Based on AHLA’s annual Health Law Connections article, this special series brings together thought leaders from across the health law field to discuss the top ten issues of 2022. In the tenth episode, Valerie Rock, Principal, PYA, speaks with Robin Locke Nagele, Principal, Post & Schell PC, about the expansion of Advanced Practice Professionals (APPs) during the pandemic. They discuss the ways in which the pandemic allowed APPs to advance as an industry, challenges for APPs in the post-pandemic environment, and the path forward for APPs seeking to capitalize on gains made during the pandemic. Sponsored by PYA.
Watch the conversation here.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Based on AHLA’s annual Health Law Connections article, this special series brings together thought leaders from across the health law field to discuss the top ten issues of 2022. In the tenth episode, Valerie Rock, Principal, PYA, speaks with Robin Locke Nagele, Principal, Post & Schell PC, about the expansion of Advanced Practice Professionals (APPs) during the pandemic. They discuss the ways in which the pandemic allowed APPs to advance as an industry, challenges for APPs in the post-pandemic environment, and the path forward for APPs seeking to capitalize on gains made during the pandemic. Sponsored by PYA.
Watch the conversation here.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
A H L a is pleased to present the special series, highlighting the top 10 health law issues of 2022, where we bring together thought leaders from across the health law field to discuss the major trends and developments of the year support for a H a. And this series is provided by PPY, which helps clients find value in the complex challenges related to mergers and acquisitions, clinical integrations, regulatory compliance, business value, fair market value assessments, and tax and assurance for more information, visit pya, pc.com.
Speaker 2:Thank you for joining us with, uh, ALA top 10 issues and health law for 2022, excited to bring up the rear at the, the last of these sessions, um, for the 10th, um, I'm Valerie rock I'm with, uh, PPY, I'm a principal with PPY and in our compliance department, and I oversee our revenue integrity services. And today we're going to be talking about apps and the expansion of those apps utilization as it relates to COVID and how that might be a pathway forward, um, for continued expansion of those, um, apps. So today I have the author of the article, um, for the top 10 article Robin Nagle she's with Poston Schnell. So I'll let her introduce herself as well.
Speaker 3:Hello everyone. Um, and thank you, Valerie. I'm, uh, Robin Nagle. I, uh, practice he healthcare law with post and shell in Philadelphia. Uh, and I have a healthcare regulatory and compliance practice, and I also work a lot in medical staff, uh, and privilege issues, uh, but, uh, uh, definitely a, a good component of my work relates to advanced practice profess, uh, and the various settings in which they practice. So I'm very happy to be here today.
Speaker 2:Great. Thank you, Robin. So we are going to talk about apps today. I wanna make sure that we're all on the same page on what an a P is. Um, so you heard, uh, Robin say advanced practice professional. You might hear advance practice practitioner or provider, um, but you also may hear them called nonphysician practitioners, Medicare calls them that. So when we're talking about these guidances today, you, if you're looking for that within the Medicare manual, you wanna make sure that you're looking up in PPP or nonphysician practitioner, not a PPP that can be a little using. Um, we've had lots of different terminology, um, to call nurse practitioners, physician assistants, and other, um, allied professionals. So, um, we wanna make sure we're talking about the same, the same thing, but, um, today that's who we're talking about, the non-physician practitioners that are serving our patients and are really our future for addressing physician shortages that are anticipated. So we wanna make sure that we're looking at how these trends, um, might be moving forward as it really, since we've had some expansion there. So to kick things off. In what way Robin, have you seen, uh, COVID presented, has presented an opportunity to advance, um, the practitioners within the industry?
Speaker 3:Um, sure. Well, um, with the, obviously the federal and state emergency declarations and co O waivers, uh, as with every other, um, you know, facet of the healthcare industry, we, we just launched into an all hands on deck environment, uh, where, you know, the, the goal was to facilitate as much care as reasonably can be provided in every setting where it can be provided, um, keeping patients out of hospital, uh, as one of the top priorities. And in that, uh, environment, uh, there was a relaxation of a number of the, uh, traditional restrictions on a P P practice, uh, things like supervision requirements, uh, location requirements, where they can practice, uh, how they can practice, obviously going into patient's homes and across state, uh, boundaries. Uh, we saw of course, a great expansion in the use of telehealth, not only by physicians, but by, uh, all kinds of apps practicing now across state lines. Um, and really the, uh, one of the primary goals and opportunities was to relieve the burden on physicians for the primary care services that advanced PR practice professionals do very well. Um, and I think that as part of that, they were able to demonstrate, uh, you know, their, the quality and efficiency of their services in doing that.
