AMERICAN ENTERPRISE INSTITUTE

IS THERE A DOCTOR — OR A NURSE — IN THE HOUSE? SCOPE OF PRACTICE REGULATION AND HEALTH CARE REFORM

PANEL DISCUSSION PARTICIPANTS:

CINDY COOKE, AMERICAN ASSOCIATION OF NURSE PRACTITIONERS;

BENEDIC N. IPPOLITO, AEI;

R. SHAWN MARTIN, AMERICAN ACADEMY OF FAMILY PHYSICIANS

MODERATOR:

TIMOTHY P. CARNEY, AEI

12:00 PM–1:00 PM THURSDAY, MAY 11, 2017

EVENT PAGE: http://www.aei.org/events/is-there-a-doctor-or-a-nurse-in-the- house-scope-of-practice-regulation-and-health-care-reform/

TRANSCRIPT PROVIDED BY DC TRANSCRIPTION – WWW.DCTMR.COM TIMOTHY CARNEY: Thank you all for coming. I’m Tim Carney. I am a visiting fellow here, at the American Enterprise Institute. I’m also the commentary editor at the Washington Examiner. My work here at AEI has generally involved competition and regulation, and sometimes we’ve talked about whether regulation is actually harming consumers by taking away choices.

But when I give an example on the spectrum of absurd regulations, at one end is requiring florists to be licensed before they can arrange flowers. On the other end, I use the example of airplane pilots or surgeons, that we wouldn’t want those — just anybody setting up — hanging out a shingle saying volunteering to cut you open for money.

And “health care is different” is one of the arguments that we hear again and again during health care reform debates. So, on this question, regulation of the provision of health care, we find lots of differences across states. We find lots of lobbying debates, lots of questions. There’s questions of safety. There’s questions of choice. There’s questions of economic liberty. And that’s what we’re going to talk about today.

We brought in three excellent speakers who will discuss this. It’s going to be very discussion based, so there’s not just going to be a Q&A period at the end. If you guys have questions, think of them, and I’ll turn to you so, you know, work up your questions early on and try to condense them into as short of a question and something that ends in a question mark, hopefully, when we do it.

So let me first introduce our speakers. First, we have Shawn Martin, who is — and correct me if I get your titles wrong — vice president at the American Association of Family Physicians, vice president of advocacy. Is that correct?

SHAWN MARTIN: Correct.

MR. CARNEY: And we have at the other end another American association, the American Association of Nurse Practitioners. Cindy Cooke is the president of that organization.

Ben Ippolito is an economist here at the American Enterprise Institute. He works on health care. I’m sure there’s more to his title, but I think that’s the adequate sufficient part for our purposes today.

So I want to — so we’re going to start with Ben presenting just some background information that I think is very relevant for this. So take it away, Ben.

BENEDIC IPPOLITO: Believe it on not, based on that introduction, Tim and I have actually met before. I am an economist here at the American Enterprise Institute, and I tend to focus on issues in health care.

But what I thought I would do before we get to the very complex personal liberties discussions would be start out with some basic facts about what is it exactly that kind of underlies this whole discussion related to scope of practice and why do we think it’s an area that’s relevant for policymakers to consider.

And so I wanted to start with a slide that’s basically how I feel like 80 percent of the health care talks I go to starts, with some version of US health care is extremely expensive. That’s not a surprise to anybody in this audience, I suspect. We spend a lot of money on health care relative to other things we could spend money on. We also spend a lot of money relative to what any other country seems to spend on their health care.

And so there’s this tremendous public policy emphasis on, you know, how do we get this line to be a little bit lower? You know, we’re probably never going to a UK, but how do we restrain cost of health care in this country? But I think that’s at least one way to characterize this discussion about scope and practice, right?

The fundamental question at least more broadly is: Are there supply-side reforms that we could engage in that could perhaps try and chip away at this high-cost rate and potentially change access and things of that nature?

So given that we’re expensive relative to other countries, I think — and we’re talking about the supply side in health care — it’s useful to characterize what does the United States look like in terms of providers relative to other countries. And so a natural place to start is the flow of physicians, so the number of medical school graduates in a country.

The United States — this is data from the OECD, and it’s on a per capita basis. The United States doesn’t produce a particularly high number of medical school graduates. It’s not inherently a good or bad thing. It’s just a fact. Obviously, the mechanism is that we have — we don’t just let anybody become a doctor if they go to medical school. And there’s only so many spots in medical school. And the population of this country grows faster than the number of medical school slots; therefore, we don’t have that many physicians on a per capita basis.

That number isn’t growing particularly fast over time. There’s a little bit of growth over time, but it’s not particularly dramatic. And so what do you get if you don’t graduate that many people and it hasn’t increased that much over time? Well, you end up with a situation, unless you have massive physician migration, you end up in a situation where you don’t have a particularly high number of physicians in the country. Again, not inherently bad. It’s just a fact.

You know, somewhere — the number probably should not be zero and the number should not be literally everyone in the country is a physician, and so there’s some optimal in there. I don’t want to say what that optimal number is. It’s just it’s relevant to know that we don’t have a particularly high number of physicians.

And so you can kind of see where the arguments begin to start. Geez, we spend a lot of money; we don’t have that many physicians. Maybe I wonder if they have a lot of market power. So what if we could something to try to inject a little bit more competition, get some more providers in here? Could that be something that helps with our overall cost issue? And I think that argument is kind of crystalized when you look at the growth of other kinds of providers in health care.

So physicians haven’t grown a lot. NPs and PAs and other nonphysician providers have grown quite quickly. And so when you look at this, I think it’s tempting to say, “Well, geez, wait a minute. We’ve got this huge supply of potential providers here. What if we really unleash them? Could we then really inject a lot of competition, drive down prices, increase access, and so on and so forth?” I don’t want to sit here and say that that is a correct or wrong argument but rather just say that I think that’s a reasonable of framing at least one of the key arguments that people make in this realm.

