Financing and Health Care Policy and the role of the NP
SECTION A (1.5pages minimum)
Reimbursement for NP Services
Reimbursement processes and rates for services provided by NPs vary between funding sources.
Differentiate between public, private and managed health care plans. Research the application
process for NPs to join the panels for reimbursement and the rates of reimbursement for services
provided by NPs. Share with your colleagues which panel(s) you researched and what you
learned.
Include a reference list at the end of this section 4 minimum.
SECTION B (1.5 pages minimum)
Healthcare Reform and the NP
Health care reform has prompted numerous debates in regard to reimbursements for providers,
such as NPs, Physician Assistants (PAs) and MDs. What are the arguments, data, and rationale
used by proponents and opponents of healthcare reform? What is your perspective on the
implications of healthcare reform in regard to the role of the NP?
Also, in less than 300 words assess how regulatory, legal, and legislative issues impact advanced
practice nurses and discuss how this plays into healthcare reform.
SECTION A: Reimbursement for NP Services
Reimbursements for the services provided by nurse practitioners (NP) constitute a significant
part of the health care programs offered in the United States of America and there are
considerable variations in the extent of reimbursement rates according to the processes adopted
as well as between funding sources (Safriet, 1992). For example, there a various public, private
and managed health care plans in the US and there are relative variations between them on basis
FINANCING AND HEALTH CARE POLICY 2
of the reimbursement rates as well as adopted reimbursement process. In particular, the major
health care plans include Medicare, Medicaid as well as commercial indemnity insurers, health
maintenance organizations and/or commercial managed care organizations (MCOs) and finally
schools or businesses that want provision of health services for their student or employees
respectively. Each of the above mentioned health care plans have varied rules and regulations on
reimbursement process and rates for the services provided by NPs (Safriet, 1992).
The particular differences that exist between the above mentioned health care programs are in
form of management, ownership as well as reimbursement rates as well as reimbursement
process. For example, both Medicare and Medicaid health care programs are managed by the
government to provide health insurance services to its citizens who meet threshold requirements
for inclusion (Stanley, 2010). All the latter health care programs are privately managed or
managed by non profit making organizations. Moreover, these health care programs are
differently owned where both Medicare and Medicaid are owned by the government while the
rest health care programs are either privately managed or managed by non profit making
organizations.
Furthermore, in order for the NPs to join the panels for reimbursement the application process
also vary considerably as well as the reimbursement rates for the health care services that the
NPs provide (Stanley, 2010). In particular, the for an NP to join the Medicare reimbursement
panel, the must be holders of state licenses as an NP while at the same time an holder of a
certification as an NP by a nationally recognized certifying professional body. Some of the
nationally recognized professional bodies for certifying NPs include National Certification
Corporation, Americans Nurses Crediting Center, Critical Care Certification Corporation, as well
FINANCING AND HEALTH CARE POLICY 3
as American Academy of Nurse Practitioners (Stanley, 2010). Moreover, since January 1, 2003
individuals who intend to apply for Medicare reimbursement panel must also be in possession of
a master’s degree from a recognized institution of higher learning. Upon meeting the above
mentioned requirements an individual NP can apply to join Medicare reimbursement panel
(HealthCare.gov).
According to Medicare the reimbursement rates to the services provided by NPs, the NPs are
paid 80 per cent of the 85 per cent of the rate of physicians Fee Schedule for any medical
procedure where an NP participates since in Medicare an NP must always offer his/her services
in conjunction with a physician to qualify for reimbursement (Medicare & Medicaid Services).
References
American College of Nurse Practitioners, Retrieved from:
http://www.discovernursing.com/about-us
Centers for Medicare & Medicaid Services, Retrieved from: http://www.cms.gov/
HealthCare.gov, Retrieved from: https://www.healthcare.gov/
FINANCING AND HEALTH CARE POLICY 4
Safriet, B.J., (1992). Health care dollars and regulatory sense: The role of advanced practice
nursing. Yale Journal of Regulation, 9(2), 417-488.
Stanley, J.M. (2010). Advanced Practice Nursing: Emphasizing Common Roles, (3 rd ed.). New
York, NY: F.A. Davis Company.
FINANCING AND HEALTH CARE POLICY 5
SECTION B: Healthcare Reform and the NP
Reimbursements for health care providers such as NPs, MDs and Physician Assistants (PA) have
prompted numerous debates with regards to health care reform. For instance, over the last two
decades key issues that have influence health care system in the United States and in particular
with regards to reimbursement for the services provided by health care providers. The key
debates have revolved around improvements of health care access while containing the costs and
maintaining quality for the health care services. However, the direction of this debate has always
been changing in direction on basis of newly upcoming issues (Griner, 1995). For example, the
rapid increases of health care costs in the 1980s together with global recessions of the early
1990s brought another new issue regarding to making sure that security of health care benefits
that accrue from the health care programs are sustained. Based on this premise, the main debate
with regards to reimbursements has not only revolved around the rates or process, but around the
cost of health care services access (Stanley, 2010).
The arguments by proponents have been that the cost of health care access should be maintained
as low as possible even if it means reducing the reimbursements rates, but on basis of a
stringently controlled procedure. This includes devising a procedure through which NPs, MDs
and Physician Assistants (PA) reimbursement rates could be maintained as affordable as possible
in order to make them easily accessible while ensuring quality is not compromised (Stanley,
2010). Since a considerable number reimbursements are done by public health care programs
such as Medicare and Medicaid, proponent of reduction in reimbursement rates argue that this
would reduce the amount of money the government uses on this programs meaning that if the
FINANCING AND HEALTH CARE POLICY 6
same budget is maintained the more people would access quality health care affordably courtesy
of these public health care programs. On the other hand, the opponents of this debate argue that it
would not only compromise with the quality of health care services but also it will significantly
reduce the motivation of health care providers such as NPs, MDs and Physician Assistants (PA)
as a result of low reimbursement rates (Stanley, 2010). My perspective on the implications of
healthcare reform in regard to the role of the NP is that the same reimbursement rates should be
maintained, but the government should increase budgetary allocations for these programs to
ensure wider access (Stanley, 2010).
Regulatory, legal, and legislative issues have the potential o significantly impact advanced
practice nurses into healthcare reform (Safriet, 1992). For instance, regulatory issues help to
ensure that the threshold requirements are met by advanced practice nurses in order to guarantee
quality. Moreover, the legal and legislative issues impact advanced practice nurses by making
sure the necessary laws and rules are formulated to ensure healthcare is stringently controlled
with regards to intended reforms (Stanley, 2010).
FINANCING AND HEALTH CARE POLICY 7
References
American College of Nurse Practitioners
Centers for Medicare & Medicaid Services,
Griner, P.F. (1995). The work force for health: Response. 20/20 Vision: Health in the Twenty-
first Century. Washington, DC: Institute of Medicine, 102-103.
Safriet, B.J., (1992). Health care dollars and regulatory sense: The role of advanced practice
nursing. Yale Journal of Regulation, 9(2), 417-488.
Stanley, J.M. (2010). Advanced Practice Nursing: Emphasizing Common Roles, (3 rd ed.). New
York, NY: F.A. Davis Company.