President Trump signed a new executive order (EO) on October 3 relating to new policies the administration intends to implement in the Medicare program. The EO on Protecting and Improving Medicare for Our Nation’s Seniors builds upon a previous EO from October 2017, Promoting Healthcare Choice and Competition Across the United States, and the subsequent report, Reforming America’s Healthcare System Through Choice and Competition. The EO is intended to reform the Medicare program overall. The policy proposals address Medicare Advantage plans which are granted more flexibility under law in determining coverage and payment, as well as the traditional fee-for-service program.
Section 5 of the EO affects advanced practice registered nurses (APRN) and physician assistants (PA) in significant ways that the administration hopes will allow patients to spend more time with their providers. This section directs the Secretary of Health and Human Services (Secretary), within one year, to propose reforms to the Medicare program that would:
- Eliminate excessive supervision requirements that prevent APRNs and PAs from delivering appropriate diagnosis and quality care;
- Provide equal pay for equal work, with Medicare reimbursing APRNS and PAs at the same level as physicians for the same procedures;
- Remove certain unspecified conditions of participation (CoP) requirements; and
- Enable APRNs and PAs to practice to the full extent of their education and clinical training.
EO’s are typically broad and don’t get into the finer details of what is being proposed or the actions that will be taken. While we can make logical assumptions with some instructions in the EO, there are others that are less clear and we will work with the administration to clarify these issues as proposals are developed.
The subsections of the EO that would eliminate the unspecified supervision requirements, conditions of participation requirements, and licensure requirements in Medicare that limit clinicians from practicing at the top of their profession, would be done through the federal regulatory process. This involves the Secretary writing a “proposed rule” (i.e. regulation) and allowing for a 60-day public comment period. After which, the Secretary will publish a “final rule” and the new regulations will move into the implementation process. ANA will be engaging with the Secretary throughout the process to get the best regulatory results for nurses.
The third subsection dealing with pay disparities between physicians and other clinicians only instructs the Secretary to conduct a comprehensive review of regulatory policies. Currently, the Medicare statute stipulates that nurse practitioners and clinical nurse specialists are paid at 85 percent of the physician fee amounts that are set annually by CMS for fee-for-service. Based on previous actions and communications with the Secretary, we expect he will do what he can to eliminate pay disparities in certain parts of Medicare through regulation and also advise Congress to eliminate the pay disparities through legislation. Any legislation would need to be introduced and go through the normal legislative process.
One wild card in this proposal is the elimination of unspecified CoP requirements. CoP are federal regulations that certain health care facilities must comply with in order to be reimbursed by Medicare and Medicaid. While we would like to see some CoPs go, like the one that requires a certified registered nurse anesthetist to be supervised by a physician, there are others that positively benefit nurses and patients alike.
ANA is pleased that the Administration recognizes the value of APRN services to health care consumers and the Medicare program. We look forward to working with the Administration and Congress on on the development and implementation of these policies through the regulatory and legislative processes.