Ann M. Hoppel

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”

If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”

Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.

Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?

Dismal Rates of Coverage

The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.

In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)

“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”

There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”

Underestimating the Disease

Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.

“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”

Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”

Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.

Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.

“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”

Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”

Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”

A Matter of Patient Safety

Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”

However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”

“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”

The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.

The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–­associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–­associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.

In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”

But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”

That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.

Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”

Bottom Line: Get Vaccinated!

How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)

Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”

Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”

Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.

AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”

Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”

Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”

The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”

It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”

If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”

Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.

Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?

Dismal Rates of Coverage

The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.

In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)

“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”

There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”

Underestimating the Disease

Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.

“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”

Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”

Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.

Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.

“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”

Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”

Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”

A Matter of Patient Safety

Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”

However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”

“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”

The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.

The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–­associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–­associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.

In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”

But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”

That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.

Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”

Bottom Line: Get Vaccinated!

How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)

Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”

Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”

Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.

AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”

Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”

Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”

The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”

It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”

If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”

Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.

Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?

Dismal Rates of Coverage

The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.

In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)

“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”

There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”

Underestimating the Disease

Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.

“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”

Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”

Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.

Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.

“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”

Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”

Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”

A Matter of Patient Safety

Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”

However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”

“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”

The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.

The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–­associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–­associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.

In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”

But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”

That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.

Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”

Bottom Line: Get Vaccinated!

How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)

Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”

Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”

Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.

AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”

Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”

Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”

The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”

It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”

Editor’s Note: Part 1, featuring American Academy of Physician Assistants President Patrick Killeen, MS, PA-C, appeared in the July issue.

Penny Kaye ­Jensen, DNP, APRN, FNP, FAANP, has a wealth of experience at the state and national levels. She has practiced at the VA Medical Center in Salt Lake City for 16 years, was in the first cohort of DNP students at the University of Utah, and was one of seven NPs to staff a medical clinic during the 2002 Olympic Winter Games, held in Salt Lake City.

On the national front, she was recently appointed to the Joint Commission Ambulatory Professional and Technical Advisory Committee (2010-2012) and to the Veterans Affairs’ Office of Academic Affiliations Primary Care Medical Home Academic Subcommittee (2010-2012). She also became President of the American Academy of Nurse Practitioners (AANP), for which she had previously served as a state and a regional director.

Despite an undoubtedly jam-packed schedule, Jensen answered a few probing questions for Clinician Reviews.

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency? 

Jensen: I have been an integral part of AANP’s leadership for the past year, witnessing the tremendous amount of work that goes on behind the scenes. I have had the opportunity to be President-Elect at one of the most exciting times in the organization’s history. I call it the “perfect storm.” Health care reform has been at the forefront, which has resulted in increased visibility for NPs. [My predecessor as President] Dee Swanson was featured on Fox News, with an estimated two million viewers tuning in to hear about NPs and our role in health care reform.

I have received invitations to present to various nursing and medical organizations and was able to participate in a Senate briefing focusing on health care reform. AANP was invited to President Obama’s press conference on health care reform in March 2010, and I was able to attend and shake hands with our president.

I also have had the opportunity to attend many national and regional meetings throughout the United States, and to give interviews and craft position statements regarding NP practice and our contributions to health care.

I have had the best mentor in the world; Dee Swanson has been remarkable and will be a tough act to follow. 

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Jensen: It is my goal to continue to increase the public awareness of NP practice and to advocate for the profession. There are major misconceptions by the public, legislators, media, and even other health care providers regarding NP practice. These issues should be addressed through consistent and accurate messaging. NPs need to continue to speak with a unified voice.

There is strength in numbers, and AANP’s membership continues to increase. We are building coalitions with other NP organizations and other health care providers and stakeholders. It is my hope that these coalitions will continue to grow and strengthen under my leadership.

I will continue to advocate for licensed independent practice for NPs in each of our states. Many states have been able to accomplish this by developing alliances with other regions within our country. It is important to promote consistent access to quality advanced practice nursing care within states and across state lines. This is critical for the advancement of our profession and would increase access to qualified NPs. 

The issue of increasing membership is integral to AANP’s effort to influence national policy; better laws would mean more NPs in the US and better access to quality care. Each year, US nursing schools prepare 7,000 to 8,000 NPs but must turn away approximately 6,000 qualified applicants due to faculty shortages and lack of funding.