Speaker 2:Sure. So were, were there studies done along the way during COVID that helped demonstrate capabilities?
Speaker 3:Well, there have been numerous studies over the past several years that have demonstrated that, uh, for instance, CR PS and PAs can provide primary care services, uh, at the level of quality and efficiency that is at least equal to what physicians can provide. Um, and well also that they can be effectively deployed, particularly in areas of pH where physician access is limited. I would say during COVID, there have been studies and reviews done they're necessarily more anecdotal because we're in the middle of a global pandemic, but they've highlighted, uh, that the waivers that allowed apps to practice at the top of their licensure evaluating, diagnosing, ordering, prescribing, and managing care in less restrictive environments really, uh, provided an opportunity, um, to, uh, to, to provide, generate powerful evidence of their capabilities. Um, I, I noted, uh, that health affairs, uh, in a COVID related thought piece that was really focused on the challenges of, of physician practice in the COVID environment. Um, pointed out that a apps can help relieve the burden on physicians, um, and reduce physician burden, uh, which itself can cause medical errors and safety issues. So recognizing that the ability OFS to kind of expand the reach, particularly in that primary care setting, uh, or environment, um, uh, you know, is, is helping to relieve, um, the burden on the higher level practitioners.
Speaker 2:You sure. So what challenges lie ahead for apps during a post COVID environment?
Speaker 3:Well, of course, uh, with the ending of the emergency declaration and waivers, as with every other aspect of the medical industry, um, a apps are being thrust back into the same restrictive practice environment that existed pre COVID. And there are significant restrictions, uh, to a P P practice. Um, you know, the barriers that exist in men and, and by the way, these are very, very state specific. So you really have to look at, uh, what's going on in each of the individual states, but in many states they're still, um, CR NPS and a are still required to protect practice pursuant to supervision agreements, or potentially the somewhat less, uh, restrictive collaboration agreement where you don't have direct supervision and, uh, responsibility by the physician, but you still have to have a kind of collaborative, um, environment where you are consulting in the, they are kind of paying attention to what, uh, the a P is doing. Um, one of the things that, um, I, I know that a PPPs have pointed out as somewhat restrictive are the fact that still in many states, um, their practice is regulated by, uh, medical boards that is physicians and osteopaths, you know, licensing and overseeing the scope of practice of, uh, apps. And, uh, there is an argument that is being made, that it, you would really have a more effective oversight authority if it's made up of, uh, folks that are in the practice, uh, you know, are really, uh, familiar, directly personal, really familiar with, uh, the capabilities, the training, the scope of practice, uh, that, uh, apps are, are, are capable of. Um, and also, you know, let's face it, there's a concern that if a P practice continues to be regulated by medical boards, there's a certain amount of competitive, or anti-competitive them, us, uh, that might have a tendency towards keeping that practice more restrictive. Um, so those are limitations that exist, uh, limitations, obviously on billing and owning one's own practice, you know, uh, unless apps can really be able to provide the service independently bill for the service, collect the revenues and own and manage their own practices. They are gonna continue to be somewhat beholden, you know, to the, to the physician industry, um, things like signature requirements and orders, prescriptions records, all of these things camper the day to day functioning of, and, and those clearly still exist post COVID,
Speaker 2:Right? It does seem like a challenge because if there is not some level of oversight, cuz clearly PAs and MPS don't have the same education exactly as a physician. So there is, there's kind of like a UG of push and to that, that, um, needs to be overcome at some level to allow those, um, PAs and MPS to practice independently. It's interesting that it may be the physicians themselves that kind of hold that back because of that, um, that feeling like they're taking over the same space. So, um, hopefully we can overcome that because there is a need, right, for thoses to have that, um, ability to see those patients or else we will have a shortage. So hopefully we can get everybody aligned. So are there any signs that COVID has provided an impetus for more permanent change?