And so I conclude with just this basic quick run of facts here with what I think is the fundamental question here. So there’s a reason that there are supply restrictions. Like Tim said, you don’t want just like any random person coming in and doing your surgery. It’s very hard for a normal person to actually observe the true quality of a physician.

And so we might like the idea that there’s some basic requirements. You have to go to a certain amount of school; you have to have a certain amount of training to be able to do particular things. The question, of course, is: Where is that balance between ensuring safety and ensuring relative efficiency?

And I think that’s really, fundamentally where this gets so tricky and what makes it such an interesting policy topic. But I think with that, I’m kind of interested to hear what our panelists have to say about it, so I’m going to stop there and maybe come back to those issues later.

MR. CARNEY: Great. I do think that’s great framing. If there was any hesitance in my introducing you, Ben, it’s that I’ve actually avoided pronouncing your last name for the years that we’ve known each other. And then I realized that I had to say it right now. Ippolito is correct, correct?

MR. IPPOLITO: I’ve heard it a lot of other ways.

MR. CARNEY: All right. So I want to start with you, Shawn, give you sort of the first say. What is the important — how would you describe what you think is the proper way — you know, without detail, an hour-long speech, whatever — the proper way to divide up the scope of practice, divide up what doctors should be doing and what non-doctors should be doing, and in what ways.

MR. MARTIN: Thanks, Tim. Thank you all for having me. So that’s a dissertation topic. But I’m going to boil it down. So I think there’s a couple of things here, and I think your question shows — I’m going to try to use your question to highlight kind of a transition that I think is happening in the health care marketplace, which is I think that question was something that we grappled with in the ’80s and ’90s of, you know, how do we identify roles, how do we attach payment to those various roles, and what are the upper and lower limits of each individual, you know, health care provider in the marketplace, and then how — you know, how do we pass laws that create floors and ceilings around that.

And I think this transformation that’s kind of happening now, particularly in primary care is, you know, how do we identify loosely a team and how do we let that team determine what the roles are inside the respective, you know, patient populations and becoming a little more patient centric in how we put together teams and what payment models do we need to put in place to kind of foster the identification and delivery of services through a team- based concept.

And this isn’t, you know, fully formed. I mean, this doesn’t work in some rural areas because the team is you and me, and you know, we have to do what we can do. But I think in more sophisticated delivery models, you’re starting to see this take shape. And I think both from my personal perspective and from the academy’s perspective, we have been approaching this the last few years of kind of getting out of this replacement mind-set of how do we replace X with Y and really looking at like a supplemental, you know, how do we supplement everything that’s out there. I mean, physicians are not — primary care physicians are not positioned to do this on their own in most delivery systems. I mean, there’s going to have to be a team and vice versa.

And so I think the transformation is taking hold. But to your earlier point, you know, there are ever regulations that prohibit teams from functioning at the highest level possible because of Stark and other regulations that tend to, you know, get in the way of —

MR. CARNEY: Sorry. What is Stark?

MR. MARTIN: So the Stark laws are, you know, largely self-referral laws and the types of services that individual providers can provide to their patient population, you know, inside a contained unit. So, you know, pharmacy typically was how it played out in the ’80s. Physicians could not longer, you know, own pharmacies and prescribe and dispense, some things like that, even though that’s starting to change a little bit. But, anyway, that’s another probably lecture.

MR. CARNEY: All right. Cindy, how would you address this question of what ought to be or any of the points that Shawn made? What ought to be sort of the proper role, division among doctors, nurse practitioners, other practitioners?

CINDY COOKE: Okay. Well, I too thank you for inviting me. And I really think that this is a very important and very timely topic because it’s a real key issue I believe holding our country back from better health, better access, better cost, and better value. And I would focus on today’s licensure laws as around the scope of practice because, in my view, they really haven’t kept pace with the education and expertise of everyone at the table. And so — because we each have different expertise and knowledge to bring to the patient.

You know, I would say that there’s a cost factor in the states that do not have what we call at the AANP full practice authority. There’s a cost with collaborative agreements or supervisory agreements that actually drive up the cost of health care. And so I think that in far too many states —

MR. CARNEY: So just, again, some people in this crowd swing in this issue and some people in this crowd are coming to be enlightened. So the collaborative and supervisory, just briefly explain this.

MS. COOKE: Well, 22 states and the District of Columbia actually enjoy what we call full-practice authority, which is the ability to assess, diagnose, prescribe, and really take care of the patient under the board of nursing. The other states require either a collaborative or a supervisory relationship with a physician in order to provide that care. In many instances, nurse practitioners are paying physicians a great sum of money in order to provide that collaborative or supervisory piece of paper.

I would purport that — and I actually live in a collaborative state. I can give you a personal example. I have a collaborative agreement with my husband, who is a family physician and a member of AAFP and a fellow, so I actually know this very well. I also have a DC license. I was working in a federal facility, and so I just had to have a license from somewhere.

But when my husband decided to retire — and this happens across our nation every day — he went to the Board of Medicine website; I went to our Board of Nursing website in Alabama. We terminated our collaborative agreement. Within seconds, I receive an email from the Board of Nursing saying I was no longer licensed to practice as a nurse practitioner in the state of Alabama.

Nothing about me had changed. My education had not changed. My expertise had not changed. I was still able to provide that same care. If I had not been in a federal facility and with a license in a full-practice state, my patients will have all of a sudden been cut off from care that they were receiving. And in the civilian community, this happens every day, whether a physician in a collaborative or supervisory state — you know, physicians retire. They get ill, and they have to step away from practice. They pass away.

