A bump in the road for APRNs and Patients: The Senate Opioid SUD Legislative Package

  

ANA and other associations representing advanced practice registered nurses (APRNs) have been lobbying for years to make permanent the authority for Nurse Practitioners (NP) to prescribe medication-assisted therapy (MAT) for opioid-addicted patients and to extend the authority to the other three APRN specialties. ANA government affairs staff has been informed there are Senators with “holds” on this package meaning it can’t move forward until there are more negotiations. While we are disappointed the package does not currently include this provision, we still have several more bites at the apple.

The Comprehensive Addiction and Recovery Act of 2016 (Public Law No: 114-198.), commonly referred to as CARA, included a provision that allowed NPs and Physician Assistants (PA) to take 24 hours of training to prescribe MAT for opioid-addicted patients. (This is referred to as “DATA 2000 waved” or just “DATA waved” authority.) This prescribing authority sunsets in 2021. The reason the prescribing authority is set to expire in 2021 was developed as a budgeting gimmick by Congress to keep the overall projected cost associated with CARA low. This provision was never intended to be a demonstration project – it was because Congress couldn’t find a way to offset the projected cost for permanent prescribing authority.

In June, the U.S. House of Representatives passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (H.R. 6), or the “SUPPORT for Patients and Communities Act” for short. Section 3003 of this bill has an agreed upon compromise version of what we have been lobbying for. It permanently extends the MAT prescribing authority for NPs and PAs and allows the other three APRN specialties the authority for five years. It also instructs the Department of Health and Human Services to conduct a study on the efficacy of prescribing MAT, and possible associated narcotics diversion issues, on all providers, including physicians. This would give the opportunity to for us to have data showing how important it is to have more access points for patients and that APRNs are just as qualified to treat opioid substance use disorder as physicians.

While this latest development is disappointing, it’s not over. Both the House and the Senate need to come together to pass identical legislation before any of this is signed into law. We have a large coalition of bipartisan legislators in the House and Senate who all agree that this is good policy. The current disagreement is over how to offset the projected cost estimated by the Congressional Budget Office (CBO). The ANA, along with the other associations representing APRNs, are on top of this issue and will be fighting for the inclusion of Section 3003 into any final package. It’s not over.

Further Reading

The CBO’s scoring rules for determining the cost of legislation are very complicated, convoluted, and don’t always make logical sense. The U.S. Drug Enforcement Agency (DEA) isn’t held to CBO’s scoring rules, and in January 2018, published an economic impact study on CARA. They found that from when the DATA 2000 waiver began through February 21, 2017, there were 33,663 DATA-waived physicians compared to 1,247,716 total physicians. Since February 2017, when NPs could first obtain the DATA 2000 waiver until May 5, 2018, 5,649 NPs have obtained a DATA 2000 waiver compared to 248,000 total NPs. That means proportionately, in less than two years, NPs have received almost as many waivers as physicians received in 17 years (2.3 percent of NPs v. 2.7 percent of physicians).

The DEA estimates that the total economic burden of the opioid epidemic is $75.7 billion, which amounts to $41,000 per patient. They also estimate that the net economic benefit of authorizing NPs and PAs to provide MAT, primarily due to increased labor productivity and decreased healthcare and legal costs, will be $640-729 million dollars over five years. Based on the DEA’s estimate that 5,235 NPs and PAs would obtain the waiver, this amounts to an average costs savings of approximately $122,254-139,255 for every NP or PA obtaining the waiver.

ANA strongly believes that extending the prescribing authority to the other APRN specialties will only further the success of this policy. ANA advocates for all RNs and APRNs to practice to the full extent of their education and practice authority, allowing individualized treatment plans for all patients and increased access to health care services, including MAT.

For additional information or comments, please contact Sam Hewitt, ANA’s senior associate director for federal government relations at Samuel.hewitt@ana.org

Short-Term and Association Health Plan Rules Sell Patients Short

  

The Trump administration is set to implement two regulatory policies over the next several months that stand to create significant disruption in the individual health insurance market. The U.S. Department of Health and Human Services (HHS) recently published a final rule on short-term, limited duration insurance plans while the U.S. Department of Labor (DOL) recently published a final rule expanding the availability of Association Health Plans (AHPs).

HHS on August 3rd published its final rule implementing changes to short-term, limited duration insurance plans (ANA voiced its opposition to this proposed rule in April). These plans were initially intended as a stopgap in the event that an individual temporarily lost health insurance coverage. This final rule allows these plans to last for up to 12 months, up from three months under previous regulations, and allows them to be renewed for up to 36 months. These plans are not subject to the Essential Health Benefits (EHBs) requirements under the Affordable Care Act (ACA). The short-term, limited duration insurance final rule will take effect on October 3rd, 2018.

DOL on June 21st published its final rule implementing changes to AHPs (ANA voiced its opposition to this proposed rule in March). AHPs have been around for decades and are considered employer-sponsored insurance plans, and are thus not subject to certain ACA requirements for individual health insurance coverage, including the coverage of EHBs. The DOL final rule expands the definition of “employer” under regulations governing AHPs, and thus expands the types of employers and associations that can form AHPs. The AHPs final rule will take effect on August 20th, 2018.

Both final rules expand the availability of individual health insurance coverage that is not subject to the EHBs requirements under the ACA. These rules will facilitate the proliferation of insurance coverage that does not cover EHBs; the Congressional Budget Office estimates that six million more Americans will be covered by such insurance plans by 2023. This will make it more difficult for older individuals and those with pre-existing conditions to purchase individual health insurance coverage while driving up prices in the federal and state health insurance exchanges and threatening to fracture the national healthcare system framework established under the ACA.

States are already pushing back against these rules. New York and Massachusetts have sued the Trump administration over the expansion of AHPs, which they claim will “invite fraud, mismanagement, and deception.” And states have the power to regulate short-term, limited duration plans, some of which, including Maryland and Vermont, have already done so. States including Pennsylvania and Virginia have also expressed deep concerns over these as well as the fact that insurance brokers often use deceptive marketing tactics to promote them.

ANA strongly supports innovation and creative approaches to ensuring comprehensive, affordable healthcare coverage for all Americans. These proposals, however, have the opposite effect by driving up premium prices, pushing individuals in at-risk populations out of the insurance market, and widening population health disparities. Healthcare stands to be a major issue in the 2018 midterm elections – 22 percent of respondents to a June 2018 NBC News/Wall Street Journal poll named healthcare as the most important factor in deciding their vote. ANA urges its members and anyone concerned about nursing issues to support candidates who uphold our core values and principles for health system transformation. It is vital that nurses’ voices as the nation’s most honest and ethical profession are heard in the public sphere, and that nurses make their influence known.