Speaker 3:Well, um, I think there's been a lot of movement at the state level and of course it has to happen predominantly at the state level in terms of license licensure and scope of practice. Um, so we are seeing laws passed just in the past year in various states, um, relaxing supervision and collaboration requirements, um, expanding scope of practice, eliminating some of the counter signature, uh, burdens and so forth. Um, and so yes, uh, I think there are, um, some significant gains that have been made right in the area of, uh, CR P for example, just to give a few examples. Um, so Del I, I talked about the licensing board, you know, versus the nursing board, the medical board, so Delaware this year, or move to the licensing authority for CR NPS, from the board of medicine to the board of nursing, that's seen as a step forward, Massachusetts granted full practice authority to CR NPS. Um, and they passed emergency regulations this year that for instance, allow CR NPS, uh, psychiatric nurse, mental health, clinical specialists, and other nurse practitioners, um, to prescribe without supervision that is to prescribe medication without supervision. After they've gone through an initial two years of supervised practice. So you go through the initial period and then you move into independent practice. Um, Arkansas authorized a pathway for full independent practice for qualified nurse practitioners. Uh, they have to complete about 6,000 hours of supervised practice under a collaborative agreement with a physician. Uh, but then they can move into independent practice, um, and a similar path for certified nurse midwives. Um, one caveat there, uh, the law permits them to, uh, prescribe schedule two controlled substances, but only with a collaborative agreement. So if they want to have that ability, they're gonna have to have a collaborative agreement in place for that, um, Illinois and, you know, just sort of reflecting the, the pandemic environment that we're in Illinois and Oklahoma past laws authorizing APRNs to complete death certificates, um, and a new Louisiana law authorizes psychiatric mental health nurse practitioners who are practicing pursuant to a collaborative agreement to make the decision or to order voluntary admission or, uh, to certify for emergency, uh, uh, admission, uh, patients for psych treatment facilities. Um, so those are a number of examples where laws have been passed that are recognizing, you know, the, the, the capability, uh, of allowing this greater scope of practice for, for nurse practitioners.
Speaker 2:That's great. We've definitely seen some, um, real push forward even in the telehealth space in regards to access to care for mental health issues. So that's, um, been a good trend. So allowing those PAs and MPS to provide services in that areas also excellent to see, um, what about, uh, other ways that PAs have had gains in this area?
Speaker 3:So, um, yeah, there are a number of states that have made a gain, uh, past legislation, uh, authorizing increased PA practice. Um, Tennessee, I mentioned, uh, Delaware creating the board of nursing for licensure of CR NPSs, Tennessee passed a similar law, taking, uh, licensure for PAs from a committee of the medical board. And, uh, instead putting it under a board of PAs, um, uh, to, to supervise that, um, Oregon moved from PA supervision agreements to collaborative agreements, which again, as I said before are less restrictive. Um, and it also relaxed requirements, um, relating to PA dispensing medications, uh, and made some permanent, um, uh, you, you mentioned telehealth and, uh, Oregon has basically find PA ability to do telehealth, uh, to match that of physicians. Um, and they do have good, uh, laws already on the books, allowing, uh, physicians and now PAs to be practicing telehealth, to be practicing across state lines, um, you know, to, to make the licensure issues, uh, more manageable. Um, so, um, that those are very positive developments. Um, Florida made a number of changes for PA practice, um, the ability to prescribe and dispense prescription medications to authenticate documents, to supervise medical assistance. So PA supervising MAs, um, they also modernize the education and training requirements in a variety of respects. And so having relaxed some of those supervision requirements, they then also increased the, uh, the number of PAs that a physician can supervise, uh, from four to 10. So you still need the supervision agreement, but the physician can now supervise more PAs, uh, because the supervision requirements are somewhat relaxed. Um, similar thing happened in, uh, Washington state. Uh, they increased the, uh, supervision ratio from five to 10 physician to PA, um, in they also another element of what they did in Washington was to eliminate the requirement of, uh, approval of the supervision agreement, still need supervision agreement, but you no longer have to get the Washington commission approval of that agreement. Um, Pennsylvania, likewise remove the, uh, board. It's still a medical board, but the medical board approval of PA supervision agreements, uh, you still have to file them with a board, but they no longer have to approve them. And, uh, they created more flexibility in terms of, uh, counter signature requirements. Uh, for instance, the PA and the physician for the first two years of practice physician actually has to review and sign off on a hundred percent of the PA's records. But after that first two years, the physician and the PA can decide what they think is the appropriate amount of review and counter signature on a go forward basis. So, um, you know, after that initial period, it, uh, allows for a lot more flexible. Um, so, you know, all of these things on one level could be seen as kind of baby steps towards, you know, the goal that the APS have a full, independent practice. Uh, but I do think that we've seen a number of gains in the past year and that each one helps create momentum, uh, for future changes.