So that is especially burdensome for patients’ access to care in rural and urban areas as well. Both are underserved. So I think that — what we know is there are not enough clinicians around to — but there’s plenty of patients.

MR. CARNEY: Isn’t it — so tell me if I’m summing this up right. A lot of the collaborative or supervisory rules basically mean a doctor has to be involved, whether you’re saying the nurse practitioner has to work for a doctor or work with a doctor, considering that doctors have by definition more training. That seems on its face like a very reasonable thing to say, “OK, we’re going to let nurse practitioners do lots of stuff, but there’s got to be a doctor in the house.”

MS. COOKE: Well, I would say no because — and I’ve discussed this with my colleagues at the American College of Physicians just recently. We all collaborate with other clinicians — physicians, nurse practitioners, PAs. We all collaborate with each other — specialists, primary care, dieticians, physical therapy, occupational therapy. We all bring expertise to the table but driven by patient need.

Does a physician like my internal medicine physician, do they have to have a piece of paper requiring them to collaborate when the patient need really drives that? No. The piece of paper does not mean that I’m going to collaborate any more or less. I will always do that when my patient need drives that. I did it every day.

But after the experience that I’ve had, I’ve been able to provide that care in the military setting, in a full-practice authority way in order to take the honor to serve the men and women in our military, our retirees, and their families.

MR. CARNEY: So one last question. When you say full practice, explain what you still couldn’t do that, say, a doctor could do?

MS. COOKE: A physician?

MR. CARNEY: Yes.

MS. COOKE: Okay. Well, because there’s lots of us who have doctorates. I have one, too, so, you know —

MR. CARNEY: Even lots of the economists in this building have doctorates.

MS. COOKE: Exactly. And we’re all doctor something. So, you know, we all — that’s an educational title. So, in clarity, our physician colleagues.

MR. CARNEY: Yes. Physician. Thank you.

MS. COOKE: Who I obviously love dearly. So it’s really important to note — I have lost your question.

MR. CARNEY: So what can’t you do that a physician can do?

MS. COOKE: Okay. There are some things even in areas of full-practice authority states, at the federal level that really do inhibit our care, such as ordering home health. They have to have a physician face-to-face visit in order to have home health ordered. I will tell you that nurse practitioners make sure each and every day that the patients that need home health get it.

We make sure we advocate for our patients. If it’s a — patients, when they need home health, do not need it two weeks from now. They need it now. It’s something that can allow people to be released from the hospital sooner or actually keep them out of the hospital and prevent that costly hospitalization. We make sure that that happens.

But, currently, under — OK, I can order home health for any patient until they become Medicare eligible. So our Medicare beneficiaries are not — I am not allowed to do that, and that’s because the Medicare law was written in the’60s when nurse practitioners were basically caring for children. And so that has expanded greatly for nurse practitioners to now care for patients across the life span.

But I am — I cannot write for home health, and that’s a challenge. I cannot write for diabetic shoes, which sounds kind of silly. I can write for their insulin or for any medication that takes care of that, but patients with diabetes have a challenge with their feet. And if I can prevent an ulcer or an infection to prevent any kind of amputation, because once you have an amputation, it gradually increases from there and increases the cost of care.

But, right now, I can’t order diabetic shoes — again, because of these Medicare statutes. Because once the physician writes the prescription for the care of their diabetic shoes, they actually have to assume the care of that diabetes, according to law. If a patient is in a rural area and the physician is two hours away, that is a challenge, and care decreases. The patient should have the choice of where they receive that care.

MR. CARNEY: Shawn, any responses or replies?

MR. MARTIN: Yeah. I would completely agree with all the limitations that exist, and Medicare certainly hasn’t in all instances kept pace with realities in the — I’m going to use the word marketplace, but kind of delivery ecosystem, and I do think there’s limitations on, you know, us realizing true efficiencies across a delivery model because of some of the things that Cindy’s outlined.

And, you know, there’s others. There’s, you know, limitations on who can input into the medical record and who can sign the medical record for the purposes of billing and coding, and all of these things exist. And you know, 55 years’ worth of overlaying regulations become difficult to kind of untangle.

I think the — you know, I don’t — your early question was kind of the idea of a covenant I guess between regulators and the public. You know, I kind of have a mixed feeling on that. And, honestly, I mean, kind of growing up in state government, I think it’s, you know, important for whomever, whether it’s a legislator or a governor, to, you know, have a process to ensure some — or provide some assurances to the public of that state. How they go about that I think is a debate that we’re obviously having here today and will, you know, continue for a while. I don’t think it should be overly restrictive, but I still continue to believe that that covenant needs to exist in some form.

MR. CARNEY: Sure. So if we could get specific, why should a nurse practitioner not be allowed to set up a family practice without the supervision of a physician?

MR. MARTIN: Well, I mean, I wouldn’t argue that they shouldn’t be allowed to necessarily do that. I think they should have minimal — I mean, the state — I think it’s within the rights of the state to determine what is an acceptable amount of educational training, you know, practice experience, etc., that would afford them the ability to do that within any jurisdiction.

And I think what I was saying, Tim, is I think that, you know, ability of the states needs to be retained, and they can define that as they see fit.

MR. CARNEY: No. As a federalism issue, that’s — yeah. That’s a place where I’d agree. And, I mean, I guess I’m going to ask later whether the others do, so now, the state has that right. And they do —

MR. MARTIN: Yeah.

MR. CARNEY: — as Cindy pointed out.

MS. COOKE: Absolutely.

MR. CARNEY: Twenty-two states allow this full practice. So now you’re at the state house and the state legislator says, “You know, why should this nurse practitioner not be allowed to set up basically a family practice without the supervision or collaboration of a physician?”

