Advance Practice Providers Ordering Home Care

Senator Collins (R-ME) and Senator Conrad (D-ND) introduced senate bill 2814 on November 20, 2009. This bill would allow for advance practice providers other than physician to order and monitor home care services for patients. Despite several State laws that already allow this, it is not allowed by the Federal Government so it is prohibited under federal reimbursed payment systems such as Medicare and Medicaid.

This legislation is way overdue. Not clear is if it will allow for these advance practice providers to bill for Care Plan Oversight. This should be allowed due to the regulatory requirements for reviewing and communicating with the home health agency.

The legislation is currently assigned to the Senate Finance committee for review. This is Sen. Collins statement from the Senate floor in November.

“Mr. President, I rise today on behalf of myself and Senator Conrad to introduce legislation to ensure that our seniors and disabled citizens have timely access to home health services under the Medicare program.

Nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists are all playing increasingly important roles in the delivery of health care services, particularly in rural and medically underserved areas of our country where physicians may be in scarce supply. In recognition of their growing role, Congress, in 1997, authorized Medicare to begin paying for physician services provided by these health professionals as long as those services are within their scope of practice under state law.

Despite their expanded role, these advanced practice registered nurses and physician assistants are currently unable to order home health services for their Medicare patients. Under current law, only physicians are allowed to certify or initiate home health care for Medicare patients, even though they may not be as familiar with the patient's case as the non-physician provider. In fact, in many cases, the certifying physician may not even have a relationship with the patient and must rely upon the input of the nurse practitioner, physician assistant, clinical nurse specialist or certified nurse midwife to order the medically necessary home health care. At best, this requirement adds more paperwork and a number of unnecessary steps to the process before home health care can be provided. At worst, it can lead to needless delays in getting Medicare patients the home health care they need simply because a physician is not readily available to sign the form.

The inability of advanced practice registered nurses and physician assistants to order home health care is particularly burdensome for Medicare beneficiaries in medically underserved areas, where these providers may be the only health care professionals available. For example, needed home health care was delayed by more than a week for a Medicare patient in Nevada because the physician assistant was the only health care professional serving the patient's small town, and the supervising physician was located 60 miles away.

A nurse practitioner told me about another case in which her collaborating physician had just lost her father and was not available. As a consequence, the patient experienced a two-day delay in getting needed care while they waited to get the paperwork signed by another physician. Another nurse practitioner pointed out that it is ridiculous that she can order physical and occupational therapy in a subacute facility but cannot order home health care. One of her patients had to wait 11 days after being discharged before his physical and occupational therapy could continue simply because the home health agency had difficulty finding a physician to certify the continuation of the same therapy that the nurse practitioner had been able to authorize when the patient was in the facility.

The Home Health Care Planning Improvement Act will help to ensure that our Medicare beneficiaries get the home health care that they need when they need it by allowing physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives to order home health services. Our legislation is supported by the National Association for Home Care and Hospice, the American Nurses Association, the American Academy of Physician Assistants, the American College of Nurse Practitioners, the American College of Nurse Midwives, the American Academy of Nurse Practitioners, and the Visiting Nurse Associations of America. I urge all of my colleagues to join us as cosponsors of this important legislation.”