Speaker 2:Absolutely. So we talked about kinda the regulatory aspect. What about the billing and payment aspects?
Speaker 3:Well, I'm gonna start by flipping this back to you because I know that you are a billing and coding expert and that you've worked very, uh, very significantly in the PA space, um, from chatting before I know that you have some concerns about the new Medicare requirements. So why don't you talk a little bit about that?
Speaker 2:Sure. So as, as you know, or as you, some people may or may not know, um, there's been a change or shift in guidance in regards to the way that you bill and select an ENM code, an evaluation and management code, um, starting in 2021, based on that change there, the shared visit guidance and the critical care guidance that were in the Medicare manual no longer made sense. And they were no longer aligned with that new guidance. So there was a petition by physicians and other providers that said that needs to be removed. We need to revisit this. Let's, let's get this aligned. So in 2022, in the fee schedule, Medicare physician fee schedule for 2022, it was finalized. Um, that the way that you select the level service for a scenario, when you have an a P P and a physician doing a service on the same day, so shared visits in a facility setting that you would use, whoever provided more than 50% of the time, that is the provider, the billing provider for the claim. So in most cases, we know that apps are usually the ones that go in, they get all the D the data they're gathering the information on the patient. They're making sure that they are looking through the history, looking through the exam components, um, kind of do the, doing that preliminary medical decision making. And from that the P takes that information and then makes some decisions about it and may get clarification on some exam elements, some history elements and things like that, and then make a decision on the, you know, the medical decision making and assessment plan. Um, so in a majority of cases, you would have an a P P doing majority of the time for that scenario in 2021. And, and up to 2021, you would build that shared visit in a hospital setting facility setting under the physician, but now BA based on these new guidelines, you would be billing that under the a P P. Now we know, um, get a hundred percent of the fee schedule and apps get 85% of the fee schedule from a reimbursement perspective. That means that either there's probably gonna be a shift in patient flow, or the physician is gonna say, well, I'm just gonna take more time to see this patient. There's going to be some kind of shift because the, the, you know, we've kind of pulled away the reason to use these apps. If we're going to reduce the total amount of reimbursement by 15%, um, for the same service in 2021 in previous, um, to that. So it is going to be a real challenge to see how, um, moves forward. But this is an example of changing the guidance that might have sounded like a good idea where you're gonna, you know, treat thes as a part of that physician group and pull'em all together. And bill under one provider and bill under the predominant provider. That sounds good until you realize it's going to be a 15% reduction. In addition to that, physicians are often paid on work RVU. So now, if the bill is going out under the a P instead of the physician, now, the physician comp model is no longer. It, it no longer works because now you don't know how much that physician work was associated with that service. The, the physician basically lost from the data. So it, it is going to be a challenge. And I think it goes against the a P P utilization, not for their utilization. And so I'm, I'm concerned about that, that it's, um, it's going to, you know, flip in the wrong direction. So I do recommend, you know, getting, um, you know, on the phone to CMS and others, you know, people that represent you within CMS in your max, uh, about this and, and try to figure out a way that it it's going, you know, for a good solution to this. Um, because I don't know that this is a step in the right direction, um, an additional area, um, that we've seen things kind of moving forward is that credentialing for private payers has increased for apps. Um, a lot of them are credentialing now, whereas in the past they have not credentialed. So now when we go into a physician from practice, oftentimes they're saying, yes, we credential our IPPs and we don't bill incident two anymore that we just bill under the, a PPP when, when they're doing service, which is great, which is getting back to that top of license kind of scenario, where the, a PPP can do an independent service bill under his or her number and, and be done with the it versus trying to kind of finagle it to end up under the physician. Um, so we are seeing some trending forward there, but again, you know, one guidance in, in the wrong direction can kind of bring a steps back instead of steps forward.