MR. MARTIN: Well, I’m a big team-based guy so I think collaboration should always be, you know, inherent in our delivery system of the future. I think the episodic base nature of delivery systems from, you know, the ’50s and ’60s forward created a lot of inefficiencies both on, you know, performance or quality, but also on cost. I think it overspends.

So, Tim, I would turn the question back. I would never suggest in a state house that a nurse practitioner not be allowed to set up a practice. What I would say is that, you know, the regulations that allow that to happen, what is the education standard, what is the training standard, what is the continual certification or whatever the appropriate term is standard so that there is a minimum assurance that every individual that does that has met a minimum education and training standard that that state or that individual or that board or whomever it would be, feels is appropriate to provide assurances of competency to the citizens of that state.

MR. CARNEY: Okay. I guess I’ll ask Cindy. If you were to give an example of sort of a rule that exists on a state level or in Medicaid or the VA or whatever that you think is the first one you’d like to shoot down or reform, what would that be?

MS. COOKE: That list is long. I would say that there is one state that has a team- based licensure linking in Virginia. And to me, that’s a real challenge because licensure should not be the basis for — to link your license to a team-based model. Absolutely it takes a team to care for patients these days. And, you know, as a nurse practitioner, I hear across the country nurse practitioners actually are nurses first who go on for further education at the master’s or the doctoral level.

And really a lot of what I hear is that they want to be a nurse practitioner, especially in primary care, to keep patients out of the hospital from these chronic diseases that we have seen grow exponentially over the last few decades. And so what I see is to work together with teams, but not — I don’t think it’s necessary to link your licensure to that team.

MR. CARNEY: So that means a person’s license to practice in states that they can only practice as part of a team.

MS. COOKE: That’s correct. And I don’t think that that licensure linking is necessary. Do I think that we — I mean, I worked in a primary care clinic. I had access to family physicians, internal medicine physicians, pediatricians, a psychologist, a dietician, and it was a very primary-care-centered home.

And we all brought our expertise to every patient every day. Physicians would ask me questions because we all have different areas of expertise. I would ask them questions. It always was a little reassuring to me when I would go to my physician colleague and I would say, “OK. This is what I’ve got, this is where it is,” and they wouldn’t know either.

So none of us know it all. We can’t. And so that’s where it really is important to work together collaboratively and bring our expertise to the table for wherever the patient need is driving us.

MR. MARTIN: I just wanted to add — I meant to say this earlier. So today we have, you know, a family physician and a nurse practitioner up here. You know, from our lens of looking at this issue, there are a lot of people on the health care team, and there are a lot of, you know, organizations, disciplines, and professions that are looking to expand or constrict their, you know, scope of practice, laws, and regulations.

So this is a bigger universe, particularly to the academy. And I know we’ve worked with AANP on some of these too about, you know, how do you approach this across multiple disciplines. And you see some states with pharmacy, you have the naturopaths in some states. But there’s a lot of activity, good and bad, you know, taking place in the states. And it’s a pretty broad issue.

MR. IPPOLITO: Well, I’d like to ask a question, just changing gears slightly. So we’re kind of dancing around this idea of what’s essentially the optimal set of regulations for a given state to implement.

One of the things that I think about when I think about these kind of questions is, OK, you need to be able to measure something, right? When you go to a state house and you want to sell this, you know, we want to expand scope of practice, tighten scope of practice, whatever it may be, there’s some sort of outcome that you’ve got to sell, all right? And it’s not inherently obvious to me what the most important outcome is. And this is my question for you.

And so I ask this because — you know, I sort of tease that, you know, scope of practice gets brought up a lot because of costs. It’s this idea that we can really put some competitive pressure on payments to providers. That’s probably true. I think a fair reading of the literature would say that states that expand scope of practice have modestly lower price for things like well family visits or well child visits.

But — so I have a Ph.D. in economics, and you have to — in order to get the total spending, you do price times quantity, and the problem is the price may go down, the quantity may go up, right, so we have better access, which is kind of a nice way of saying utilization goes up. And so — (inaudible) — get it’s not necessarily true that cost is going to be lower on net.

And so that’s the kind of question I could imagine somebody in a state house asking, “You know, geez, what are we doing to get out of this?” And so I’m curious, for both of you, when you’re in that kind of environment, what are the outcomes you think about? What do you think are the most important? If you could kind of prioritize things, you know, kind of take that wherever you like.

MS. COOKE: Well, we always look at outcomes, and the outcomes are multifaceted. South Dakota recently passed legislation to become the 22nd state to have full-practice authority. And in their state regulatory overhead alone, they estimated the savings to the state could be greater than $70,000 just in regulatory cost. So in state cost for regulations for that collaborative or supervisory agreement, that could be a regulatory savings every year at the state level.

I would purport that, yes, your utilization may go up if you have increased access to care, which it should, but it also in my mind, as a primary care provider, to actually improve the health of that patient and actually decrease cost. It’s very hard when you have healthy behaviors focused to put a cost to that.

But if I can keep a patient from having diabetes or a patient with diabetes, if I can help keep that well controlled so that it decreases their cardiovascular risk, it decreases their risk of amputation, it decreases their risk of diabetic retinopathy or blindness or kidney disease and decreases the cost of dialysis — thank you, Andrew — that’s where the cost really can be seen over time. It’s hard to really enumerate that value in a concrete way. But we really can see the outcomes when we have that. And nurse practitioner, we watch our outcomes very, very closely, and our outcomes are very comparable to our physician colleagues.

MR. CARNEY: Shawn, do you have an answer for what measures you look for?

