Category: Health Care

Recognizing the Value of Nursing Under Universal Health Care Coverage

  

The debate over how the nation structures its health care delivery system has waged on for decades. At the heart of this debate has been how to ensure coverage and access to needed health care services for patients. Looking at a system where most get their health needs covered by Medicare, Medicaid, or commercial, employer-sponsored covered, many recognized that too many Americans continued to be left behind. On one side of the debate, we have seen a push towards a single-payer system—like what is in place in Canada and the United Kingdom. Others, pushing for more market-based solutions to expand coverage through private plans.

At ANA, we have long supported movement toward adopting a single-payer health care system as the most desirable option. That is a health care system that is structured where services provided are financed by one payer, typically the government. Since that position was formally adopted in 1999, ANA has altered its advocacy on ensuring all Americans have access to health care coverage and nursing care, rather than focusing on how the health care system is financed. This evolution is a result of a shift in conversations about health care reform and delivery system, which was fully realized with the passage of the Affordable Care Act (ACA)—which celebrates its 11th anniversary this year. This landmark legislation made several critical reforms to the nation’s health care delivery system that continue to influence health care policymaking today.

The ACA adopted some market-based solutions to expand access to coverage through the creation of federal and state-based marketplaces, while at the same time expanding eligibility for the Medicaid program to vulnerable adult patient populations. In addition to focusing on coverage, the ACA has helped to trigger a broader movement to value and quality in how health care services are provided and paid. We know that many of our nurses are integral in leading and ensuring the success of value-based models and other innovations that better the care for patients, recognized through underlying payment structures.

As ANA engages with Congress and policymakers, it is key that the association’s position better reflect the current conversations and priorities, as well as allowing flexibility that allows the association to weigh in on proposed legislation and regulations. This will only serve to allow our voice to be more effective on behalf of our members—making it clear that the existing support of a single-payer system must be updated. Rather, we must adopt a replacement policy that endorses universal health coverage that recognizes the value of nursing. As defined by the World Health organization, universal coverage is a system wherein everyone has access to the health care services they need.

Through promoting universal health coverage that recognizes the value of nursing, ANA has the opportunity to continue to amplify the vital role nurses play in changing and improving the nation’s health care delivery system. Nurses are key to the provision of high-quality care to patients—regardless of the patient’s health care coverage. What is critical in these debates is the recognition of the nurse role through equitable payment for the services they provide to patients. Additionally, as policymakers continue to drive innovation and reform into the delivery system, nurses must be allowed to practice at the top of their license to fully contribute to the success of any system changes.

While our complex health care delivery system is far from perfect, there are many opportunities to shape policies that impact coverage, care, and ultimately the nursing profession. Over 30 million of our fellow Americans remain uninsured, a number likely to continue to grow due the economic challenges we all face due to the COVID-19 pandemic. This will likely lead to actions that work to ensure greater access to health care coverage. We also know that innovation and delivery system reform will continue to be an area of focus for policymakers. The role of the nurse must be forefront in these conversations and—most importantly—in any resulting legislation or regulations. Adopting a position that recognizes that access to health care coverage is most important, regardless of the underlying financing, lets us focus on ensuring that the value of nursing is fully recognized in our health care delivery system.

Over the next few weeks, members should watch ANA’s communication platforms as we near this year’s Membership Assembly. Dialogue forums are back, and we look forward to a robust conversation about moving ANA from endorsing a single-payer system to one that supports universal access to health care that fully recognizes the value of nursing.

Large health care investments cap off eventful 2020 as we look ahead into 2021

  

What a historic year it has been on so many levels. Leaving behind the first year of a new decade that saw struggles which we could not have foreseen in January 2020, and going into a holiday season that looks vastly different from years passed and a future that is still unclear – it’s easy to focus on the negative. However, despite the trials and tribulations of this year, it is important and inspiring to recognize all of the ground-breaking work that ANA and nurses have done in the policy, government affairs and advocacy spaces, as we look towards what is on the horizon in 2021.

At the time of publication, Congress is in the process of passing a year-end package that will avert a government shutdown, include money for vaccines and COVID-19 aid to frontline workers, boost the economy, and include language to protect patients from surprise billing for health care. ANA has been working with our allies in Congress, and advocating to get these items addressed. Please be on the lookout for further details on the year-end package by visiting ANA’s new advocacy page. In the meantime, let’s acknowledge the progress made throughout 2020, which was necessitated by the COVID-19 public health emergency (PHE).