Improved funding for nursing faculty, loan repayment programs, and nurse-managed centers, and the initiation of graduate nursing education funding, if passed, would increase the number of highly qualified NPs available to provide care and to educate future NPs.

CR: What impact do you foresee health care reform having on your profession? How might NP practice change as a result of these changes?

Jensen: Because health care is at the top of the national agenda, as well as on the minds of most Americans, it is in the best interest of consumers that they receive all the facts available about health care professionals so that they can make intelligent and informed decisions when selecting the provider of their care.

The nation is currently experiencing a shortage of primary care providers. As recently as 2008, less than 10% of graduating medical students chose careers in primary care, while 70% of NPs practice in the primary care setting. These numbers suggest that changes in the health care system are inevitable—and that in whatever system emerges from the current reform efforts, NPs will play a dominant role in improving Americans’ access to primary care.

One of the concepts being discussed is the medical home, which promotes whole-patient wellness and disease prevention by developing partnerships between patients and a team of health care providers. Since the inception of the NP role, we have followed this type of practice model. NPs are uniquely positioned to absorb the increasing demand for primary care, and AANP is actively promoting NPs as a natural choice to assume leadership of medical home teams.

The inclusion of NPs in medical home legislation is critical. This model strives to deliver coordinated primary care directed by a single health care provider. NPs are not a threat, as some of our medical colleagues believe. We too are trying to answer the challenge of keeping pace with the demands for quality health care for everyone.

CR: How would you rate the current level of recognition your profession has with the public? How can we increase public awareness of NPs?

Jensen: Public awareness has grown over the past five years due to the expansion of retail clinics, which have been a very successful venue to showcase NP practice. However, this has also affected the perception of some consumers, who feel NPs can only treat acute illness and work within a narrow scope of practice. This is simply not true.

In addition to diagnosing and managing acute episodic illnesses, NPs have been managing patients with chronic illness successfully for many years. A large body of research has established that NPs provide high-quality, cost-effective, comprehensive, personalized, patient-centered health care with excellent patient outcomes. NPs place a strong emphasis on health promotion and disease prevention, which is imperative to reduce the relentless increase in spending on medical care.

We are always trying to get the message out. Under the leadership of our new CEO, Tim Knettler, and the Board of Directors, AANP recently hired a public relations firm. In our 25 years we have never had a national PR firm represent our organization. The company, Weber Shandwick, launched a very successful campaign for the Susan G. Komen Foundation. As Dee Swanson often says, “Everybody knows what a pink ribbon means.” It is my hope that during my term, NPs’ visibility will improve dramatically.

The early results of the consumer surveys undertaken by our PR firm have confirmed a frustrating truth long known to NPs: 50% of those surveyed did not know that NPs can prescribe medications, diagnose, or treat patients without a supervising physician.

Confusion over the role of NPs has led to state laws and regulations governing our work. Although many of the barriers to independent practice have been removed, many still remain. While many states grant full independence to NPs, some still require NPs to work under the direct supervision of a physician.

On a daily basis, NPs have an opportunity to impact the public’s perception about NPs, our abilities, and those we serve. NPs are constantly challenged with countering misinformation or verifying the positive outcome data that are published, but unfortunately we spend a large amount of time correcting misleading or erroneous information reported by the media. 

This year, National NP Week will take place from November 7 to 13. NPs in individual states are encouraged to request proclamations from their governors or mayors to improve NP visibility locally. AANP supplies the materials needed, including a resource guide, press release, and radio spots (PSAs) that we can give to local radio stations.

CR: How can we increase collaboration between NPs and PAs at all levels (national, state, individual practice setting)?

Jensen: As with all other health care providers, our patient population should be our utmost concern. We both have separate issues as related to licensure and supervision, but we do have many issues that we work closely together on.

I think it is critical to build coalitions with PAs for addressing areas of common concern: for example, access to affordable medications for our patient population and access to quality health care.

We share common concerns that affect our practice and ability to provide high-quality care for our patients. It is very important to recognize the value of our PA colleagues; on a daily basis, we often consult with one another and welcome the opportunity to work together on many issues, such as professional practice and health policy. NPs collaborate with health care providers at all levels and certainly work with PAs on those issues. Our training is different, but we work well together as part of the health care team.