MR. MARTIN: Yeah. So I think there’s a couple of things. I like the quantity utilization argument. I think, you know, the Dartmouth team and Elliott Fisher used this back, you know, a few years ago kind of in a physician-to-physician comparison that the vacuum will be filled. If you have 100 physicians, they will maximize their services, you know, in any given market regardless of quantity or competition. So I think that’s an interesting dynamic.

The regulatory cost, you know, extends beyond licensure and certification. I mean, there’s, you know, a large amount of regulatory cost at primary care simply for participation in programs, whether that be private payers, Medicare, Medicaid, etc. So I would echo that, you know, maybe some of these regulatory costs, you know, need to be lower.

You know, a measurable outcome for me at the state level I think are twofold. One, you know, is are we demonstrably reducing, you know, the time period between seeking services and receiving services in any given field? You know, our field is primary care. So, you know, will this law or regulation decrease the amount of time between a patient seeking and receiving care in a desired setting so not the emergency room?

And then the second thing is are we appropriately, you know, providing appropriate services to the patient in an appropriate manner. So, to your point, I mean, you know, are we just driving utilization of services or are we actually addressing the needs of the individual with the resources that we’re making available, whatever those may be.

I think the third thing, which Cindy pointed to, you know, primary care, we all face the same challenges, which is it’s hard to — it’s not a knee replacement. You know, we don’t have infection rates. We don’t have, you know, mobilization post-surgery. Our evaluations are longitudinal. And the intensity of disease or slowing the progression of disease is really difficult to measure. And I think we all have that in common.

And, you know, those are things that, you know, when you go to legislatures or regulators and talk about the slowing of the progression of disease in any particular population of patients, you know, they’re lost at that sense. So that’s a difficult thing for all of us.

MS. COOKE: Absolutely.

MR. CARNEY: Again, if there’s any questions from the audience — yeah. We’ll take one now. Sorry, there’s a microphone that’s coming your way, and it will be there in one sec.

Q: My name is Peter Levin, and I was the friend of the year or something for the nurse practitioners a few years ago in Washington. I don’t know what I was. They gave me a certificate.

MS. COOKE: You were the nurse practitioner advocate.

Q: Advocate.

MS. COOKE: Yes.

Q: And I have lived — I’m old enough to have lived when the first family practice programs got started in medical schools where I were and what was — and the reaction. And I also followed — I wish I could remember what it is, but the nurse practitioners put out a thing every year, and you could see how their privileges have increased and their licensure has become independent across state by state in the country.

And it’s inevitable — it originally had to do with, first of all, physician supervision and, second of all, prescribing drugs of different levels. And that will move inevitably. There’s no question about that. It’s a delight to see someone from the family practice group and the NP group up here working — there’s a time where they wouldn’t have been happy with each other. But that’s over.

There’s not going to be great savings. A visit is going to cost a visit. Our health insurance system is so screwed up that that’s where the costs, in all due respect to all the AEI economists, that’s where it has to be reformed if we’re going to have any lower cost.

MR. CARNEY: So, I mean, I guess I’d like some — because that’s a big claim, right, that there’s not going to be —

Q: It’s a big issue.

MR. CARNEY: — that there’s — that expanding the number of people who can provide service X wouldn’t drive — you’re expanding the supply of X, I do not have a doctorate. Dr. Ippolito I think would confirm that, in general, expanding the supply of something would reduce the price. And I’m this close to my own doctorate.

MR. IPPOLITO: No. It’s a good question. It’s a good point. So there’s a difference between the price for a given visit, you know, which might be modestly lower and then the increased access. There’s literally more people who can provide things. And so those two things do offset each other to some extent.

You bring up the insurance issue, which I think is actually kind of interesting to think about. I don’t think it’s necessarily where we’ve seen a lot of action, but if we think about — one of the lessons of the ACA exchanges has been insurers have really had to get really aggressive about trying to control costs.

Well, there’s all sorts of ways to control cost. And one might even think about, if there’s a subset of providers out there that charges considerably less than another set of providers, you can almost imagine an insurance network that was more focused on those kind of providers. In fact, Kaiser Permanente in some sense is like that. You have to go — many people — you know, it takes forever to get past an NP or a physicians assistant.

So I wouldn’t say this is totally divorced from the insurance question. In a sense, actually there are some ways in which those two things get interplayed. It potentially gets some of these gains that I think you’re probably alluding to.

Q: What I really was — is that we’re moving a certain way. Nurse practitioners are coming out of programs. I wish that there were more family practitioners coming out just to replace on the front line. But the economics of our system are such that it does not encourage family practice. If you can make, you know, $400,000 a year being a radiologist, it’s awfully hard to run your office.

The other thing I can say having tried to start a nurse practitioner primary care thing, it costs an enormous amount of money. That’s where there’s tremendous regulation. Everywhere — how you get rid of infected supplies, the licensure for this, the licensure for your lab. I mean, all physicians have this, and all practitioners do this, but it really costs a lot of money to start up a practice. It’s not just using the extra room in the house.

MR. MARTIN: I think this is a good point. One kind of word of caution for your — you know, I think we’re witnessing transitions away from traditional fee-for-service or episodic based-payment models towards more global models, you know, are starting to demonstrate the ability to decrease trend on spending. You know, they’re not always lowering it in the first year, but you’re starting to see some meaningful reduction in the trend of spending over a population of patients.

And I almost completely forgot my other points. I’m sorry about that. And it was the best point of the day, too. (Laughter.)

MR. CARNEY: Nick, grab the mic. And we’ve got a question in the back.

Q: Hi. Andrea Vassar from AARP, and I nominated Peter Levin for the DC Nurse Practitioner Advocate Award when I was president of the Nurse Practitioner Association in DC.

