News for NPs & PAs


Vol. 2 • Issue 2 • Page 10

Front&Center

No Cosignatures Needed for Respiratory Care Orders

The Centers for Medicare and Medicaid Services (CMS) has revised regulatory language to allow physician assistants and nurse practitioners to order inpatient respiratory therapy services for Medicare patients without a physician’s cosignature. The original language was enacted in 1986 and attracted little attention until the Joint Commission revised its policy to align with CMS in July 2009. The new rule became effective Oct. 1.

Previous language required MDs or DOs to order inpatient respiratory therapy. CMS had therefore required a physician cosignature on orders placed by NPs or PAs. The new rule also clarifies requirements for providers ordering rehabilitation services, allowing hospital rehabilitation orders from “qualified, licensed practitioners who are responsible for the care of the patient and who are acting within the scope of practice under state law.”

Michael Powe, vice president of the advocacy and government relations department for the American Academy of Physician Assistants, told ADVANCE that his staff met with Barry Straube, chief medical officer for CMS, in February to discuss cosignature issues.

“We asserted that the regulation requiring a physician’s cosignature on ordering respiratory therapy was outdated and inconsistent with Medicare’s current policies that allow PAs to initiate orders under their own signatures,” he said. “We made the case that the rule only served to hinder the provision of efficient and timely care to patients.”

Previous requirements hindered NP- and PA-written orders for respiratory care in hospitals in particular, because most computerized systems there require signatures within a certain time frame. When a physician cosignature is required, care can be delayed.

MinuteClinic Visits Up 36%

As the industry celebrated the inaugural Convenient Care Clinic Week in August, MinuteClinic reported that its patient visits rose 36% in the second quarter compared with the same period in 2009.

“[Patients] are visiting fewer primary care doctors and specialists. Obviously, the sluggish economy and continued high unemployment has impacted people’s ability to afford physician visits,” said Tom Ryan, chairman and CEO of CVS Caremark, owner of MinuteClinic. Ryan made the comment during a quarterly conference call with analysts, according to news reports.

After this announcement, a flurry of media reports predicted a drop in demand for primary care physicians, largely based on Ryan’s quoted comment. According to the transcript of the earnings call, however, Ryan’s comment was not related to the increase in patient visits to MinuteClinic.

Tom Charland, CEO of convenient care analyst Merchant Medicine, told ADVANCE that what does influence increased visits to convenient care clinics is a rise in high-deductible health insurance plans.

“It seems to me that, yes, the economy is causing people to look more carefully at when they go to the doctor, but . companies are offering high-deductible health plans because that’s all they can afford to offer. . That favors retail clinics because retail clinics are so good with price transparency.”

The increase in patient visits is “on plan” for MinuteClinic, says Charland, who calculated in 2009 that the chain would need an increase of about 33% per quarter to reach its goal of financial profitability by the first quarter of 2012.

As of Sept. 1, 1,190 convenient care clinics were operating in the United States – a modest uptick after growth of the industry stalled in 2008. But MinuteClinic has announced that it plans to double its 453 clinics in the next 5 years. In 2010, ambitious predictions like these have been few and far between.

Paulette Thabault, NP, chief nurse practitioner officer for MinuteClinic, said the growth will result from expansion of services and an increased awareness of the clinics. MinuteClinic now offers monitoring services for previously diagnosed chronic conditions including diabetes, asthma, high cholesterol and high blood pressure. Thabault added that as healthcare reform is implemented, there could be additional growth. “I think there’s definitely some connection between having insurance and seeking healthcare services,” she said.

Diversity Scholarships Awarded to NPs

The Nurse Practitioner Healthcare Foundation (NPHF) has awarded the 2009-2010 AstraZeneca Diversity Scholarships, which provide financial support for graduate nurse practitioner education for minority students. This year, three NP students received awards of $4,000 each.

Juliet T. Chandler, a family NP from Seaside, Calif., was born in Manila, Philippines, lived in Saigon, and moved to the United States at age 10. She practices as a diabetes educator and a public health nurse, and is a preceptor for several universities and colleges. She is pursuing a PhD in nursing at the University of California in San Francisco. Chandler provides volunteer healthcare services to uninsured diabetes patients and coordinates health screening events. Her goal is to improve the quality of and access to care for uninsured, indigent immigrants.

Marcia M. Harris, from Cedar Hill, Texas, practices as a family NP in a special needs offender program in Dallas. When she started her nurse practitioner career in an economically disadvantaged neighborhood, she saw the urgent need to be able to offer both primary care and mental health services. This led to her pursuit of postmaster’s work in the psychiatric-mental health nurse practitioner program at the University of Texas in Arlington. Harris volunteers as a tutor, mentor and healthcare provider in several locations and at events.

Jacqueline E. Higuera, from Ann Arbor, Mich., is an adult NP student who has practiced in occupational health and labor and delivery. She has teaching experience as a professor in Bogota, Colombia. Higuera participates in diverse community service activities through the University of Michigan, where she studies and performs volunteer work. Her goal is to work with women from principally Hispanic and black underserved communities to improve their healthcare knowledge and decision-making skills.

Court’s Reversal Prohibits N.J. PAs From Perfoming Needle Diagnostic Tests

A New Jersey appellate court recently reversed a trial court ruling that stated PAs could perform needle electrodiagnostic tests, including needle electromyography studies and nerve conduction velocity tests. The reversal means that physician assistants can no longer administer diagnostic tests that use needles.

In the 2009 case that started the legal trial, neurologist Arthur C. Rothman sued Selective Insurance Co. of America because the automobile insurance company would not reimburse for electrodiagnostic tests administered by Bracha “Beth” Mazin, PA-C, to a patient after a car accident. The rulings resulting from the trial of this claim dictated that PAs could administer and collect data from the tests and physicians could interpret the results.

After the ruling, the Medical Society of New Jersey and the American Medical Association’s Litigation Center filed an amicus curiae brief in the Superior Court of New Jersey in support of the insurance company, claiming that the ruling could be interpreted too broadly. The American Academy of Physician Assistants (AAPA) and the New Jersey State Society of Physician Assistants filed an amicus curiae in support of Rothman. New Jersey law states that “a person shall not perform needle electromyography unless that person is licensed to practice medicine and surgery” in the state.

As a result of this appeal, the court ruled in August that physician assistants are “not licensed to practice medicine and surgery” and are therefore not legally allowed to perform electrodiagnostic tests, according to Selective Insurance Co. of America v. Rothman.

Ann Davis, PA-C, AAPA senior director for state advocacy, told ADVANCE that the PA advisory committee to the New Jersey State Board of Medical Examiners previously had ruled three times that these procedures were legal for PAs to perform, and the rulings had never been challenged.

“Many parts of the practice of medicine are delegable to PAs,” she said, “so this seemed to us like something within Rothman’s purview.” Rothman requested a motion to reconsider, which the appellate court denied.

Just prior to the appellate court’s ruling, the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) revised its policies to list specific providers it recommends as qualified to perform electrodiagnostic testing. The language now states that “nonphysician providers, including physical therapists, chiropractors, physician assistants, and others, lack the appropriate training and knowledge to perform and interpret EMG studies and interpret NCSs.”

The AANEM further states that physician assistants are qualified to perform the procedure “with direct physician supervision.”

“The way that you fix something like this is by changing the statute to make it more clear that physicians have more delegatory authority,” Davis said. She added that New Jersey PAs continue to look critically at the law to ensure that all healthcare teams are able to work efficiently.

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