Editor’s Note: Part 1, featuring American Academy of Physician Assistants President Patrick Killeen, MS, PA-C, appeared in the July issue.

Penny Kaye ­Jensen, DNP, APRN, FNP, FAANP, has a wealth of experience at the state and national levels. She has practiced at the VA Medical Center in Salt Lake City for 16 years, was in the first cohort of DNP students at the University of Utah, and was one of seven NPs to staff a medical clinic during the 2002 Olympic Winter Games, held in Salt Lake City.

On the national front, she was recently appointed to the Joint Commission Ambulatory Professional and Technical Advisory Committee (2010-2012) and to the Veterans Affairs’ Office of Academic Affiliations Primary Care Medical Home Academic Subcommittee (2010-2012). She also became President of the American Academy of Nurse Practitioners (AANP), for which she had previously served as a state and a regional director.

Despite an undoubtedly jam-packed schedule, Jensen answered a few probing questions for Clinician Reviews.

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency? 

Jensen: I have been an integral part of AANP’s leadership for the past year, witnessing the tremendous amount of work that goes on behind the scenes. I have had the opportunity to be President-Elect at one of the most exciting times in the organization’s history. I call it the “perfect storm.” Health care reform has been at the forefront, which has resulted in increased visibility for NPs. [My predecessor as President] Dee Swanson was featured on Fox News, with an estimated two million viewers tuning in to hear about NPs and our role in health care reform.

I have received invitations to present to various nursing and medical organizations and was able to participate in a Senate briefing focusing on health care reform. AANP was invited to President Obama’s press conference on health care reform in March 2010, and I was able to attend and shake hands with our president.

I also have had the opportunity to attend many national and regional meetings throughout the United States, and to give interviews and craft position statements regarding NP practice and our contributions to health care.

I have had the best mentor in the world; Dee Swanson has been remarkable and will be a tough act to follow. 

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Jensen: It is my goal to continue to increase the public awareness of NP practice and to advocate for the profession. There are major misconceptions by the public, legislators, media, and even other health care providers regarding NP practice. These issues should be addressed through consistent and accurate messaging. NPs need to continue to speak with a unified voice.

There is strength in numbers, and AANP’s membership continues to increase. We are building coalitions with other NP organizations and other health care providers and stakeholders. It is my hope that these coalitions will continue to grow and strengthen under my leadership.

I will continue to advocate for licensed independent practice for NPs in each of our states. Many states have been able to accomplish this by developing alliances with other regions within our country. It is important to promote consistent access to quality advanced practice nursing care within states and across state lines. This is critical for the advancement of our profession and would increase access to qualified NPs. 

The issue of increasing membership is integral to AANP’s effort to influence national policy; better laws would mean more NPs in the US and better access to quality care. Each year, US nursing schools prepare 7,000 to 8,000 NPs but must turn away approximately 6,000 qualified applicants due to faculty shortages and lack of funding.

Improved funding for nursing faculty, loan repayment programs, and nurse-managed centers, and the initiation of graduate nursing education funding, if passed, would increase the number of highly qualified NPs available to provide care and to educate future NPs.

CR: What impact do you foresee health care reform having on your profession? How might NP practice change as a result of these changes?

Jensen: Because health care is at the top of the national agenda, as well as on the minds of most Americans, it is in the best interest of consumers that they receive all the facts available about health care professionals so that they can make intelligent and informed decisions when selecting the provider of their care.

The nation is currently experiencing a shortage of primary care providers. As recently as 2008, less than 10% of graduating medical students chose careers in primary care, while 70% of NPs practice in the primary care setting. These numbers suggest that changes in the health care system are inevitable—and that in whatever system emerges from the current reform efforts, NPs will play a dominant role in improving Americans’ access to primary care.

One of the concepts being discussed is the medical home, which promotes whole-patient wellness and disease prevention by developing partnerships between patients and a team of health care providers. Since the inception of the NP role, we have followed this type of practice model. NPs are uniquely positioned to absorb the increasing demand for primary care, and AANP is actively promoting NPs as a natural choice to assume leadership of medical home teams.

