mission/the-economic-and-societal-costs.aspx
Tennessee: Vaginal birth without complications, $7,829 Cesarean without complications, $12,116 (35% higher) Source: http://www.mappinghealth.com/maternitycare
Cost improvement possible with 1% change 80,000 births annually in Tennessee (57% with Medicaid) 34% cesarean = 27200 births x $12116/birth = $329,555,200 66% vaginal = 52800 births x $7829/birth = $413,371,200 Total annual cost = $742,926,400 IF ONLY 1% DECREASE 33% cesarean = 26400 births x $12116/birth = $319,862,400 67% vaginal = 53600 births x $7829/birth = $419,634,400 Total annual cost = $729,496,800 Cost savings = $3,429,600 annually Source: http:www.mappinghealth.com/maternitycare
Midwife-Led Models of Care Systematic review Primary outcomes Less likely to have epidural or spinal Increased spontaneous vaginal birth Less preterm birth (less than 37 weeks) Conclusions: More satisfied Less likely to have intervention As good, if not better, outcomes 15 studies involving 17,674 women Source: Sandall, Jane, et al. "Midwife led continuity models versus other models of care for childbearing women." The Cochrane Library (2016).
State laws & rural CNM practice 9 US states studied (TN not included) CNMs provide care at 1/3 of all rural maternity hospitals higher in states without supervisory restrictions 25% of rural hospital administrators plan to add CNMs Growth of midwifery practice in rural hospitals will improve access to high-quality maternity care Source: Kozhimannil, K. B., Henning Smith, C., & Hung, P. (2016). The Practice of Midwifery in Rural US Hospitals. Journal of Midwifery & Women s Health.
National health statistics & state regulation of Midwifery practice Those states with autonomous midwifery practice had Lower odds of: Cesarean birth Preterm birth Low birthweight 12 million births included Births with fewer medical procedures & better outcomes lead to reduced cost Scope of practice laws increase the maternity care workforce, access to services, & maternal & infant health In any state s best interest to reduce restrictions on midwifery practice Source: Yang, Y. Tony, Laura B. Attanasio, and Katy B. Kozhimannil. "State scope of practice laws, nurse-midwifery workforce, and childbirth procedures and outcomes." Women's Health Issues 26.3 (2016): 262-267.
Summary Tennessee has 47 counties with no hospital obstetric services Women s health provider shortages will increase Tennessee is ranked very low in maternity care outcomes CNMs are well-qualified providers with outcomes that are high-quality with lower cost CNM care reduces preterm birth, cesareans, & other costly interventions States that allow CNMs to practice at their level of education & training increase healthcare access & improve health outcomes leading to decreased healthcare cost
Certified Registered Nurse Anesthetists (CRNAs)
Who are CRNAs? A CRNA is an Advanced Practice Registered Nurse (APRN) who meets the requirements set forth in TCA 63-7-126 et seq. & has been granted an APRN certificate to practice by the Board of Nursing and holds a national specialty certificate from NBCRNA. Provide safe, high quality, cost-effective anesthesia care and related services. Practice in every setting throughout Tennessee & US in which anesthesia is delivered: Traditional hospital surgical suites and obstetrical delivery rooms Critical access hospitals Ambulatory surgical centers (ASTCs) VA Healthcare facilities U.S. Military hospitals Public Health Services Offices of dentists, podiatrists, ophthalmologists, plastic surgeons and pain management specialists Work collaboratively with: Surgeons Obstetricians Anesthesiologists Dentists Other healthcare providers
Who Are CRNAs? Education Admission requirements for nurse anesthesia education programs: BSN prepared (4 years) Intensive Care Nursing Experience (Average 3.5 years) Requires rigorous academic program of graduate study mandated by COA (2.25 years to 3 years). Attain minimum number of Clinical Cases and Clinical Hours 600 cases required (2015 national average is 865 cases) 2,000 hours (2015 national average is 2,620 hours) Successful completion of NBCRNA National Certification Examination. Continuing Education to maintain certification as CRNA.