But I’d like to expand this to other advanced practice registered nurses. And particularly I’m thinking today of certified nurse midwives. They have such excellent research showing there are lower rates of C-sections and, for the women in the room, lower rates of episiotomies. Huge cost savings. But in Cindy’s state, in Alabama, they are so restricted. There’s only 35 certified nurse midwives —

MS. COOKE: In the entire state.

Q: — in the entire state. So that’s just some of the ridiculous regulations.

MS. COOKE: And women in Alabama are — there are so few providers of any prenatal or women’s health care, OB care, that women are driving two to three counties away to receive this care, which is a real challenge when you’re in labor. Having been there, I cannot even dream that. But, you know, it is a challenge for all APRNs, you’re correct. It’s a challenge.

MR. CARNEY: For some reason, episiotomies come up at every panel I host here. I don’t understand why that is.

MS. COOKE: I did not bring that up.

MR. CARNEY: So I’ll ask you, Shawn, I mean, given that there are a lot of these places where there is a shortage of providers, doesn’t that call for a new — you were referring to federalism earlier, lots of cases where we ought to do what we can to make sure that there aren’t these regulatory barriers to nurse practitioners or other providers providing what they can? Shouldn’t that be a priority of state legislatures to say, all right, we’re going to make sure that these barriers aren’t any higher than they ought to be? And the corollary question to that would be: Are they in some states — are the regulatory barriers to practice by nurse practitioners higher than they ought to be? And can you think of any cases where you’d agree?

MR. MARTIN: So I’m going to say yes to the latter part of your question. I think clearly the ability for qualified health care professionals to enter the marketplace whether — whatever that means, you know, probably deserves analysis and reform. I don’t think there’s any doubt about that. I think the debate is, you know, what does that process look like. And there’s, you know, some models that we’ve talked about and promoted.

So your first question, the first part of your question — obviously the answer to that is yes. State legislatures, you know, in general should take very seriously their obligation to, you know, ensure appropriate access to health care for their citizens and, you know, identify policies that, you know, promulgate the distribution of health care professionals of all types in all communities. I think this is where the challenge comes.

And I’ll say it with a smile so we don’t get heated, but even in states that have had the most experience with various expansions of scope of practice or open practice laws, you know, their post-evaluation has not resulted in reductions of things like HPSAs, you know, demonstrable increases in access to care for vulnerable populations, whether that be rural or urban, because health care providers of all types — physicians are guilty of this — they cluster. So they all cluster to each other.

And so, you know, when we think about how do we get Cindy and her husband, you know, to go somewhere different, the laws and regulations for a nurse practitioner and physician are the same. I mean, the motivations to get them to go somewhere different — I don’t know if you’re in Birmingham or not, but I need it for my story here.

MS. COOKE: I’m sorry. We’re in Huntsville. Yeah.

MR. MARTIN: Huntsville. So, you know, how do we get a nurse practitioner or a certified nurse midwife or a physician or an obstetrician to leave that clustering mentality and go out and provide services? And, you know, this is where the experimentation has taken place.

But I think — I cringe a little bit about, you know, we’re going to do X, and then all these people are going to go out in these rural counties because, you know, history and statistics just demonstrate that, yes, that’s happened a little bit, but not to the rate that it’s really going to solve rural and urban access problems.

MS. COOKE: It does take time to get — and I think that educating both physicians and nurse practitioners and PAs that come from rural communities that want to go back to their rural community is key. But in those states that have those restrictions, it becomes a true challenge.

But I can say that in Arizona, in the five years after they adopted full-practice authority, they actually saw an increase of nurse practitioners coming to that state and being licensed there of over 50 percent. And actually, the counties — when our rural classified counties actually saw the largest increase, with more than 70 percent of those rural counties seeing more nurse practitioners in practice, so it can happen.

But, yes. You know, physicians are — and nurse practitioners are very similar I think, because we’re people, and we find that where we train, we become comfortable, and we’d like to stay there.

But really it is imperative for us to make those attractive in rural communities and have support for those providers no matter what their area of expertise is. You know, it is harder for our rural clinicians to get access to specialty care. You know, I talked to my colleagues in Alaska, and it’s a plane ride away. It’s not just a two-hour drive. You know, you have to get on a plane to get somewhere.

So, you know, it’s imperative for us to look at those models and to really strategize and work together to solve that problem, not do this in siloes, OK? We’ve got all the answers here, and we’ve got all the answers here, and never the twain shall meet. That’s really not solving the problem.

MR. CARNEY: All right. Another quick question to follow up on that one. Why would it be that nurse midwives would have, you know, a better record, so to speak, than doctors?

MS. COOKE: You mean obstetricians?

MR. CARNEY: Obstetricians. Yeah, on C-sections and episiotomies. And is there a trade-off in some way where there is other ways in which their record looks worse?

MS. COOKE: Nurse midwives are trained in a different way in a different model. And we really advocate for patients and being patient with that.

I mean, my own personal story is — now, I was delivered by a family physician who was very patient with me. I had a prolonged labor. But, you know, I delivered in the normal vaginal way, so that’s very much what nurse midwives do. They also advocate if the baby is in trouble, they’re going to be the first one to see it and actually get them to the people that need it and to make sure that that is what comes out of that.

But I think that the way that we are trained, babies don’t come on a schedule. They’re not delivered 9:00 a.m. to 5:00 p.m. It really is a patient waiting game, and I think that that’s where that model of care is where that is driving.

MR. CARNEY: Do you have any comments, Dr. Ippolito?

MR. IPPOLITO: On the obstetricians? (Laughter.)

MR. CARNEY: All right. Moving on.

MR. IPPOLITO: No. I mean, you should ask a question. But I mean one thing to scale this up a little bit is some of the things you do in the research on this stuff is there’s an issue in health care. Obviously, over time, you really come to really value the volume as a metric of quality, and so people who have a relatively narrow scope of what they’re doing, they do the same thing a lot, actually do tend to do things a little bit better, at least for a number of procedures and such. And so there’s at least some plausible evidence that in some cases that is relevant.

