Texas Medicaid Reimbursement of APNs

1. Texas Medicaid Reimbursement of APNs Sandra B. Tovar, MSN,RN,CS,PNP 8-16-05

3. Brief Personal Experience Valuable legislative experience. Establish relationships/networking. Encourage involvement in political process. Rural Texas - ability to recognize value of access to care.

4. 1970 - 1980 Access to Care Federal Rural Health Clinic Act - 1977. In order to qualify, the clinics had to be staffed by NPs or PAs. Was advantageous for clinics to qualify. No reimbursement of NPs. How could you use NPs without standing orders? Would Texas law permit it?

5. Late 1970 - Crisis Interim studies on NPs working under standing orders. Physician unable to work and examine every patient�and provide medications.

6. Texas Attorney General Opinion-1978 Ruled that Nurses needed to have a specific order for a specific patient at any site. Only exception - Immunizations

7. 1979 Standing Order legislation passed Gave physician authority to delegate the ability to administer and provide medications. Recognition for patient populations, as opposed to individual/specific patient. First recognition of NP to work under standing orders.

8. In 1981 - Federal mandate - CNMs were to get reimbursed at 70%. Negotiations with Texas Department of Human Services. Implementation - long process. In 1985 - CNMs achieved 70%. Early Gains

9. Reimbursement Concerns - 1988 Reduction in funding of Community Health Centers (CHCs) in rural areas. If funds cut, fewer physicians would be employed, requiring hiring of more NPs. 40-50 CHCs in state - primary providers of indigent population. Texas Nurses Association formed coalitions.

10. 1989 HB 18 Omnibus Health Care Rescue Act Limited prescription privileges at sites serving medically underserved. Helped establish Rural Health Clinics. Trial lawyers supportive on behalf of consumers.

11. House Bill 18 This legislation enabled the highly successful medically underserved clinics model, and substantially increased access to health care in rural Texas through Rural Health Clinics. Rural Community Health Center unable to employ sufficient physicians to remain open, created need to hire NPs and PAs.

12. Texas Department of Health (TDH) Authorized to designate medically underserved sites. Nursing astute in defining language for �sites serving medically underserved populations.� possibly in Austin, Texas or a small rural community.

13. External Factors Federal Reimbursement Issues - Concern for Access to Care helped provide NP more authority.

14. Reimbursement Drives Practice APNs successful in acquiring legal authority to practice, yet required sufficient reimbursement to practice at all sites. Rural communities unable to sustain 2 physicians, yet could sustain 1 physician and 2 APNs. In rural communities, the billing �incident to� was not feasible because APNs were not providing the service �incident to.�

15. OBRA Due to shortage of Medicaid providers, in 1989, Congress enacted a provision in the Omnibus Budget Reconciliation Act (OBRA) that allowed the services of certified PNP/FNP to be covered by Medicaid. Law directed the states to develop mechanisms for the direct reimbursement of PNP/FNPs by July, 1990.

16. Late 1980s Provided testimony to TDH � shortage of providers serving Medicaid recipients. Low reimbursement for pediatric services & push for preventive care (EPSDTs). Overhead the same for physician and for NP, clearly 70% of a poor rate was unacceptable. How do NPs prove they are cost effective?

17. 1991 Medicaid Reimbursement Gained for All APNs As an APN service billed under the APNs Medicaid provider number. 85% of the physician rate. Physician involvement as required by law and Board of Medical Examiners (BME).

18. 1995 Texas Legislature expanding prescriptive authority for APNs while continuing the concept of delegation, collaboration and the use of protocols similar to the 1989 law.

19. Ad-Hoc Committee borne out of negotiations within the 1995 legislation Committee composed of 15 members - 5 from each organization representing nursing, medicine, and physician assistants. Shared legislative and regulatory agenda that facilitates physician/APN/PA collaborative practices.

20. 2005 APN Medicaid Legislation Rider in Article II requiring APNs and PAs to bill under their own provider number at the rate of 85%. Pending Health and Human Services Commission (HHSC) rules to change rate to 92%, budget crisis. Valid research on APN practice and cost effectiveness will be possible.

21. APNs increasing Access to Care State Impact Emphasized a poll released in April 2005, by Texas Primary Care Coalition indicating a dramatic decline in number of primary care physicians accepting new Medicaid patients: In 2000, was 67%, now 46%. Total APNs in Texas 9,861 as of 9-1-04: 1379 Clinical Nurse Specialists 2606 Certified Registered Nurse Anesthetists 344 Certified Nurse Midwives 5532 Nurse Practitioners

22. Case Presentation � February �05 8 year old Hispanic female previously on Medicaid with history of moderate Asthma. Medically uninsured for 8 months - no medical coverage - unable to obtain controller medication or see APN in office for follow-up or episodic care. Resulted in 3 hospitalizations and 2 ER visits.

23. Cost of Controller Medication with Moderate Asthma & AR Medium dose inhaled corticosteroid & long acting inhaled beta2agonist-$194.00 Leukotriene modifier-$116.82 Antihistamine-$94.25 Nasal corticosteroid spray-$94.86 Rescue Inhaler-Short- acting Bronchodilator prn-$19.24 Nebulized bronchodilator- beta2agonist for symptom prn-$87.06 Total 1 month supply - $606.23

24. Estimated Cost of Hospitalization Pediatric ICU - daily rate $2,600.23 Daily regular room rate $1,043.00 + Lab, X-rays, Resp. care, meds ??? $$$ Avg. rate for 24hr observation $5,000.00 includes lab, oxygen, medications Reimbursement to hospitals based on final diagnosis and type of insurance coverage. *Note: Case presentation quote from McAllen Medical Center, McAllen, TX

25. Projected Cost for 8 Year Old Asthmatic Effect of lack of care ??? Extrapolate figures. Enormous detrimental impact on the patient and their families if they do not have Medicaid coverage and access to care. Increased fatality risk.

26. In Summary APNs are Mechanism to Increase Care in a Cost Saving Manner. Texas has had increased access to care with improved utilization of APNs. Our Texas experience reinforces that Medicaid (Federal) reimbursement of APNs is a necessary requirement to sustain practice.

27. Now is the time for the rest of the country to do the same! More states need to move in this direction. APNs ARE MAKING A DIFFERENCE IN PATIENT�S LIVES.

28. Closing Remarks