APRIL IYY2. VOL SS. NO 1

A O K N .IOUHNAI,

Legislation Reimbursement for advanced practitioners examined; new laws address disease transmission, employment discrimination, advance directives

Reimbursement for advanced nurse practitioners is addressed in the Nov 25, 1991, issue of F~~rler-ul Rcgisrcr-. In a final rule that implements the Omnibus Budget Reconciliation Act (OBRA) of 1989, the Health Care Financing Administration (HCFA) sets forth a fee schedule for payment for physicians’ services effective Jan 1, 1992. The final rule also states that allowed amounts for nurse practitioner (NP) and clinical nurse specialist (CNS) services provided in rural areas after Jan 1, 1992, may not exceed the following: 75% of the physician fee for services provided in hospitals (including assisting at surgery) and 0 85% of the physician fee for all other services. In nonrural areas, allowed amounts for services in a nursing facility may not exceed the physician fee schedule for that service. Two proposed bills would increase payment. Sens Charles Grassley (R-Iowa) and Daniel Patrick Moynihan (D-NY) have introduced S 2 103, the Primary Care Health Practitioner Incentive Act, which would provide direct Medicare reimbursement to NPs, CNSs, and certified nurse midwives (CNMs). Under the provisions, these nurses would be paid 97% of the physician fee schedule for services they are legally authorized to provide under state law. According to the Jan 10, 1992, issue of Capital Updute, the payment would apply regardless of location or practice setting and regardless of whether the nurse was under the supervision of, or associated with, a physician. In addition, IOU2

these practitioners would receive bonus payments, as physicians do, if they work in health professional shortage areas. The Senators also introduced S 2 104, which would provide similar benefits to physician assistants. The bills have been referred to thc Finance Committee. In a related matter, passage of the Medicare Rural Incentive Act of 1990 allowed CNSs and NPs in rural areas to receive direct reimbursement for inpatient and outpatient services. Through prospective payment, however, billing has been bundled, and in some areas, nurses have been unable to bill directly for inpatient services. A technical amendment that would unbundle part A services and allow nurses to bill directly is likely to remedy the situation this year, according to Pamela Mittelstadt, R N , M P H , associate director of the American Nurses Association’s (ANA), division of government affairs.

Medicaid coverage of nurse practitioner services also is addressed in the Federal Register. The HCFA issued a proposed rule on Dec 23, 1991, to implement the OBRA of 1990 requirement that state Medicaid agencies cover the services of family nurse practitioners and pediatric nurse practitioners. These services must he offered to all “categorically” needy recipients and may be offered to the medically needy as well. T h e FPder-nI R e g i s t e r - s t a t e s that NPs improve the quality and accessibility of health care services, increase the productivity of medi-

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A O R N JOURNAL

The AORN Board of Directors has approved a Task Force on the RN first assistant. cal practices and institutions, and decrease the load on physicians, especially in underserved areas. The rule states that NP services are those that are within the scope of practice authorized by state law or regulations. The services may be provided regardless of whether the NP is under the supervision of, or associated with, a physician. Senate bill 1842, which was introduced by Sen Tom Daschle ( D - S D ) , would expand Medicaid coverage to services provided by all NPs and CNSs. The goal of the bill is to promote provider choice and enhance the availability and quality of health care for unserved and underserved citizens. The bill has three cosponsors and has been referred to the Finance Committee. Some of these issues may affect RN first assistants who are granted advance practice status in their states. As such, the AORN Board of Directors has approved a Task Force on the RN first assistant. The Board also changed advance practice initiatives from a priority 3 to a priority 2 on its legislative agenda. In priority 3 , the Association followed the issue. Now, under priority 2, AORN will sign on to ANA’s positions. AORN President Jean Reeder, RN, PhD, CNOR, has written to members of the Senate Finance C o m m i t t e e e n c o u r a g i n g them to cosponsor S 2 103, S 2 104, and S 1842.

Nurses will be protected against hepatitis and acquired immune deficiency syndrome (AIDS) under new regulations f r o m the Occupational Safety and Health Administration (OSHA). The bloodborne pathogens standard, which was issued in December, will protect more than 5.6 million workers and prevent more than 200 deaths and 9,200 bloodborne infections each year, according to the Dec 6, 1991, Federal Register. The standard requires that health c a r e

employers provide protective equipment and procedures to prevent the transmission of hepatitis B, AIDS, and other bloodborne diseases. The regulations require exposure control plans, engineering controls, workplace practices, personal protective equipment (eg. gloves. masks, gowns), housekeeping procedures, and employee training aimed at reducing exposure to hepatitis B and the human immunodeficiency virus (HIV). They also require postexposure procedures to guarantee treatment and confidentiality and prevent further transmission of the disease. The standard also requires employers to offer, at their expense, voluntary hepatitis B vaccinations to all employees with risk of occupational exposure and prescribes appropriate medical follow-up and counseling after an exposure. The standard became effective March 6. 1992. Exposure control plans must be completed within 60 days: initial information and training should take place within 90 days, and other measures must be in effect within 120 days.