Earlier this year, the U.S. Congress and the President signed into law the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Included in the law is language that reauthorizes Title VIII Nursing Workforce Development Programs and authorizes Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs) to order home health care for their patients. These are longtime ANA federal legislative priorities, and we applaud Congress and the administration on their passage in the early stages of the pandemic. Advanced Practice Registered Nurses (APRNs) like NPs and CNSs are key to COVID-19 care and maintaining access to non-COVID-19 care throughout the crisis.

By summer, ANA was becoming a regular voice for nurses as Congress sought additional solutions to PHE challenges in the healthcare system. ANA President Ernest Grant testified at a hearing before the Senate Finance Committee, “Part 2: Protecting the Reliability of the U.S. Medical Supply Chain During the COVID-19 Pandemic.” Dr. Grant was there to answer the many questions Senators had about the impact of COVID-19. Questions ranged from what more the federal government could do to strengthen the supply chain, to the needs of nurses on the ground.

ANA also responded on behalf of nurses to proposals outlined in a white paper released by the Senate Health, Education, Labor, and Pension (HELP) Committee. The Committee requested input on what the U.S. had learned from the past 20 years of public health preparedness and response, and how we can better prepare for future pandemics. ANA’s response focused on how to rebuild and maintain state and federal stockpiles, improving public health capabilities, and increasing medical supply surge capacity and distribution. 

ANA has been consistently present with effective advocacy on personal protective equipment (PPE), which has been in short supply all year. As a result, the enterprise was tapped as leadership of a broad-based the coalition that will be a united voice to Congress and the administration on PPE and supply chain issues, to improve public health.

As we pivot to start working with the incoming administration, ANA has hit the ground running, providing substantive recommendations to transition leaders, and applauding the appointment of a registered nurse to President-elect Biden’s COVID-19 Task Force. We have communicated the many ways in which ANA and nurses can be a resource to the transition and the upcoming administration. We continue to solidify relationships to ensure that ANA will maintain a strong voice in the White House and key agencies in the months ahead.

Like the rest of the Policy and Government Affairs team, the ANA Political Action Committee (ANA-PAC) experienced a very successful year in 2020 despite the multitude of challenges it faced at the start of the pandemic. For starters, the PAC continued its winning streak with a 95 percent win rate in the 2020 general election for the nearly 100 candidates the PAC supported based on their pro-nursing agendas. Members of ANA drove their support unlike in years passed to the tune of over 5,600 contributors to the PAC which was an increase of 34 percent over 2019 and counting! And it doesn’t stop there: the financial strength of the PAC continues to improve as receipts are up 3 percent over last year and this number only continues to grow as we head toward the year end. Policy and GOVA will be spending the early part of 2021 strategizing our support for our existing nursing champions and starting new outreach efforts to those new freshman members of Congress. Stay tuned for updates in the next ANA-PAC quarterly newsletter.

ANA advocacy on federal regulatory policy has also strengthened nurses and demonstrated the power of nurses’ voices. With the COVID-19 PHE extended until March 2021, Medicare payment flexibilities gained in 2020 will continue. A number of these provisions expand access to APRNs for non-COVID-19 care as well as COVID-19 care, which has been a boon to patients and their providers throughout the pandemic, especially in rural areas.

The readiness of the Centers for Medicare and Medicaid Services (CMS) to remove regulatory barriers to practice has come as a result of direct advocacy over the years by ANA and partner organizations. The voices of frontline nurse providers were also heard, as CMS gathered first-hand accounts and created space to share this information on regular conference calls with nurses about the impacts of COVID-19 on their practice.

The pandemic has demonstrated the value of APRNs across the health care system, and CMS’ actions tell us that Medicare leaders are hearing us. The future is indeed bright, as CMS continues to review unnecessary barriers and craft regulatory relief. ANA policy leaders are right there, urging specific changes, and making a powerful case for making permanent changes to expand access to APRNs. We saw some success in the physician payment rule for 2021, which removed federal restrictions on APRN supervision of diagnostic tests.

CMS was not the only agency hearing nurses’ voices as important decisions were made. Early and often, ANA repeatedly called for steps to improve protections for frontline providers, including a return as soon as possible to pre-pandemic standards for PPE.

We made our case to the Occupational Safety and Health Administration, the Office of Minority Health at HHS, the Department of Veterans Affairs, Federal Emergency Management Agency, Government Accountability Office, and the White House Economic Advisors. ANA has become the “go to” organization for agency staff when they hear about events happening on the ground to work together to improve conditions for nurses. 

