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Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Page 1: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

Scope of Practice:Colorado and the Current Debate

October 5, 2011

Impact Conversation Series

Page 2: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

2

Today’s Discussion

• Primary Care: A booming market• The National Conversation• State of the Debate in Colorado• APN & PA Survey Findings• Planning now for new solutions

Page 3: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

Primary Care: A booming market

Page 4: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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On the Horizon: Primary Care Need

• In Colorado 500k more “newly insured”

• How much care will they seek?

• Where will they seek care?

175,000

153,000

214,000

Page 5: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Gaps in Primary Care

Page 6: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Who Can Practice Primary Care?

Page 7: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Scope of Practice

Cost-effective care & providers, access

Training & complexity of care

Page 8: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

Progression of the Debate

8

Cultural

Page 9: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

The National Conversation

Page 10: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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The Importance of Frame of Reference

Nursing Perspective

Physician Perspective

IOM Perspective

Growing literature: plenty for everyone

Page 11: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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National-level reform

Mid-to-long range change

Immediate term change

Federal role

State role

Page 12: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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The Promise of Medical Homes

• Reduced costs• Improved care quality• Reduced medical errors• Higher patient satisfaction• Fewer health disparities

Page 13: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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The Promise Deferred

Not today or tomorrow • Require transformation• Workforce as members of “care

teams”• Technology is not “plug and play”• Health care neighborhoods• Payment reform

Page 14: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Accountable Care Organizations

A model for reforming health care delivery and payment

• Integrated care delivery• Payments linked to cost-reducing

quality benchmarks• Performance measurement

Page 15: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Scope of Practice: Market Dynamics

Page 16: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

State of The Debate in Colorado

Page 17: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Our Primary Care Workforce

Physicians NPs PAs

90

28

8

65

30

15

Primary Care Providers per 100,000 population

US Colorado*

NOTES: Estimates do not include non-primary care practitioners.*Colorado providers include practicing/working providers only.SOURCES: GAO, Peregrine, DORA, Colorado Office of Demography, CHI)

Page 18: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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State Role: Leverage Points

• Practice Acts (legislative decisions)• Medicaid payment structure• Insurance regulation

Page 19: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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CO

Page 20: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Scope of Practice: APNs

Pre-2008 2008 2009 2010 2011

Page 21: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

APN & PA Workforce Surveys

Page 22: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

Colorado NPs

No primary care specialty

32%

Primary care specialty

68%

NOTE: The total of all specialties sums to more than 100% because each respondent could select more than one specialty.SOURCE: 2010 Colorado Advanced Practice Nurse Workforce Survey, Colorado Health Institute, Q14, Q15, Q24

Page 23: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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NPs: Many recent graduates

1980 or be-fore

1981-1990 1991-2000 2001 or after

9%14%

31%

46%

Year of graduation

Page 24: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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NPs: A homogenous profession

NOTE: The total of all specialties sums to more than 100% because each respondent could select more than one specialty.SOURCE: 2010 Colorado Advanced Practice Nurse Workforce Survey, Colorado Health Institute, Q14, Q15, Q24

Female91%

Male9%

Gender

White, not Hispanic

94%

Hispanic/Latino

2%

Race-ethnicity

Page 25: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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NPs: Age and career cycle

34 years or younger

35 - 44 years

45 - 54 years

55 - 64 years

65 years or older

18%21%

19%

36%

5%

Page 26: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Enforceable policies establishing re-imbursement commensurate with clin-

ical services provided

Institutional policies that reflect APN scope of practice under law

Physician-APN convenings on issues of scope of practice and collaborative

models of care

95%

95%

92%

NPs: Policy opinions

Page 27: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Colorado PAs

*PAs were classified as primary care if they practiced family/general medicine, general internal medicine, general pediatrics or prevention/wellness at least 50% of their practice time during a typical work week.

SOURCE: CHI: 2011 Physician Assistant Workforce Survey, Q24, Q17, Q1.

Primary Care Specialty Care0

200

400

600

800

1000

1200

Female (75%)

Female (60%)

MaleMale

Specialty & gender

Nu

mb

er

of

PA

s

43% of PAs 57% of PAs

Page 28: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Associate's Degree

Bachelor's Degree

Certificate Master's Degree

0% 1% 0%

13%9%

29%36%

58%

31%27%

33%

16%

60%

43%

31%

13%

Education and age <2930-3940-4950+

PAs: Increasingly educated

SOURCE: CHI: 2011 Physician Assistant Workforce Survey, Q24, Q2, Q13

Page 29: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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PAs: Policy opinions

State/federal loan forgiveness for those PAs practicing in underserved areas of

Colorado

Private reimbursement that reflects equal pay for equal work

Allow home health, SNF and hospice care ordering to be delegated to PAs under

Medicare

98%

90%

85%

SOURCE: CHI: 2011 Physician Assistant Workforce Survey, Q8

Page 30: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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What the surveys tell us:

• Important primary care providers• Meeting higher education standards• Some of the same issues as

physicians• NP issues: Reimbursement,

institutional policies, physician convenings

• PA issues: Reimbursement and Medicare scope

Page 31: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

Planning now for new solutions

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The late stages of the debate

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Are the Changes Enough?

Calls for Disruptive Innovation• Clinician-led teams, practices• Telehealth• Leveraging new practitioners: Community

health workers/patient navigators/care managers?

Innovation

Page 34: Scope of Practice: Colorado and the Current Debate October 5, 2011 Impact Conversation Series

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Options Moving Forward

• Aligning financial structures & institutional policies

• Paying for value• Building consensus: NPATCH• Support for loan forgiveness• Evaluate Community health worker

models