The inclusion of NPs in medical home legislation is critical. This model strives to deliver coordinated primary care directed by a single health care provider. NPs are not a threat, as some of our medical colleagues believe. We too are trying to answer the challenge of keeping pace with the demands for quality health care for everyone.

CR: How would you rate the current level of recognition your profession has with the public? How can we increase public awareness of NPs?

Jensen: Public awareness has grown over the past five years due to the expansion of retail clinics, which have been a very successful venue to showcase NP practice. However, this has also affected the perception of some consumers, who feel NPs can only treat acute illness and work within a narrow scope of practice. This is simply not true.

In addition to diagnosing and managing acute episodic illnesses, NPs have been managing patients with chronic illness successfully for many years. A large body of research has established that NPs provide high-quality, cost-effective, comprehensive, personalized, patient-centered health care with excellent patient outcomes. NPs place a strong emphasis on health promotion and disease prevention, which is imperative to reduce the relentless increase in spending on medical care.

We are always trying to get the message out. Under the leadership of our new CEO, Tim Knettler, and the Board of Directors, AANP recently hired a public relations firm. In our 25 years we have never had a national PR firm represent our organization. The company, Weber Shandwick, launched a very successful campaign for the Susan G. Komen Foundation. As Dee Swanson often says, “Everybody knows what a pink ribbon means.” It is my hope that during my term, NPs’ visibility will improve dramatically.

The early results of the consumer surveys undertaken by our PR firm have confirmed a frustrating truth long known to NPs: 50% of those surveyed did not know that NPs can prescribe medications, diagnose, or treat patients without a supervising physician.

Confusion over the role of NPs has led to state laws and regulations governing our work. Although many of the barriers to independent practice have been removed, many still remain. While many states grant full independence to NPs, some still require NPs to work under the direct supervision of a physician.

On a daily basis, NPs have an opportunity to impact the public’s perception about NPs, our abilities, and those we serve. NPs are constantly challenged with countering misinformation or verifying the positive outcome data that are published, but unfortunately we spend a large amount of time correcting misleading or erroneous information reported by the media. 

This year, National NP Week will take place from November 7 to 13. NPs in individual states are encouraged to request proclamations from their governors or mayors to improve NP visibility locally. AANP supplies the materials needed, including a resource guide, press release, and radio spots (PSAs) that we can give to local radio stations.

CR: How can we increase collaboration between NPs and PAs at all levels (national, state, individual practice setting)?

Jensen: As with all other health care providers, our patient population should be our utmost concern. We both have separate issues as related to licensure and supervision, but we do have many issues that we work closely together on.

I think it is critical to build coalitions with PAs for addressing areas of common concern: for example, access to affordable medications for our patient population and access to quality health care.

We share common concerns that affect our practice and ability to provide high-quality care for our patients. It is very important to recognize the value of our PA colleagues; on a daily basis, we often consult with one another and welcome the opportunity to work together on many issues, such as professional practice and health policy. NPs collaborate with health care providers at all levels and certainly work with PAs on those issues. Our training is different, but we work well together as part of the health care team.

Editor’s Note: Part 1, featuring American Academy of Physician Assistants President Patrick Killeen, MS, PA-C, appeared in the July issue.

Penny Kaye ­Jensen, DNP, APRN, FNP, FAANP, has a wealth of experience at the state and national levels. She has practiced at the VA Medical Center in Salt Lake City for 16 years, was in the first cohort of DNP students at the University of Utah, and was one of seven NPs to staff a medical clinic during the 2002 Olympic Winter Games, held in Salt Lake City.

On the national front, she was recently appointed to the Joint Commission Ambulatory Professional and Technical Advisory Committee (2010-2012) and to the Veterans Affairs’ Office of Academic Affiliations Primary Care Medical Home Academic Subcommittee (2010-2012). She also became President of the American Academy of Nurse Practitioners (AANP), for which she had previously served as a state and a regional director.

Despite an undoubtedly jam-packed schedule, Jensen answered a few probing questions for Clinician Reviews.

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency? 

