Expanded Role of Non-Physician Practitioners in Health Reform Expanded Role of Non-Physician Practitioners in Health Reform Charlotte Jefferies Horty, Springer & Mattern Relevant Laws and Regs: • Centers for Medicare & Medicaid Services (CMS) - Conditions of Participation (CoPs) • Accreditation standards • Hospital licensing laws and regulations • Professional licensure laws and regulations • Medicare billing rules 1
Expanded Role of Non-Physician Practitioners in Health Reform CMS Credentialing and privileging for those providing a “medical level of care” through Medical Staff process “Medical Level of Care” • Is the APC performing a task that has historically (within the last 20 years) been performed by physicians? • Could the task that the APC is performing “kill or cause significant harm” to the patient? 2
Expanded Role of Non-Physician Practitioners in Health Reform Policy Questions • What non-physician practitioners should practice in the hospital? • What should they be permitted to do? • Who should be involved in designing privileging criteria for specialty practice and peer review? Status • Employed by Hospital • Employed by Physicians • Self-employed 3
Expanded Role of Non-Physician Practitioners in Health Reform Categories • Licensed Independent Practitioners • Advanced Practice Clinicians • Dependent Practitioners • Alternative/Complementary Advanced Practice Clinicians Individuals who practice under the supervision of or in collaboration with a physician(s) and are granted clinical privileges. 4
Expanded Role of Non-Physician Practitioners in Health Reform APCs • Advanced Practice Registered Nurse (“aka CRNP”) – Certified Nurse-Midwife – Nurse Practitioner – CRNA – Clinical Nurse Specialist • Physician Assistant • For PAs, certification is required for licensure, • Most Nursing Boards require certification for APRNs, • Medicare billing rules have specific requirements 5
Expanded Role of Non-Physician Practitioners in Health Reform Hospitals can define level of physician oversight, supervision, collaboration; may be more strict than state law. Factors to Consider for Adequate Supervision • Practice setting (number of patients, satellite office, etc.) • Physician availability • Number of other APCs physician supervises 6
Expanded Role of Non-Physician Practitioners in Health Reform Rules of Thumb for APC Supervision: • Physical presence not required, but immediate electronic availability is • Supervising physician can supervise only procedures within his/her scope of practice • Physician may supervise only limited number of individuals CMS ─ Framework for “Evidence-Based” Privileging • Education • Special training • Quality of specific work • Patient outcomes • Current work practice • Maintenance of continuing education • Certifications • Licensure 7
Expanded Role of Non-Physician Practitioners in Health Reform Is “on-the-job” training for specialty practice in hospitals acceptable? Medical Staff Process Must Include: • Verification of education, training, and licensure or certification • Verification of experience and ability to perform privileges (by peer reference) • Assessment of ACGME core competencies 8
Expanded Role of Non-Physician Practitioners in Health Reform Medical Staff Process Must Include: • Department chief report on clinical privileges • Recommendation by the MEC • Final action by the Board Medical Staff Process May Include: Review and recommendation by the Credentials Committee 9
Expanded Role of Non-Physician Practitioners in Health Reform APC Review Committee • Can’t be used to replace the MEC, BUT… • Could replace the Credentials Committee’s role in APC credentialing What about hospital-employed APCs? 10
Expanded Role of Non-Physician Practitioners in Health Reform Hospital-Employed LIPs and APCs • Credential and privilege through the Medical Staff process. • May use results of credentialing process when making hiring decisions. Threshold Qualifications Unrestricted license Unrestricted DEA Not terminated from another staff No felony convictions Not excluded from Medicare 11
Expanded Role of Non-Physician Practitioners in Health Reform Query the National Practitioner Data Bank! Can you grant temporary privileges to APCs? 12
Expanded Role of Non-Physician Practitioners in Health Reform Yes, the same rules for granting temporary privileges apply for APCs. APCs must have clinical competence assessed through peer review process 13
Expanded Role of Non-Physician Practitioners in Health Reform Peer Review PIP Continuum Reprimands Letters of Guidance Informational Letters “Cup of Coffee” Conversations Normal Review FPPE 2 FPPE 1 Collegial Intervention OPPE If there is a concern with Mr. Bounds’ performance, how is it likely to be identified? 14
Expanded Role of Non-Physician Practitioners in Health Reform If we decide to have a collegial intervention with Mr. Bounds, who should be involved? Is Mr. Bounds entitled to a “medical staff hearing”? 15
Expanded Role of Non-Physician Practitioners in Health Reform If the Board upheld the hearing panel’s recommendation to revoke Mr. Bounds’ privileges, is this reportable? Reporting to the NPDB is not required but is permitted. 16
Expanded Role of Non-Physician Practitioners in Health Reform Reporting to State Board is required. What can APCs do? 17
Expanded Role of Non-Physician Practitioners in Health Reform Three Key Questions to Ask Is the activity within the APC’s scope of practice according to state law? Three Key Questions to Ask Is the activity permitted by the supervision or collaboration agreement with the supervising physician? 18
Expanded Role of Non-Physician Practitioners in Health Reform Three Key Questions to Ask Has the Hospital specifically authorized the type of APC to perform the activity? What Can They Do? Prescribe drugs? Progress notes? �� ������ �� ��� � �� �� �� �� �� ���� �� �� � �� �� ��� ����� �� �� �� ��� 19
Expanded Role of Non-Physician Practitioners in Health Reform It depends on state law and may depend on practice setting. Can APCs admit patients? 20
Expanded Role of Non-Physician Practitioners in Health Reform Admit Patients to the Hospital? “Patients must be admitted to the hospital by a licensed practitioner permitted to admit patients under state law.” CMS Conditions of Participation Admit Patients to the Hospital? “If a patient is admitted by a practitioner other than a physician, he or she must also be under the care of an MD/DO, with the name of the MD/DO identified in the medical record.” CMS Conditions of Participation 21
Expanded Role of Non-Physician Practitioners in Health Reform Can an APC prepare the discharge summary? MD/DO may delegate writing the discharge summary to other qualified health care personnel. 22
Expanded Role of Non-Physician Practitioners in Health Reform “[W]e would expect MD/DO responsible for patient during hospital stay to co-authenticate and date the discharge summary to verify its content.” Can APCs be included on the on-call schedule? 23
Expanded Role of Non-Physician Practitioners in Health Reform Contact must still be made by ED with on-call physician. ED physician has ultimate authority to decide who responds. Qualified Medical Personnel EMTALA authorizes MSE to be performed by QMP “as determined by hospital bylaws or rules and regulations.” 24
Expanded Role of Non-Physician Practitioners in Health Reform Membership Issues Should APCs be members of the Medical Staff? With or without vote? 25
Expanded Role of Non-Physician Practitioners in Health Reform Should APCs be appointed to: • Medical Staff Committees? • MEC? • Credentials Committee? • Peer Review Committee? (with or without vote?) • American Academy of Nurse Practitioners (AANP) • American Nurses Credentialing Center (ANCC) • National Certification Corporation (NCC) • Pediatric Nursing Certification Board (PNCB) • American Association of Critical-Care Nurses (AACN) • Certification Corporation • American Midwifery Certification Board (AMCB) aka American College of Nurse Midwives (ACNM) • The National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA) aka American Association of Nurse Anesthetists (AANA) • Oncology Nursing Certification Corporation • Council on Certification of Nurse Anesthetists • National Board for Certification of Hospice and Palliative Nurses 26
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