Thread by @rosehoban

Here: northcarolinahealthnews.org/2017/03/16/nur…

And others.

"Need to effectively utilize #CNMs has never been greater," says Kohl from midwife.org

Finding a supervising provider may prove difficult.
Body of evidence has consistently shown that although these barriers do not improve care.

Kohl:
"Time to follow the economics and evidence and remove supervision of practice"

Notes that team based care is the "future of #healthcare in the US"

Hmmm she's not advancing her slides. This one is interesting:

Her 16th slide:

Hise notes that in WNC, there's "professional midwives" moving into the space that should be occupied by #CNMs

He notes that the @MissionHealthNC system has closed maternity units in the western part of the state.

@MissionHealthNC Hise: If we don't have a viable option for #CNMs, we'll have a different market move into that space.
Kohl: that's something we grapple with. No one really understands what a #midwife is, bc no one really "owns" the term. Much conflation.

@MissionHealthNC Kohl: targeting federal funding to enhance grants to #APRN / #midwife school.
Notes workforce shortage in maternal child health. Will be helpful to remove barriers to practice, and would allow for more students to practice via national health service corps

@MissionHealthNC Next up: Jordan Roberts from @JohnLockeNC
What we see as benefits for NC of granting #APRNs full practice authority.
What is access? Numbers of people covered? or available access to receive care?

@MissionHealthNC @JohnLockeNC Interesting that @JohnLockeNC is against #medicaidexpansion but for increasing practice authority for #APRNs

Ah. Strange bedfellows in politics.

johnlocke.org/nc-medicaid-ex…

@MissionHealthNC @JohnLockeNC Roberts: growth rates in provider supply/ demand in coming years.
#ncga

@MissionHealthNC @JohnLockeNC Frames this argument as a regulatory reform issue, "it gets bogged down with the passion around this issue, but at its core that's what it is"

@MissionHealthNC @JohnLockeNC Roberts says, "NC is falling behind" when it comes to adapting to #Healthcare #workforce challenges

Moves onto #tax benefits of full practice authority. Cites Conover study we wrote about here: northcarolinahealthnews.org/2015/03/17/stu…

@MissionHealthNC @JohnLockeNC Conover claimed annual lower investment in #healthcare costs plus increased #tax revenue of between $20-38M
Roberts: What we know from the reseasrch is that these professionals cost less to train, get out into field faster, reimbursed for less, less administrative bloat

@MissionHealthNC @JohnLockeNC Studies find #APRNs use less medical services than #MDs.

Roberts: opponents say APRNS would order more tests, etc. not borne out in the data.
#ncga
we can do a lot to focus more on #primarycare

@MissionHealthNC @JohnLockeNC Also notes issues with rural health care, NC is riddled with health care shortage areas #HPSAs

"Big need in rural areas ... where NPs are more likely than physician counterparts to go out to practice"

@MissionHealthNC @JohnLockeNC Not a silver bullet for solving all #rural #healthcare issues in the state, but could chip away at it.

"If we could get people more comfortable seeing a provider, we could save a lot of health care on the back end"

@MissionHealthNC @JohnLockeNC Roberts now moving onto benefits of direct #primarycare

He makes argument that NPs could do the same thing as MDs.

@MissionHealthNC @JohnLockeNC Final points:
Employer costs for health insurance reduces amount of money available
for wages AND #APRN authority would allow them to work in #retailhealthclinics that are widespread = market adaption
#ncga

@MissionHealthNC @JohnLockeNC Roberts notes that as a @JohnLockeNC presenter, there would be no need for new taxes to do this.

@MissionHealthNC @JohnLockeNC Baker: in terms of outcomes, in Sept 2020, Journal of Internal Medicine notes that #APRNs more likely to rx #opioids in states with loosened practice authority.
Notes Hattiesburg, MS study they found #APRNs did more referrals to #EDs, other providers.

@MissionHealthNC @JohnLockeNC Roberts: for a lot of studies there are limitations and overall trends show better results than the ones you cite.

Cunningham: yes, this is regulatory reform. We put in place regs on prescribing #opioids that should address Baker's concerns.

@MissionHealthNC @JohnLockeNC Next up: Karen Smith, family doc from Raeford. She's a good example of someone who came from rural, returned there.

#ncga

@MissionHealthNC @JohnLockeNC Smith: work between MDs and #APRNS are collaborative.
Training of #healthcare professionals matters.

Notes the @NCMedBoard has a position statement that's largely aligned with @NCMedSoc
position. Notes rigor of physician training.

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc Smith: Why is physician preparation so rigorous?

This is what it takes for "comprehensive, hands on, standardized and proven" compared to #APRNs training that's "not standardized

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc Every #healthcare professional has a fundamental role to play, Smith says.
#ncga
There's a need for collaborative, physician-guided care team. "Cannot overemphasize that... patients want physicians by their side"

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc 95% of voters believe a physician is vital for optimum according to survey by the @AmerMedicalAssn

Smith says she's supervised #APRNs at different stages of their careers, has seen differences. An increasing number of NP programs are fully/ partially online. No standardization

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn Smith says she's seen "substantial variation" in #APRN education.

She's found inconsistencies across the board in education, readiness and training in the #APRNs she's supervised.

Tells recent anecdote.

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn Better to have #APRNs in collaborative practice she argues. "These are the same experiences shared by my colleagues across the state... country" acknowledges there are no flawless practitioners, but training matters, Smith says
#ncga

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn Cites @CMSGov project, found only 25p of #APRN graduates went on to provide care in medically underserved counties.