Jensen: I have been an integral part of AANP’s leadership for the past year, witnessing the tremendous amount of work that goes on behind the scenes. I have had the opportunity to be President-Elect at one of the most exciting times in the organization’s history. I call it the “perfect storm.” Health care reform has been at the forefront, which has resulted in increased visibility for NPs. [My predecessor as President] Dee Swanson was featured on Fox News, with an estimated two million viewers tuning in to hear about NPs and our role in health care reform.

I have received invitations to present to various nursing and medical organizations and was able to participate in a Senate briefing focusing on health care reform. AANP was invited to President Obama’s press conference on health care reform in March 2010, and I was able to attend and shake hands with our president.

I also have had the opportunity to attend many national and regional meetings throughout the United States, and to give interviews and craft position statements regarding NP practice and our contributions to health care.

I have had the best mentor in the world; Dee Swanson has been remarkable and will be a tough act to follow. 

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Jensen: It is my goal to continue to increase the public awareness of NP practice and to advocate for the profession. There are major misconceptions by the public, legislators, media, and even other health care providers regarding NP practice. These issues should be addressed through consistent and accurate messaging. NPs need to continue to speak with a unified voice.

There is strength in numbers, and AANP’s membership continues to increase. We are building coalitions with other NP organizations and other health care providers and stakeholders. It is my hope that these coalitions will continue to grow and strengthen under my leadership.

I will continue to advocate for licensed independent practice for NPs in each of our states. Many states have been able to accomplish this by developing alliances with other regions within our country. It is important to promote consistent access to quality advanced practice nursing care within states and across state lines. This is critical for the advancement of our profession and would increase access to qualified NPs. 

The issue of increasing membership is integral to AANP’s effort to influence national policy; better laws would mean more NPs in the US and better access to quality care. Each year, US nursing schools prepare 7,000 to 8,000 NPs but must turn away approximately 6,000 qualified applicants due to faculty shortages and lack of funding.

Improved funding for nursing faculty, loan repayment programs, and nurse-managed centers, and the initiation of graduate nursing education funding, if passed, would increase the number of highly qualified NPs available to provide care and to educate future NPs.

CR: What impact do you foresee health care reform having on your profession? How might NP practice change as a result of these changes?

Jensen: Because health care is at the top of the national agenda, as well as on the minds of most Americans, it is in the best interest of consumers that they receive all the facts available about health care professionals so that they can make intelligent and informed decisions when selecting the provider of their care.

The nation is currently experiencing a shortage of primary care providers. As recently as 2008, less than 10% of graduating medical students chose careers in primary care, while 70% of NPs practice in the primary care setting. These numbers suggest that changes in the health care system are inevitable—and that in whatever system emerges from the current reform efforts, NPs will play a dominant role in improving Americans’ access to primary care.

One of the concepts being discussed is the medical home, which promotes whole-patient wellness and disease prevention by developing partnerships between patients and a team of health care providers. Since the inception of the NP role, we have followed this type of practice model. NPs are uniquely positioned to absorb the increasing demand for primary care, and AANP is actively promoting NPs as a natural choice to assume leadership of medical home teams.

The inclusion of NPs in medical home legislation is critical. This model strives to deliver coordinated primary care directed by a single health care provider. NPs are not a threat, as some of our medical colleagues believe. We too are trying to answer the challenge of keeping pace with the demands for quality health care for everyone.

CR: How would you rate the current level of recognition your profession has with the public? How can we increase public awareness of NPs?

Jensen: Public awareness has grown over the past five years due to the expansion of retail clinics, which have been a very successful venue to showcase NP practice. However, this has also affected the perception of some consumers, who feel NPs can only treat acute illness and work within a narrow scope of practice. This is simply not true.

In addition to diagnosing and managing acute episodic illnesses, NPs have been managing patients with chronic illness successfully for many years. A large body of research has established that NPs provide high-quality, cost-effective, comprehensive, personalized, patient-centered health care with excellent patient outcomes. NPs place a strong emphasis on health promotion and disease prevention, which is imperative to reduce the relentless increase in spending on medical care.

We are always trying to get the message out. Under the leadership of our new CEO, Tim Knettler, and the Board of Directors, AANP recently hired a public relations firm. In our 25 years we have never had a national PR firm represent our organization. The company, Weber Shandwick, launched a very successful campaign for the Susan G. Komen Foundation. As Dee Swanson often says, “Everybody knows what a pink ribbon means.” It is my hope that during my term, NPs’ visibility will improve dramatically.