MR. MARTIN: And do you see like a selection bias? So, I mean, obviously, obstetricians are going to do more surgical-type procedures, so I mean, patients prefer a midwife.

MR. IPPOLITO: Yeah. For sure.

MS. COOKE: Absolutely.

MR. IPPOLITO: So it’s a split. It’s a combination of how much — how many things are you doing versus how — (inaudible) — but anyway.

MR. CARNEY: All right. Sir, right there with the red tie. Microphone is coming.

Q: Thanks. I’ll just make a quick comment about the OB/midwife issue that in the last several years — I don’t know if it’s exactly three, five, seven — Medicaid has changed how they pay, and they stopped paying for early elective deliveries. And the number of C-sections have dropped, so that data may be changing. It may also be, as Shawn said, a selection bias. But, as Shawn said, they do have an incentive too.

My question gets back to — you guys have gone into the rural hole a little bit here. I want to expand that a little bit. And what Shawn had mentioned about, you know, team- based care — I wonder if you guys could talk about the concept of differential regulations to encourage different things to happen in rural areas because access is less and whether that involves greater scope of practice in a rural area, less regulations for setting up independent practice, greater use of telemedicine for consultation. You brought up the diabetes — you know, a home health or a social worker at the home use telemedicine to consult back to the clinician, whether it’s a nurse practitioner, physician, endocrinologist, and say, “Hey, this person’s foot’s messed up. They need a diabetic boot. They need to come in to see somebody.” You know, those kinds of things. So the differential regulations for rural areas and greater use of telemedicine. Thank you.

MR. CARNEY: Shawn? Cindy?

MR. MARTIN: Big question. You know, I have to start my rural comments with I grew up just past nowhere in northwest Oklahoma, so when you got to the edge of town, you just drove a little further.

So I think rural communities are challenged. Some of them are, you know, an emotional stickiness that the rural community thinks they need a physician or provider there every single day of the week. And the realities are that the economic model just doesn’t exist to support that. So now you’re into kind of what you’re talking about of portable, you know, services either coming in in person or via technology.

I think team-based models make that, you know, more available because you can — you know, we study a lot of medical home or advanced primary care models where the members of the team rotate through rural communities either digitally or in person. So they’re able to have kind of a satellite spoke-and-hub type system.

The home health thing is where I think there’s a lot of promise because when you look at cost, to Ben’s point, I mean, you know, just limiting the migration of a patient in need from wherever they are to an emergency room is just an incredible amount of savings to the health care system, especially in a rural community because now you’re talking about ambulance rides or stops in critical access hospitals and transitions then to larger tertiary care centers. So I see telemedicine as a really big, important tool to accomplishing some of those goals.

So we just did a big telemedicine survey of our members at the academy. About 70 percent of them want to use it, and about 20 percent of them do. I don’t really understand — that is a huge delta, huge delta. So I haven’t dug into all the numbers.

So it says two things to me. One, either the regulatory structure of deploying that in my practice is so restrictive I can’t do it, or the cost of technology just isn’t to a point that incentivizes them to put that technology in their practice. The ROI is not there yet.

I mean, look, the first iPhones were $1,000. So that day is coming where I think you’ll see a greater utilization of telemedicine in a meaningful way to extend services beyond, you know, kind of the four walls of the practice, personally. That’s not an official academy position whatsoever.

MS. COOKE: We refer to it as telehealth because it’s not just medicine. Psychologists use it all the time. Our mental health colleagues are really exploring ways that people who don’t have access to mental health or social work can actually access it.

So telehealth is to me a broader umbrella. Our colleagues in Alaska — and I’ll bring them up again — say that they’ve been using that for decades with ham radios, and now that we have so many tools, it’s now being regulated. So it’s a real challenge to us. And I think that that is really a very amazing tool because now people with their own iPhones can have, you know, places that a clinician can look in their ears or get an EKG or actually listen to their chest for their heart and lung sounds.

So I think the growth of that will be fun to watch and see how we do it. The regulation of it to me is one more layer of your bureaucracy that we do it, but obviously, there needs to be a payment for how we get paid for that because it is time and it is expertise that needs to be reimbursed. So I think that we will see this as we go on, how that moves along.

I think for our rural communities just past nowhere, and there are many in this nation, there’s not a state in this nation, even the smallest ones, who don’t have a large amount of rural area. And so we need to make sure that those are well served. But I would also purport that in our urban areas, there are vast areas of a challenge in access to care.

MR. CARNEY: Yes, up front here.

Q: Thank you. Hi. I’m Jane Koppelman with the Pew Charitable Trust. And we actually are doing a lot of research and advocacy around a mid-level dental professional, so I can appreciate this discussion. We’re trying to promote dental therapy across the states, which is a provider that can drill and fill and do simple extractions.

I have a question to the nurse practitioner physician assistant representatives about your view on a legal strategy for addressing regulations that can be proven to not protect patient safety and drive up the cost of care. To what extent would seeking, you know, a legal strategy to legally challenge those regulations be effective in your view? I’m just trying to figure why it hasn’t been done more. Thank you.

MR. : The dentists will fight you to the death.

Q: No kidding.

MS. COOKE: The first thing I want to say is I would always hesitate to use the word “mid-level.” I don’t provide mid-level care. There’s not a high level. Does that make the RN a low level? No. We all bring our expertise to the table. We all are held to the same standards of care.

Q: Maybe we’ll call them dental disruptors.

MS. COOKE: Whatever, but you know, and people say, you know, what do we call you? Call NP or NPA. I mean, and physicians. We all have — bring something to the table.

