ANA works to ensure nurses are equipped to treat their patients’ pain effectively

  

As the largest healthcare provider group in the country, nurses are no strangers to treating pain, including chronic, acute, and emotional pain. Nurses are also subject to their own personal pain, and they are not alone. Today, there are approximately 50 million adults in the US living with chronic pain and over a third of those adults’ pain interferes with their daily activities. ANA is monitoring and advocating along with our nursing partners, around the Department of Health and Human Services Pain Management report due to be finalized later this year, that promises to help providers use evidence based treatments to manage their patients’ pain while considering the nationwide opioid epidemic.

In 2011, the Institute of Medicine recommended that pain and relieving pain should be a national priority. The report goes on to say that pain is a chief driver for visits to physicians and other healthcare providers, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. We have all experienced pain and for many, if not all nurses, we have had to decide how and to what degree to treat that pain.

The Code of Ethics for Nurses with Interpretative Statements (the Code) mandates that nurses have an ethical obligation to treat their patients’ pain without bias. To minimize biases, the nurse must identify the influences and intentionally set them aside. However, the Code does not say how they must treat pain. For many what first comes to mind is treatment that involves opioids. For some diagnoses, opioids are part of the best clinical practices for treatment; for others, it may be a combination of pharmacological, restorative, and alternative therapies. Patient adherence, access, coverage, and social determinants may all affect the best option for the individual.

More recently, there has been a renewed interest in the role of pain with regards to the opioid epidemic. Pain is a separate disease from the addiction and dependence that can come from opioid use, a fact which has been recognized by the Department of Health and Human Services Pain Management Best Practices Inter-Agency task force. Encouraging to nurses, the task force recommends an individualized and multidisciplinary approach to chronic pain that also includes increased insurance coverage for Complex Management Situations. It also calls for safer opioid stewardship through a risk assessment based on the patients’ medical, social, and family history.

Nurses are also positioned to provide care coordination activities for improved patient outcomes to patients and their families suffering from chronic pain conditions and associated co-morbidities. ANA commented on the draft pain management report and will continue to advocate the role of nursing in treating chronic pain to the task force and agency. The task force will meet on May 9th and 10th to vote on final recommendations.

Recognizing pain as not just a symptom, but rather a disease for some patients, may help shape the patient-provider relationship and higher quality outcomes of care. Pain can have devastating personal, financial and social consequences. Reshaping how nurses talk about pain with their patients and taking the time to learn about and advocate for alternative therapies available in the community, can help in the immediate care of a patient and the long-term ability to complete activities of daily living.

The Medicare Payment Advisory Commission makes recommendations for APRNs

  

The value of nurses continues to be seen at the federal level. Paralleling the Administrations’ December report, that recognized the role registered nurses and advance practice registered nurses (APRNs) play in patient care, the Medicare Payment Advisory Commission (MedPAC), also made recommendations to show the value of nurses. At the most recent MedPAC meeting in January, the 17 commission members, including two nurses, unanimously voted to recommend that “The Congress should require APRNs and Physician Assistants (PAs) to bill the Medicare program directly, eliminating ‘incident to’ billing for services they provide.” The goal of this recommendation is to reduce costs in the Medicare program as well as improve Medicare’s data on who furnishes care to beneficiaries. Currently, APRNs and PAs are paid 85 percent of the rate that physicians receive under the physician fee schedule when they bill Medicare directly for the same services. Therefore, practices may be reimbursed less overall, but accurate data can be collected to show the value of nursing.

The second recommendation from the Commission reads that, “The Secretary [of Health and Human Services] should refine Medicare’s specialty designations for APRNs and PAs.” Medicare has limited information on the specialties of practice for these clinicians and therefore cannot target resources appropriately to areas of concern, such as primary care.

It is important to note that nothing in either of the recommendations would determine what services clinicians can perform, which is up to state statutes and the physicians with whom they practice. MedPAC can only make recommendations to Congress for consideration to changes to the Medicare system.

These recommendations closely parallel the Administration’s Reforming America’s Healthcare System Through Choice and Competition Report that endorses broader state and federal scope-of-practice (SOP) statutes for all health care providers, including APRNs, that allow them to practice to the top of their license and full skill set. The report also advises eliminating “collaborative practice” and supervision requirements which can impede access to care and limit the ability of providers to diagnose and treat myriad health care issues, especially in underserved populations and in rural areas where patients rely on APRNs for timely care and lifesaving treatment.

Individual states will have to determine SOP statutes, but if all APRNs who bill Medicare are designating their areas of practice as well as services provided, increased data will be available to better determine patient outcomes and highlight quality nursing services. Moreover, better data will be available for services provided by communities to allow for more informed choices at the local and state level.

ANA continues to participate in discussions regarding APRN SOP and has provided comment to MedPAC and the Administration on issues, such as expansion of telehealth services to Medicare beneficiaries, that can affect nurses and the care they provide to patients across the country.

 

Looking at Congress to help fight the opioid epidemic

  

Last week, Senator Claire McCaskill’s (D-Mo) office released a report finding that over the last six years, enough opioids were shipped into the state of Missouri to give every resident 260 pills. While that is a snapshot of just one state, combine that news with the latest report from the Centers for Disease Control and Prevention (CDC) that the number of overdose deaths involving fentanyl and similar drugs nearly doubled between the last half of 2016 and the first half of 2017, and it becomes clear that the opioid crisis is still destroying the lives of individuals, families, and communities in epic proportions.

These reports follow a new CDC alert to public health and health care professionals about the increased availability of illicit synthetic opioids, the second update to the health advisory since October 2015. As the crisis continues to transform, health care providers, government agencies and Congress are also changing their tactics to fight this epidemic.

Over the past few weeks of extensive negotiations, the House of Representatives wrapped up multiple proposed opioid crisis bills into one large package, the SUPPORT for Patients and Communities Act (H.R. 6). This iteration of the bill would grant Nurse Practitioners and Physician Assistants permanent authority to prescribe Medication-Assisted Treatment (MAT) while the other three Advanced Practice Registered Nurse (APRN) professions (Certified Nurse-Midwives, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists) would have authorization for five years. The SUPPORT for Patients and Communities Act would also require a study of the efficacy of providing MAT by all providers, including physicians. H.R. 6 will now move to the Senate where there has been concern over the CBO estimated cost of $395 million over a 10-year period. Given the important role that treatment has in solving this epidemic, ANA does not believe this cost should impede the passing of this bill and increase access to life saving treatment to those suffering from substance use disorders.

Medication-Assisted Treatment has been shown to be the most effective form of treatment for opioid use disorders. The National Institute on Drug Abuse states that combined with behavioral therapy, effective MAT programs for opioid addiction decrease overdose deaths resulting in cost savings, reduce transmissions of HIV and hepatitis C related to IV drug use, and mitigate associated criminal activity. Along with APRNs providing MAT services, all nurses with their roles as direct care givers, care coordinators, educators, and patient advocates play a pivotal role in solving this crisis by helping patients and their families understand the risks and benefits of pain treatment options.

ANA will continue to work with Congress, federal agencies, and our partners in the Nursing Community to fight to expand the nurse’s role in solving the opioid crisis. We urge everyone to now call their Senators in support of Senate bill S.2317 (Addiction Treatment Access Improvement Act of 2018) and ensure that they include it in any opioid package that is passed.