Expanded Role of Non-Physician Practitioners in Health Reform - - PDF document

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Expanded Role of Non-Physician Practitioners in Health Reform - - PDF document

Sep 02, 2023 46 likes •323 views

Expanded Role of Non-Physician Practitioners in Health Reform Charlotte Jefferies Horty, Springer & Mattern Relevant Laws and Regs: Centers for Medicare & Medicaid Services (CMS) - Conditions of Participation (CoPs)

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Expanded Role of Non-Physician Practitioners in Health Reform

Charlotte Jefferies Horty, Springer & Mattern

Relevant Laws and Regs:

  • Centers for Medicare & Medicaid

Services (CMS) - Conditions of Participation (CoPs)

  • Accreditation standards
  • Hospital licensing laws and

regulations

  • Professional licensure laws and

regulations

  • Medicare billing rules
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CMS

Credentialing and privileging for those providing a “medical level of care” through Medical Staff process

“Medical Level of Care”

  • Is the APC performing a task that

has historically (within the last 20 years) been performed by physicians?

  • Could the task that the APC is

performing “kill or cause significant harm” to the patient?

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Policy Questions

  • What non-physician practitioners

should practice in the hospital?

  • What should they be permitted to do?
  • Who should be involved in designing

privileging criteria for specialty practice and peer review?

Status

  • Employed by Hospital
  • Employed by Physicians
  • Self-employed
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Categories

  • Licensed Independent Practitioners
  • Advanced Practice Clinicians
  • Dependent Practitioners
  • Alternative/Complementary

Advanced Practice Clinicians

Individuals who practice under the supervision of or in collaboration with a physician(s) and are granted clinical privileges.

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APCs

  • Advanced Practice Registered

Nurse (“aka CRNP”)

– Certified Nurse-Midwife – Nurse Practitioner – CRNA – Clinical Nurse Specialist

  • Physician Assistant
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  • For PAs, certification is required for

licensure,

  • Most Nursing Boards require

certification for APRNs,

  • Medicare billing rules have specific

requirements

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Hospitals can define level of physician oversight, supervision, collaboration; may be more strict than state law.

Factors to Consider for Adequate Supervision

  • Practice setting (number of

patients, satellite office, etc.)

  • Physician availability
  • Number of other APCs physician

supervises

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Rules of Thumb for APC Supervision:

  • Physical presence not required, but

immediate electronic availability is

  • Supervising physician can supervise
  • nly procedures within his/her scope
  • f practice
  • Physician may supervise only limited

number of individuals

CMS ─ Framework for “Evidence-Based” Privileging

  • Education
  • Special training
  • Quality of specific work
  • Patient outcomes
  • Current work practice
  • Maintenance of continuing

education

  • Certifications
  • Licensure
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Is “on-the-job” training for specialty practice in hospitals acceptable?

Medical Staff Process Must Include:

  • Verification of education, training,

and licensure or certification

  • Verification of experience and

ability to perform privileges (by peer reference)

  • Assessment of ACGME core

competencies

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Medical Staff Process Must Include:

  • Department chief report on clinical

privileges

  • Recommendation by the MEC
  • Final action by the Board

Medical Staff Process May Include:

Review and recommendation by the Credentials Committee

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APC Review Committee

  • Can’t be used to replace the MEC,

BUT…

  • Could replace the Credentials

Committee’s role in APC credentialing

What about hospital-employed APCs?

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Hospital-Employed LIPs and APCs

  • Credential and privilege through the

Medical Staff process.

  • May use results of credentialing

process when making hiring decisions.

Threshold Qualifications

Unrestricted license Unrestricted DEA Not terminated from another staff No felony convictions Not excluded from Medicare

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Query the National Practitioner Data Bank! Can you grant temporary privileges to APCs?

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Yes, the same rules for granting temporary privileges apply for APCs.

APCs must have clinical competence assessed through peer review process

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Peer Review Continuum

“Cup of Coffee” Conversations Letters of Guidance Reprimands PIP

FPPE 1 OPPE

Normal Review Collegial Intervention Informational Letters

FPPE 2

If there is a concern with

  • Mr. Bounds’ performance, how

is it likely to be identified?

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If we decide to have a collegial intervention with Mr. Bounds, who should be involved? Is Mr. Bounds entitled to a “medical staff hearing”?

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If the Board upheld the hearing panel’s recommendation to revoke

  • Mr. Bounds’ privileges,

is this reportable?

Reporting to the NPDB is not required but is permitted.

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Reporting to State Board is required.

What can APCs do?

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Is the activity within the APC’s scope of practice according to state law?

Three Key Questions to Ask Three Key Questions to Ask

Is the activity permitted by the supervision or collaboration agreement with the supervising physician?

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Three Key Questions to Ask

Has the Hospital specifically authorized the type of APC to perform the activity?

  • What Can They Do?

Prescribe drugs?

Progress notes?

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It depends on state law and may depend on practice setting.

Can APCs admit patients?

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“Patients must be admitted to the hospital by a licensed practitioner permitted to admit patients under state law.”

Admit Patients to the Hospital?

CMS Conditions of Participation

“If a patient is admitted by a practitioner other than a physician, he

  • r she must also be under the care of an

MD/DO, with the name of the MD/DO identified in the medical record.”

Admit Patients to the Hospital?

CMS Conditions of Participation

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Can an APC prepare the discharge summary? MD/DO may delegate writing the discharge summary to other qualified health care personnel.

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“[W]e would expect MD/DO responsible for patient during hospital stay to co-authenticate and date the discharge summary to verify its content.” Can APCs be included on the

  • n-call schedule?
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Contact must still be made by ED with on-call physician. ED physician has ultimate authority to decide who responds.

EMTALA authorizes MSE to be performed by QMP “as determined by hospital bylaws

  • r rules and regulations.”

Qualified Medical Personnel

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Membership Issues

Should APCs be members

  • f the Medical Staff? With
  • r without vote?
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Should APCs be appointed to:

  • Medical Staff Committees?
  • MEC?
  • Credentials Committee?
  • Peer Review Committee?

(with or without vote?)

  • American Academy of Nurse Practitioners (AANP)
  • American Nurses Credentialing Center (ANCC)
  • National Certification Corporation (NCC)
  • Pediatric Nursing Certification Board (PNCB)
  • American Association of Critical-Care Nurses (AACN)
  • Certification Corporation
  • American Midwifery Certification Board (AMCB) aka

American College of Nurse Midwives (ACNM)

  • The National Board on Certification and Recertification
  • f Nurse Anesthetists (NBCRNA) aka American

Association of Nurse Anesthetists (AANA)

  • Oncology Nursing Certification Corporation
  • Council on Certification of Nurse Anesthetists
  • National Board for Certification of Hospice and Palliative

Nurses