The pandemic made ANA’s presence even more valuable with the American Medical Association’s (AMA) RUC and CPT committees, which are the driving force for health care reimbursement. ANA CPT advisors were at the table when the CPT codes for both the Pfizer and Moderna vaccines were developed. In a separate process, ANA advisors were consulted to account for increased practice expenses incurred during the pandemic. Throughout, ANA engaged feedback and comment from the nursing community. All of these accomplishments could not be done without the loud impassioned voice of our ANA members and RNAction advocates. This united voice sent nearly 460,000 letters to Congress, responded to public comments and engaged in several surveys where the results were presented to Congressional offices across Capitol Hill. All of the input from nurses, our nation’s most trusted profession for 18 straight years, directly impacted legislation and policy throughout the year. We have you to thank for that – your efforts on the frontlines, your expertise and your advocacy do not go unnoticed. With over 200,000 RNAction advocates, we are poised to improve the profession of nursing and conditions for your patients again in 2021.

Evaluation and Management Code Changes Coming in 2021 for 99202-99215

  

While it is only the second month of 2020, it is never too early to look to 2021, when the revised Evaluation and Management (E/M) office codes go into effect per the Centers for Medicare and Medicaid Services (CMS) CY 2020 Physician Fee Schedule (PFS) Final Rule. CMS first proposed the updated Medicare E/M codes July 2018 in the CY 2019 PFS proposed rule to address the common perception that the E/M codes were outdated and to achieve administrative simplification. What is changing?

  • Deletion of code 99201
  • Revision of codes 99202-99215P
  • Components for code selection
  • E/M level of service for office or other outpatient services can be based on:
    • Medical Decision Making (MDM); or
    • Time: total time spent with the patient on the date of the encounter, including non-face-to-face services
  • Creation of a shorter 15-minute prolonged service code

Over the next few months ANA will take a deeper dive into these changes and will continue to share further guidance from CMS. These code changes are intended for increased simplicity and flexibility.  They eliminate the need for the clinician to redocument information, therefore reducing burden and “note bloat”. ANA encourages clinicians impacted to take the next eleven months to better understand how to use the updated codes.

With code 99201 deleted; the Office or other Outpatient Services: new patient code starts with 99202. The updated code states: Office or other outpatient visit for the evaluation and management of a new patient, which requires medically appropriate history and/or examination and straightforward medical decision making. The components of history and examination are removed from this updated code.

This continues for 99203, 99204, and 99205 but with the increase in MDM to low MDM, moderate MDM, and high MDM respectively. Codes 99211 through 99215 are for established patients following a similar pattern, except that 99211 will still be available in 2021 with an update of the time to spend performing or supervising the services.

The updated modifications to the criteria for MDM remove ambiguous terms and defines previously ambiguous concepts (such as acute or chronic illness with systemic systems). To qualify for a level of MDM, two of three elements for that level of decision making must be met or exceeded. Starting January 1, 2021, the new MDM table looks like:

Number and Complexity of Problems Addressed at the Encounter
Straightforward: self-limited
Low: Stable, uncomplicated, single problem
Moderate: multiple problems or significantly ill
High: very ill
Amount and/or Complexity of Data to be Reviewed and Analyzed Data is divided into three categories: (1) tests, documents, orders, or independent historian(s) – each unique test, order, or document is counted to meet a threshold number; (2) independent interpretation of tests not reported separately; (3) discussion of management or test interpretation with external physician/other Qualified Health Professional/appropriate source (not reported separately)
Risk of Complications and/or Morbidity or Mortality of Patient Management
Includes risks associated with social determinants of health
Straightforward: minimal risk from treatment – including no treatment – or testing. (effectively no risk)
Low: low risk/very low risk of anything bad, minimal consent/discussion Moderate: would typically review with patient/surrogate, obtain consent and monitor, or there are complex social factors in management (ex: prescription drug management, decision regarding minor surgery with identified patient or procedure risk factors, diagnosis or treatment significantly limited by social determinants of health)
High: need to discuss some pretty bad things that could happen for which physician or other qualified health care professional will watch and monitor (ex: drug therapy requiring intensive monitoring for toxicity, decision regarding emergency major surgery, decision regarding hospitalization)

ANA will continue to provide updates and content as clarifications become available. Currently, The American Medical Association has a module to continue in your education on the updated E/M Office Codes and remember that these codes do not go into effect until January 2021.