MR. CARNEY: But isn’t it true that you have — that a nurse, a registered nurse has less training than a physician, than an MD, and a nurse practitioner doesn’t have — I don’t know if you have the same number of years, but certainly not the same sort of training as an MD. So can’t we use a sort of —

MS. COOKE: It’s not a hierarchy because I will say that the RNs keep our patients alive in the hospital for the 23 hours and 55 minutes that physicians and NPs and PAs are not there. So we all have our level of expertise. We are all held to a standard of care. We bring that level of care to the patient. And so I don’t think we need to make it a hierarchy.

Q: So what do you think about the legal strategy — (off mic)? The legal strategy of how do we eliminate those barriers?

Q: Yes. In other words, I mean, I know the Federal Trade Commission has — (off mic).

MR. CARNEY: Yeah. Can we get rid of them by suing?

Q: Exactly. There are standards — you know, there is a legal framework for establishing whether a scope of practice regulation is in fact necessary and defensible.

MS. COOKE: The Federal Trade Commission has weighed in a number of states on just this issue, both for PAs and nurse practitioners. It takes a lot of money, and that’s the key.

MR. CARNEY: And the Federal Trade Commission — just to sum it up, the Federal Trade Commission has said some of these regulations are not really necessary or even functioning to protect patient health but are in fact anticompetitive. Do you think that — do you, Shawn, think there are anticompetitive regulations on the books?

MR. MARTIN: Well, I’m going to answer no. So, you know, are the compositions of some of the regulatory boards currently situated to insinuate or support that they’re anticompetitive in their decisions? That’s a different question. But I would punt that back to state legislatures, not to the courts.

I mean, I think if state legislatures think that their responsibility to the citizens of that state is being limited by the composition of any board granting anything, whether it’s law or medicine or nursing or et cetera, then they should, you know, take corrective actions to prevent anticompetitive actions. But I don’t think the elimination of a process, however that’s defined in any given state, should be eliminated.

So, I mean, I would resist — you know, and this is the same thing we told the FTC — I would resist legal challenges because I think there is an important role of nursing boards and medical boards and pharmacy boards, et cetera.

MR. CARNEY: And so there’s a lot of background — I’m sure you know this better than I do, but there are lawsuits that in other fields have to do with occupational licensing, with these sort of regulations that are found to be sort of — you know, not necessary for protecting consumers and basically function as anticompetitive.

The Institute for Justice is a whole nonprofit law firm dedicated to suing on behalf of, like I said, the florists or the hair braiders, and they have had success basically making substantive due process arguments is how I would characterize it. I’m not a lawyer. Do I have to say that and disclose? (Laughter.) I don’t know what the regulatory things are.

But so this is a very live question, and it’s something that courts obviously disagree on, whether they’re — to what extent do the states have sort of plenary power to regulate if they can offer a reasonable, plausible patient-protection argument or a customer-protection argument. And, in some of these cases, the state governments are losing and, you know, the people like the Institute for Justice are winning, but it’s a mixed board.

One more question. We’ll just go right behind to save time.

Q: Yeah. I’m Carl Poser (sp). I do a lot of work on long-term care policy. So one area we could really use this would be the elderly. You know, there’s a great need for diagnosis, and Medicare pays a lot for procedures, though, and not for diagnoses. So this would be an unlikely area where a cluster would rush in.

But, I mean, I think the worry for Medicaid would be would you see — if there were reimbursement, if you had nurse practitioners being able to practice, would you see a complementary effect instead of a substitution effect, like you see probably with — in other words, just with mental health. You used to have a psychiatrist that talked to the patients. Now you have a talk therapist, a psychiatrist, and a drug producer, and they’re all getting paid, and they don’t talk to each other.

MR. CARNEY: And you’re saying that’s a worry because we’re not driving down cost, expenditure.

Q: It’s just an opportunity for the ecosystem to expand. The other thing is with long-term care, you have hospital, you know, playing ping-pong with the therapy people, and they have to have the 30-day — you know, all that stuff. So I can see the worry there. But, I mean, I think we could use them.

MS. COOKE: Well, actually, nurse practitioners do take care of Medicare patients each and every day. We actually are very passionate about our care of our — soon-to-be my — population of Medicare patients. So it is absolutely something that we are passionate about both as family nurse practitioners. We also have adult gerontology nurse practitioners who care for that population and are dedicated to that.

Absolutely to be important, especially on the front lines, whether it’s in the primary care or in long-term care, to make sure that that patient’s multiple needs are coordinated and taken care of because absolutely we want to keep them out of the hospital not just for cost effectiveness, but for so many reasons — cognitive things, psychological things. Patients especially, you know, who are very elderly — like my father does not do well when he’s in the hospital. And so we want to make sure that we keep them out of the hospital as much as we can. Long-term care is key, absolutely.

MR. MARTIN: I would echo — this doesn’t have anything to do with the pure subject, but I think these — you know, the more we study transitions of care in and the negative impact they have particularly on frail elderly, you know, it’s astonishing. I mean, just transferring them in between facilities is really detrimental to them, delirium and other types of things. So I completely agree that anything we can do to reduce transitions of care is good for the patient.

MR. CARNEY: Ben, any final comments?

MR. IPPOLITO: I was going to say, a natural complement to that of course is the payment model. I mean, you can structure a payment model such that if you keep adding providers onto a state, you’re not getting more money. And so you can kind of complement this with relatively low-cost providers in a payment system that makes sense combating the problem that you bring up, which is quite real.

MR. CARNEY: All right. It’s 1:00 p.m. We do have to wrap up, but I definitely want to thank our panelists for taking the time and coming here. Thank you all for attending.

MS. COOKE: Thank you. (Applause.)

(END)