Maps independent practice and practice sites in WY, OR, WV.

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov I'm honestly curious, what are the practice rates among #physicians in rural areas?
#ncga

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov Smith argues that in GA, changes in scope of practice laws hasn't impacted #rural areas.
Recent maps show #APRNs in NC have doubled, "rapid growth suggests we don't have an issue recruiting NPs in NC"

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov Smith goes back to Hattiesburg clinic study:
#ncga @CMSGov cost data study

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov Notes higher costs for #APRNs in Hattiesburg clinic, with higher satisfaction for #physicians

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov Independent practice for #APRNs is not for NC, patients not well served when independent, but are better served acting in teams.
Encourage root causes of #ruralhealth disparities:
- #medicaidexpansion
- #loanrepayment
- @NCMedSoc practitioner program
- #telehealth

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov Smith tells #ncga : #telehealth would be big step towards solving #ruralhealth issues
finishes with "patient safety first"

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov Cunningham: when we have professionals to come in and present, it should not be to denigrate another profession. I've worked with #physicians, but also #APRNs and #CRNAs
Doubles down on how this is a regulatory reform issue.

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov Hise: clinic reviews, are they randomly assigned to #APRNs #physicians ? Are these studies more about the assignment of cases, rather than the acuity and the care?
Smith: I respect #APRNs and #physicianassistants
"we need our nurse practitioners... PAs"

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov But we sit down and review education, skill set, comfort level, so that we don't increase the cost of care. We work collaboratively.

"Appreciate the collaboration that will land us together in a situation that will increase access to care."

#ncga

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov Now Winifred Quinn from @AARPNC public policy institute

Calling for #APRN practice authority. By 2030, one in five NCians will be >65

It will be important for NC to look at #healthcare delivery. Her members want and need choice and quality in #healthcare as well as access

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC her constituents desires are not about turf wars, but about consumers having direct access to all #healthcare professionals.

Current system prevents better access. "By removing this bureaucratic red tape, patients would also have direct access to
all APRNs in the state."

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC Notes many #APRNs are gerontology experts. Having more in the state would provide better outcomes, access.

#CNMs are excellent women's health providers even for women >50

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC First mention today of certified nurse specialists, "top clinicians who provide care to people with chronic conditions"

Talks about her experience as family caregiver, docs were great, parents hospitalized unnecessarily. If there'd been a #clinicalnursespecialist

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC could have avoided hospitalizations.

" @AARP would not be supportive of full practice authority
legislation if it in any way compromised health care quality"

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP Moves onto citing research. All her references are listed here on page 6: ncleg.gov/documentsites/…

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP Cites studies such as: @JoanneSpetz et al. (2013) reported a lower number of hospitalizations, less emergency
department use, and a lower number of chronic condition indicators in states with full
practice authority compared with those without it

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz Quinn notes analyses done by @NASEM_Health which support practice authority for #APRNs along with a 2015 study found that in states with full practice authority for #APRNs,
#Medicaid patients were more likely to get new patient appointments & experience fewer
office visit costs

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health It's back to the battle of the data. Quinn going thru litany of studies on quality, access, cost. Footnotes cite 14 studies. "Findings suggest that lifting state-level scope-of-practice restrictions on
#APRNs would, over time, increase access to 1˚ care, part'ly in rural"
areas.

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health Quinn: Notes that @MedicareGov pays #nursepractitioners at 85% of the rate it pays #physicians.
"In other words,
full deployment of primary care nurse practitioners doesn’t only make sense – it saves
dollars."

Except if you're the one submitting the bills.

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health @MedicareGov Corbin: appreciate all of the input.

We need clarity: we understand the difference in training. We've heard differing opinions about #accesstocare and cost. We've heard two stories.

Second: what does supervision mean? IN agreements, are MDs required to collaborate with #APRNs

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health @MedicareGov Quinn: not familiar with NC law. What she shared is not opinion but decades of research.

Corbin: we need to know what "supervision" means.

Notes that in Ehrlanger Hospital in Murphy, there's no #anesthesiologist only a #CRNA

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health @MedicareGov Quinn: what I understand is that #physicians review charts of patients kept over time by #APRNs "that doesn't sound like that's a real good quality check and that's what the data show"

Corbin: then what is the value-added?

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health @MedicareGov hearing from @NCNursingBoard "there are models where there are providers who work together and there is life long learning."

Supervision is a document that's signed, doesn't mean that #physician and #APRN are co-located. Does not mean they're working hand in hand.

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health @MedicareGov @NCNursingBoard This is Guilamo-Ramos speaking. "if you look at overall research, you'll see that t he outcomes are comparable"

Notes US has most expensive #healthcare system & worse mortality, morbidity. Need to move to something that will insure #healthequity & improved #healthcare outcomes

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health @MedicareGov @NCNursingBoard Cunningham: can we get data on @MedicareGov #medicaid cost savings to using #APRNs ?

Kraweic: "A nurse recently told me her supervising #physician lives in TN, he flies in every 6 months and signs his authorization and she pays him $15K/ six months"

@MissionHealthNC @JohnLockeNC @NCMedBoard @NCMedSoc @AmerMedicalAssn @CMSGov @AARPNC @AARP @JoanneSpetz @NASEM_Health @MedicareGov @NCNursingBoard That's quite the anecdote to end on.