The early results of the consumer surveys undertaken by our PR firm have confirmed a frustrating truth long known to NPs: 50% of those surveyed did not know that NPs can prescribe medications, diagnose, or treat patients without a supervising physician.

Confusion over the role of NPs has led to state laws and regulations governing our work. Although many of the barriers to independent practice have been removed, many still remain. While many states grant full independence to NPs, some still require NPs to work under the direct supervision of a physician.

On a daily basis, NPs have an opportunity to impact the public’s perception about NPs, our abilities, and those we serve. NPs are constantly challenged with countering misinformation or verifying the positive outcome data that are published, but unfortunately we spend a large amount of time correcting misleading or erroneous information reported by the media. 

This year, National NP Week will take place from November 7 to 13. NPs in individual states are encouraged to request proclamations from their governors or mayors to improve NP visibility locally. AANP supplies the materials needed, including a resource guide, press release, and radio spots (PSAs) that we can give to local radio stations.

CR: How can we increase collaboration between NPs and PAs at all levels (national, state, individual practice setting)?

Jensen: As with all other health care providers, our patient population should be our utmost concern. We both have separate issues as related to licensure and supervision, but we do have many issues that we work closely together on.

I think it is critical to build coalitions with PAs for addressing areas of common concern: for example, access to affordable medications for our patient population and access to quality health care.

We share common concerns that affect our practice and ability to provide high-quality care for our patients. It is very important to recognize the value of our PA colleagues; on a daily basis, we often consult with one another and welcome the opportunity to work together on many issues, such as professional practice and health policy. NPs collaborate with health care providers at all levels and certainly work with PAs on those issues. Our training is different, but we work well together as part of the health care team.

Patrick Killeen, MS, PA-C, may have just taken the reins as President of the American Academy of Physician Assistants (AAPA), but he is no stranger to leadership roles. His extensive resume includes tenures as President of the Society for PAs in Pediatrics and as the AAPA Liaison to the American Academy of Pediatrics. But for Killeen, one of the significant highlights was serving as President of the Student Academy of AAPA (in 1986-1987): “Without that,” he says, “I don’t think I would have continued in the track that I did.”

As he commences his newest role, Killeen found time to answer a few questions for Clinician Reviews.  

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency?

Killeen: The past year was all about health care reform. Like no other year previously, that was the hot issue. So what I learned is that we have to be very, very organized as a profession, in order to be at the table and not “on the table,” as people say. If you’re not sitting there talking about your profession, then your profession may not be noted. In the past year, in my opinion at least, the Academy has done a great job promoting what the PA profession should be doing within health care reform, without talking about the Democratic or Republican side, but rather in reference to how PAs should practice.

[On a more personal note,] Steve Hanson, the current Immediate Past President, gave me some great advice in reference to looking at the future. It was “Do everything you need to do in the moment, because the big picture is overwhelming.” And it’s really true. When you look at everything you have to do as a profession, oh my gosh, it’s so much work to be done. But if you live in the moment to get done what you need to do right now or be at the table you need to be sitting at today, you’re going to make great progress. That’s probably the best advice he gave me.

CR: What impact do you foresee health care reform having on your profession? How might PA practice change as a result?

Killeen: It’s going to be about primary care. The Obama administration just announced that about $250 million will be going to health care reform in the primary care workforce. And we know that 15%, or about $32 million, of that is going to go to PA education, and that’s going to focus on primary care.

To me, it’s amazing that PAs are already recognized, with other providers such as nurse practitioners, as being primary care providers in a medical home or chronic care management model. Those are things that weren’t acknowledged at the federal level prior to health care reform. For the PA profession, it’s placed us with a great opportunity to make an impact in primary care.

When you talk about throwing 32 million [previously uninsured] people into the primary care pool and looking at where they are getting their care—no longer, hopefully, in emergency rooms—I think PAs, NPs, MDs, and DOs are really going to have to look at their patient mix—and reimbursement has to be appropriate for that patient mix…. So for right now, I think the focus is going to be on looking at increasing the patient load and looking at appropriate reimbursement.

