Opinion Article: A Changing Landscape: The Need to Remove Legislative Barriers on Nurse Practitioners by Cynthia S. Miller, BSN, RN

Opinion Article: A Changing Landscape: The Need to Remove Legislative Barriers on Nurse Practitioners

Cynthia S. Miller, BSN, RN

n Abstract The shortage of providers in the healthcare field is having many adverse effects on patients. Allowing nurse practitioners to practice at their full scope will help to alleviate this burden and allow for the delivery of high-quality care to patients. Restrictions such as the requirement for a physician to certify the need for home health services puts unnecessary restrictions on nurse practitioners and an unneeded paperwork burden on physicians. Nurse practitioners are highly trained and capable of completing the assessment requirements needed for determining the need for home health services. The Home Health Care Planning Improvement Act of 2019 that is currently in the New York Senate hopes to remove the physician’s requirement and allow nurse practitioners to certify the need for home healthcare.

The changing landscape of healthcare in the United States warrants expansion of nurse practitioners (NPs) legal freedoms to perform their job to the fullest extent of their education and training. Our nation is at a point in healthcare where more primary care providers are needed to meet the ever-expanding needs of the population. According to the Association of American Medical Colleges (2018) the United States could be facing a shortage of up to 120,000 physicians by 2030 (Owens, 2019). Nurse practitioners provide a viable and high-quality solution to meet the need for more providers, especially in the primary care arena. Nevertheless, there are many legislative barriers that need to be overcome before NPs can fully fill the void. It is essential for nurse practitioners to take a stance against legislative barriers to full scope of practice, and work toward changing regulations. Changes to legislation directly effect how NPs can carry out their duties and these changes need to be originated by motivated NPs, not physicians. Nurse practitioners need to spearhead legislative changes so that the profession can be guided and moved toward a direction of transition and evolution. Using NPs to the full extent of their education and training would alleviate some of the pressure currently on the healthcare system, as well as promote improvement of some of the health indicators established by Healthy People 2020.

One of the many regulations that is in need of reform is the Medicare requirement for a physician to certify that a patient is in need of home health services. Currently, a nurse practitioner is not legally permitted to sign the certification for such service. According to Poghosyan (2018) NPs performed over 1.1 million home and domiciliary care visits, which accounted for nearly a quarter of all residential visits to Medicare beneficiaries. Home health services include wound care, physical and occupational therapy, patient and caregiver education, help with activities of daily living, and monitoring serious illness and unstable health status (Brassard, 2012). When patients receive home health services the hospital length of their stays decrease, and nursing home placements can be avoided, which in turn reduces the financial burden on Medicare. Such services are crucial to patients who are homebound or require care after an acute medical incident. Home health services ensure that accessible and high-quality care is delivered to patients. It is well within the scope of practice for a nurse practitioner to assess and determine the need for such services. This is a prime example of how legislation is restricting NPs’ abilities to function to the full extent of their education and training and is leading to less access to high-quality, experienced, and proficient care for patients.

In an effort to reduce the fraudulent use of home health services, Medicare now requires a face-to-face visit with a provider to determine eligibility for services. This provider can be a nurse practitioner, clinical nurse specialist or a physician assistant. However, after completing the evaluation of the patient, the provider must present their findings to a physician (Brassard, 2012). The physician then makes the final determination and submits the request. This process creates unnecessary work, delays in care, and increases cost. Physicians’ already have a tremendous paperwork burden and this unnecessary requirement adds to that burden. This process can greatly limit a patient’s access to care. For example, if a physician requires that they be the one to see the patient face-to-face, then a homebound patient would need to arrange for transportation to the physician’s offices. If an NP operates a private practice, then they must seek out a physician who will sign a certification form. Additionally, home health care agencies also have to seek out a physician for certification requirements.

The Institute of Medicine’s (2010) “The Future of Nursing: Leading Change, Advancing Health” report recommends an amendment to “the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities” (Institute of Medicine, 2010, p. 1). In response to this recommendation, the Home Health Care Planning Improvement Act of 2019 (S.296) was introduced to the senate on January 31, 2019, by Senator Susan Collins. This bill would allow Medicare payment for home health services ordered by a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife, or a physician assistant to overcome the current law that coverage can only be provided for services ordered by a physician. Nurse practitioners need to support this bill, show a united front, and demand that their state legislators show support for the act in Congress.

Nurse practitioners are an asset to the healthcare system. Pushing for legislation that would allow NPs to work to their full scope of practice is not an effort to overrun physicians. Rather, it is a collaborative measure for providers to work together to provide high-quality and highly accessible care to patients. In response to the passage of the 2010 Affordable Care Act and the aging population in the United States, the need for providers in healthcare, and particularly in home health and hospice services, is only going to continue to expand. By transforming the healthcare system and removing barriers to advanced practice nurses, patients will be able to freely access and receive quality nursing care from nurses who are the fundamental home health and hospice service as an alternative to extended hospital stays or nursing home care (Brassard, 2012).

n Referenc es

Brassard, A. (2012, July). Removing barriers to advanced practice registered nurse care: Home health and hospice services. AARP Public Policy Institute. Retrieved from https://www.aarp.org/content/dam/aarp/ research/public_policy_institute/health/removing-barriers-advancedpractice-registered-nurse-home-health-hospice-insight-july-2012- AARP-ppi-health.pdf Institute of Medicine. (2010). The Future of Nursing Leading Change, Advancing Health: Report Recommendations. Retrieved from http:// nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/ The-Future-of-Nursing/Future%20of%20Nursing%202010%20 Recommendations.pdf Owens, C. (2019, January 1). Connections: A shortage of doctors. The Berkshire Edge. Retrieved from https://theberkshireedge.com/ connections-a-shortage-of-doctors/ Poghosyan, L. (2018) Federal, state, and organizational barriers affecting nurse practitioner workforce and practice. Nursing Economics, 36(1), 43-45. Retrieved from https://www. nursingeconomics.net/ necfiles/2018/JF18/43.pdf S.296. Home Health Care Planning Improvement Act of 2019. Retrieved from https://www.congress.gov/bill/116th-congress/senate-bill/296