Speaker 3:Yeah. And I think that, um, you know, what you're pointing out is that it is so much more complex, I think, in the, in the, in institutional environment where you have physicians and, and nurses and other staff just working side by side and, uh, sorting all of that out from a, from a billing perspective, um, creates a number of challenges. And as you pointed out, uh, perhaps some workflow issues, uh, as well, um, I do think that, you know, where I see a lot in terms of the expansion of practice or the enlargement of the scope of practice being most effective, I think is on the outpatient side, particularly where, uh, you know, apps can fill in the gaps that are filled, that, that are left. Um, you know, because as we just can't have physicians in every rural, um, you know, county in, uh, in all of the underserved areas. And, um, you know, I think that that's, uh, a, a place where PS in particular can, can demonstrate their important worth. Um, an example of that, uh, from a billing perspective is a and saw. So they just, um, uh, uh, passed a Medicaid law in the past year, uh, that, um, has expanded the authority of APRNs, uh, to provide direct family medicine practices to actually have their own family medicine practices. So, uh, they are now recognized as primary care providers and team leaders of family practice professionals, uh, and patient centered mental medical homes. And, uh, the law requires the Medicaid program to reimburse APRNs, um, for ancillary services such as labs x-rays and other tests. Um, so it really does, um, sort of help promote that idea of an independent practice at the APRN level that is capable of providing primary care services, um, and billing for them.
Speaker 2:Um, great. So bringing this kind of all together, looking to the future, what do you see as the path forward for a PPP seeking to capitalize on gains made during COVID?
Speaker 3:Well, of course, the various, a P groups, what be it, physician assistants, CR NMPS or others, they all are pretty active in lobbying at the federal and the state level. And I'm sure those lobbying efforts are gonna continue, uh, you know, through 20, 22 and beyond. Um, as one example of that, uh, the American academy of physician associates or a APA, these are PAs, um, they've sort of developed a, a, um, you know, a, a target or that they call optimal team practice. Um, and what they mean by that is a future state in which PAs practice alongside physicians and other healthcare professionals, you know, as sort of equal members of the team without what they call burdensome administrative constraints limit their practice. So, you know, this translates into three concrete goals that they have. Uh, one is the elimination of the physician supervision and collaboration requirements. Uh, so they'd like to be able to practice completely on their own. And as you pointed out, you know, there's a, there's a push and pull to that because I think we all recognize that there's certainly, you know, an important role for physicians in that relationship. Um, the second one is, uh, to create, as I've mentioned, a couple of times PA boards to actually do the licensing and regulate the practice of PAs, so that they're not a cousin of, of the physician boards. And then the third is to authorize PAs to be eligible for direct payment for all public and private insurers. So their very lofty goals were very, very far from seeing that happen in the real world. But, um, you know, I think just looking back over what happened during COVID and what's happened over of 2021, um, they can point to specific laws that have been passed that are, you know, beginning to move them in that direction. And I would expect that that trend will continue in, in two and through 2022 and, and really beyond.
Speaker 2:Great. Well, thank you, Robin really appreciate, um, your time today and sharing with us in regards to this central expansion, kind of a silver lining on COVID maybe, um, that, uh, that we can take from this. And, and, um, thank you ALA for hosting these podcasts really appreciate, um, your efforts, uh, for getting this information out there so that we can all, uh, learn from what's going on in as we head into 2022. So thank you all for your time today and have a great day.
Speaker 1:Thank you for listening. If you enjoy this episode, be sure to subscribe to ALA speaking of health law, wherever you get your podcasts to learn more about ALA and the educational resources available to the health law community, American health.org,