Author: Lisa Stand

The moving documentary film 5B testifies to the compassionate, committed responses of a nurse-led community in the early days of the HIV and AIDS epidemic. 5B was a ward of San Francisco General Hospital where nurses, along with patients and their caregivers, redefined palliative care in the face of a cruel disease and a health care system in the 1980s that was tragically unprepared. The film is a tribute to nurses who were on those frontlines. On camera, veterans of 5B reflect on their experience and how they transformed care, long before the term “person-centered” entered the lexicon of health care delivery and public policy.

5B viewers are also clearly able to understand, nearly 40 years later, how nurses remain on the frontlines, and continue to play a key role in HIV and AIDS care. Today, more than one million people in the U.S. are living with HIV, and around 15 percent of these people are unaware that they have HIV. As nurse leaders in the field Carole Treston and Carol Dawson-Rose write in the December 2019 issue of American Nurse Today, we now have treatment and prevention technologies that are “proven to work and allow us to imagine an end to the HIV epidemic.”

Treatment as prevention is the approach that holds the promise of reaching that goal of ending HIV. Specifically, effective use of antiretroviral treatment can lower HIV levels to the point where HIV cannot be transmitted. Recognizing the power of this approach, the American Nurses Association (ANA) recently signed onto the U=U prevention campaign (Undetectable = Untransmittable, or, U=U). In addition, use of preexposure prophylaxis (PrEP) is a proven intervention to prevent HIV from being acquired through sexual contact.

As Treston and Dawson-Rose point out, however, not everyone is benefitting from these approaches. The barriers are many, including stigma, systemic racism, sexism, homophobia, transphobia, lack of affordable health care coverage, and other social determinants of health such as lack of transportation or housing. The implications of these challenges for nurses’ role in ending the epidemic are explored in ANA’s updated position statements Prevention and Care for HIV and Related Conditions.

Nurses are pivotal to efforts to end HIV, by supporting patient access to testing, as well as ensuring access to treatment and prevention. A new ANA publication Ending the HIV Epidemic: Frontline Interventions Every Nurse Should Know links to useful guidelines and practice resources. Many advanced practice registered nurses can prescribe HIV treatment and PrEP, and nurses can coordinate care for people living with HIV when they need support to stay in treatment.

In addition to supporting a treatment-as-prevention approach, ANA prioritizes community-based solutions that meet the needs of diverse groups of people living with HIV and AIDS. The policy statements also highlight the APRN’s role with prescriptive authority to treat and prevent HIV, and call for full practice authority at the federal and state levels. The updated policy statements are aligned with national strategies and goals, and mirror the policy priorities of ANA’s partner Association of Nurses in AIDS Care (ANAC).

Last week’s Capitol Beat offered a 10,000-foot review of the Administration’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors. This week, we take a deeper dive and connect the dots with ANA advocacy and a new success story expanding scope for advance practice registered nurses (APRNs) in Medicare.

Among other provisions, the Executive Order directs the federal Medicare agency to remove certain billing rules that can get in the way of providers caring for their patients. The initiative specifically targets Medicare practice rules that are more stringent than state laws. Medicare must propose new rules within a year’s time. This is welcome news for many APRNs participating in Medicare, who are subject to an array of confusing federal rules that keep them from practicing at the top of their profession in caring for Medicare beneficiaries.

ANA has long advocated for administrative reforms to lift separate Medicare practice restrictions on APRNs, who are subject to state licensing authorities where they practice. Most recently, in a letter to Medicare officials on September 24, 2019, ANA emphasized that federal payment rules applied to APRNs should not have the effect of restricting patient access and choice, and that Medicare beneficiaries are increasingly relying on APRNs for primary care. We also cautioned that federal restrictions on APRN practice can have systemic consequences, especially in rural, underserved, and appointment shortage areas, where new approaches are sorely needed to improve access and care experience.  

We are therefore excited to see signs in the Executive Order that nurses’ voices are being heard when it comes to health care reform. ANA and our members look forward to engaging with Medicare in the months ahead to identify some of the most troublesome barriers to APRN practice.

It is also encouraging to see that Medicare is already taking small steps to dismantle barriers to APRN care. The Centers for Medicare and Medicaid (CMS), starting next year, will allow nurse practitioners (NPs) in the state of Maryland to certify when their patients need home health care. This is a significant waiver of current law which requires an NP to bring in a physician, even when they are qualified under state practice authority to make such a decision.

The home health certification waiver in Maryland relates to a larger pilot program, which is testing a new payment system for Medicare in that state. Because of this pilot, CMS is able to authorize changes to existing law that are limited to the Maryland pilot. An act of Congress will be required to change the rules for the rest of the country. ANA supports the bipartisan Home Health Care Planning Improvement Act (H.R. 2150 / S. 296), which will allow NPs, clinical nurse specialists (CNSs), and certified nurse midwives (CNMs) to order home health care services without physician approval.

There is much work to be done to craft appropriate policies that expand access to APRN care and reward APRNs for the high-quality care they provide. ANA acknowledges and applauds the commitment of federal partners who are working with nurses to bring about the best possible results for our members and their patients.