Safe medical devices are the subject of hearings held by the House Committee on Small Business. AORN signed on to ANA testimony for these hearings. The testimony states that as health care professionals, the Association members understand that transmission of the HIV is halted by strict adherence to universal precautions and infection control practices. In addition, education of consumers and health care professionals is important. The testimony, which also was endorsed by the American Association of Critical-Care Nurses, American Association of Spinal Cord Injury Nurses. Association of Nurses in AIDS Care, and Emergency Nurses Association, states that the groups have undertaken educational programs on HIV, AIDS, and the OSHA 1083

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standards. The associations support federal policies that would require annual education for all health care workers to ensure that they are knowledgeable about universal precautions. The testimony further states that these efforts “must by coupled with engineering controlsthe most effective line of defense for worker protection against sharps injuries. The associations support 0 immediate systematic research and evaluation studies of (1) devices and equipment intended to reduce risk or injury from sharps and (2) personal protective equipment designed to reduce exposure risks, 0 funding to support systematic studies, 0 availability of proven safety devices, and continued evaluation and modification of work practices to reduce the frequency of situations in which exposure or injury risk to health care workers is greatest.

The Americans with Disabilities Act was signed into law on July 26, 1990. The part of that law that prohibits providers of public accommodations from discriminating against people with disabilities became effective on Jan 26, 1992. The section prohibiting such discrimination by employers will become effective on July 26, 1992. Employers found to have discriminated may have to alter practices, hire a qualified individual with a disability, or reinstate a person with back pay and provide reasonable accommodations. An employer who loses a case also may be liable for the defendant’s attorney’s fees and costs. The act provides a broad definition of “disability.” The definition includes people who have a physical or mental impairment that substantially limits one o r major life activities, have a communicable disease such as AIDS or hepatitis B, 0 are recovering from alcohol or drug addiction, and are regarded as disabled, whether they are or not. The definition of disability is broad; however, it applies only to people who are qualified

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for the job in question. The definition of a “qualified” person is one who “with or without reasonable accommodation” is able to perform essential functions of the job. Reasonable accommodation may include 0 altering the physical environment; 0 reassigning job tasks; 0 using part-time or modified work schedules; 0 modifying entrance examinations and training materials; 0 modifying or acquiring equipment such as adaptive hardware or software for computers, telephone headset amplifiers, ramps, or handrails; and 0 providing readers or interpreters. The act covers employers with 15 or more full-time employees; those with fewer than 25 employees will not be affected by the act until July 26, 1994. Acts determined as discrimination could include such things as 0 failing to make reasonable accommodations (eg, failing to provide an adaptive telephone to a person with a hearing impairment), 0 denying jobs because of the need to make reasonable accommodations (eg, failing to hire an individual because of the need to provide a reader for that individual), and 0 maintaining health insurance that covers all employees except those who have AIDS.

Nurses’ roles in end-of-life decisions will increase through the Patient Self-Determination Act, which went into effect in December. The new law requires that all individuals receiving medical care be given written information about their rights under state law to make decisions about medical care, including the right to accept or refuse medical or surgical treatment and the right to initiate advance directives. It applies t o all health care institutions that receive Medicare or Medicaid funds. According to a news release from the ANA, nurses play a crucial role in implementing the act through public education, research, patient

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care, advocacy, and education of other health care professionals. The ANA has taken the position that nurses should know the laws in the state in which they practice, be familiar with strengths and limitations of various advance directives, help ensure that patients’ advance directives are current, and facilitate informed decision making.

Hysterectomy outcomes will be studied through a grant from the Agency for Health Care Policy and Research. First-year funding of more than $500,000 was awarded to Kristen H. Kjerulff, PhD, of the University of Maryland, to conduct a 3 1/2-year prospective investigation of the effectiveness and outcomes of hysterectomies. Investigators will examine mortality, morbidity, health status, functional capacity, and quality of life. They also will examine the extent to which alternative surgical procedures and ovary removal affect outcomes, according to t h e December 1991 i s s u e of R e s e a r c h Activities. The study began in September 1991 and will continue until February 1995.

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undergraduate nursing scholarships. Another d i f f e r e n c e is t h e authorization levels f o r advanced nurse education and the special project sections of the NEA. The Senate authorizes $20 million for each; the House $8 million each.

Military nurses receive funding for nursing research thanks to Sen Daniel K. Inouye ( D - H a w a i i ) . T h e D e p a r t m e n t of D e f e n s e Appropriations Act for fiscal year 1992 included $1 million for that purpose. Sen Inouye included the funding to allow military nurses to conduct clinical nursing research on access to care, child abuse, health care delivery, family stress, and other areas, according to the Jan 10, 1992, issue of Capital Update. The Air Force, Army, and Navy Nurse Corps will work with the National Center of Nursing Research to review and recommend studies to be funded. This is the first defense funding allocated specifically to nursing research. LAURIE D. CRUZ SENIOR ASSOCIATE EDITOR

The Nurse Education Act (NEA) ended a three-year authorization period last October. Ongoing programs currently are maintained by a continuing resolution that provides funding at 1991 levels. The NEA must be reauthorized for federal support to continue. Two bills (HR 3508 and S 1933) that would provide that reauthorization currently are under consideration in a conference committee. The committee will resolve differences between the t w o bills, according to the Ja+ 3 1, 1992, issue of Capital Update. The Senate version authorizes $136.5 million for NEA programs and authorizes three new sections of the NEA to ( I ) enable nursing programs to expand their capacity, (2) establish rural learning experiences, and (3) fund certain employees in long-term care who enroll in nursing education programs. It also authorizes $30 million for undergraduate nursing scholarships. The House version authorizes $62 million and contains none of the Senate provisions. I t eliminates from the NEA all support or 1085

Reimbursement for advanced practitioners examined; new laws address disease transmission, employment discrimination, advance directives.

APRIL IYY2. VOL SS. NO 1 A O K N .IOUHNAI, Legislation Reimbursement for advanced practitioners examined; new laws address disease transmission, emp...
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