Who are CRNAs? Standard of Care CRNAs are NOT primary care providers. When anesthesia care is delivered by a CRNA, it is the practice of nursing. When anesthesia care is delivered by an anesthesiologist, it is the practice of medicine. The Standard of Care is the SAME for all anesthesia care regardless of who provides the service.
CRNAs & prescribing Many CRNAs meet the requirements to obtain a certificate of fitness to prescribe; however, it is not required to carry out their scope of practice for anesthesia and related services for surgical and obstetrical care. Select, order, or administer appropriate drugs during services ordered by a physician, dentist, or podiatrist and provided by a CRNA in collaboration with the ordering physician, dentist, or podiatrist that are within the scope of practice of the CRNA and authorized by clinical privileges granted by the medical staff of the facility. Write orders for RNs to administer medications during preoperative and postoperative phases of care Antibiotics, antihypertensives, antiemetics, pain medication, etc.
CRNAs: Providing access to safe, high-quality care In Tennessee and across the country, CRNAs are the primary providers of anesthesia care and related services in rural areas. Tennessee citizens rely on CRNAs for anesthesia care and related services. CRNAs are the ONLY anesthesia provider available in 41 of 95 counties (43.1%)
CRNAs: Providing access to safe, high-quality care Distribution of Tennessee Anesthesia Providers
CRNAs: Providing access to safe, high-quality care CRNA practice has a positive impact on individuals and their communities. Patients can be treated closer to home, reducing travel required to receive anesthesia care and related services for surgery and OB services. CRNAs assist rural hospitals in remaining viable by providing surgical and OB anesthesia services, and in turn, rural hospitals aid in the viability of their communities. Peer-reviewed literature shows that CRNA services: 1) ensure patient safety; 2) provide access to high-quality care; and 3) promote healthcare cost savings.
CRNAs: Providing access to safe, high-quality care In Tennessee, CRNAs practice in a myriad of models as part of a team setting and as independent anesthesia providers. Over 50% of all states DO NOT require physician supervision of CRNAs. Landmark studies consistently find anesthesia care equally safe no matter if the service is provided by CRNA practicing independently or as a CRNA working with anesthesiologist. CRNA malpractice liability premiums are 33% lower than 25 years ago, 66% lower when adjusted for inflation. Case law shows that surgeons and other healthcare providers face no increase in liability when working with a CRNA rather than an anesthesiologist. CRNAs carry insurance coverage for all the services they provide.
CRNAs: Providing access to cost-effective care Several models of care exist for reimbursement of CRNA services NOT for supervision of CRNAs. MDA directing 4 CRNAs MDA directing 1 CRNA CRNA as sole anesthesia provider Cost is of paramount concern to patients and providers. Among all anesthesia delivery models-anesthesia provided by the CRNA-only model is the most costeffective because of the elimination of duplicative supervision requirements.
CRNAs: Providing access to cost-effective care Affordable Care Act (ACA) and most managed care plans Recognize and promote CRNA services within each state s scope of practice for CRNAs Promotes a competitive, high-quality healthcare marketplace Reduced expenses to patients and insurance companies
Conclusion CRNAs are highly trained Advanced Practice Registered Nurses who play a critical role in making safe, high quality, cost-effective healthcare accessible to the citizens of Tennessee. Access - CRNAs work in every setting in which anesthesia is delivered, including hospitals, ambulatory surgical centers and physician offices. Safe - Researchers studying anesthesia safety found no differences in care between CRNAs and anesthesiologists. (Lewis, 2014-Cochrane Database of Systematic Reviews). The Standard of Care is the SAME for all anesthesia care regardless of who provides the service. Cost-effective - Nurse anesthesia care is 25 percent more cost effective than the next least costly anesthesia delivery model. (Hogan, 2010 Nursing Economic$)
Change the Conversation Better utilization of APRNs to improve access, especially in rural & other underserved areas Improved patient outcomes through collaboration across professions & settings Put patients in the center of all discussions & decisions, not the doctors, nurses, or other providers