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Killeen: For me there are two things, the first being the implementation of health care reform and all the different venues we have to look at. That’s probably our biggest thing, because again, if we’re not at the table, we’re not going to be the people who are able to implement changes.

And the second thing is research on the PA profession. I’m excited about working to develop extensive research on how PAs impact patient care, patient care outcomes, compliance to medications, compliance to smoking cessation and obesity interventions. Those are the types of things that we really need to look at. The PA profession has some of that information. But if you were to ask, “Is there one study that tells everything you need to know, or one great study that’s kind of the blueprint [for the profession]?” that would be a hard one to pick. I think this research agenda will allow the profession to really target some areas of clinical expertise, in addition to how they affect patient outcomes.

Patients need to understand that they’re receiving quality care and that it’s effective and safe; those same issues can be noted by other health care providers, insurers, and people who are doing appropriate reimbursement for physician services [provided] by a PA—because you’re in a team. As always, PAs have talked about a team approach, an interdisciplinary approach, to care. And I think that component needs to really be pushed out there, how the team approach improves patient care. In reality, the PA profession, and NPs and other groups, talk about it, but is there one really great sentinel study? That would be a difficult thing for PAs or NPs, to promote one study or one topic area that made a big impact.

CR: How would you rate the current level of recognition the PA profession has with the public? How can we increase public awareness of PAs?

Killeen: We need to do more. But overall, when you look at the profession and its marketing and public relations component, with regard to patients, I would say that the profession has slowly increased that knowledge base within the past five years. And, partly because of health care reform, we have groups like Money magazine listing the PA profession as the second-best career and Forbes.com listing ours as the best master’s degree to receive. Those media pieces are huge for the profession. And it’s really exciting to see that finally come to fruition, so the public can see that information out there.

But it doesn’t mean that every patient you see has a full understanding about your profession and its all-encompassing components. We do have a way to go, but I think as a profession we’ve made some significant strides. When you look at the future of the profession, it’s very bright. We talk about PAs’ numbers increasing and about being noted by all these different organizations—I think that says a lot.

Now, we have to take all that information and bring it down to a patient care level. I think the Academy is great at creating coalitions with other health care organizations—like the American Med­ical Association, the American Academy of Family Practitioners, the American Academy of Pediatrics—and at getting the message out to legislators. But we need to take all that information and then filter that through to the general public as well.

CR: How can we increase collaboration between PAs and NPs at all levels (national, state, individual practice settings)?

Killeen: I think there are some great opportunities there. We know that PAs and NPs work very well together clinically. But I think we do have to reach across the aisle at the state and national levels, when we talk about how we can work in teams, when we talk about the team approach to medicine or the interprofessionalism of medicine for patient care.

I think that’s something that we need to improve on, because we’re all talking about the same thing: How do we approach patient care within a medical home? How are we going to get preventive care and information out there?…. There are some great areas regarding patient care and patient advocacy that we can partner on—obesity being one of them. What kind of programs on obesity are the NP state and national organizations working on? That affects so many other aspects of life, such as hypertension, cholesterol, etc. And those are the types of partnerships that I think our profession and the NP profession should be really looking at, some of those clinical practice issues where we really make a great impact on patient care.

CR: What other message(s) do you have for your colleagues?

Killeen: I think the biggest, and the most difficult, thing is to volunteer. It doesn’t matter if you’re an NP or a PA, you need to have some component of your life to volunteer. I don’t care if it’s with the United Way or a gay and lesbian medical association—some type of group that you work with, because as a PA or an NP you’ll make a huge impact with any type of volunteer [activity]. If it’s an hour a week, that’s a huge impact for some individuals—and the more you can give, the better impact you can make. And that can be at the state level, professional level, or national level.

That’s something I’ve always done; I sort of grew up with the thought that you volunteer, you help out at church, you do your activities, because it’s the right thing to do. I would like to see more people do what they think is the right thing, by volunteering in something that they’re really passionate about. It doesn’t have to be medicine. It could be hockey or some other sport or something. But volunteering for it, being the parent who does that, makes a big impact, in comparison to the parent who is unfortunately too busy or is overwhelmed with life and activities as well.

Patrick Killeen, MS, PA-C, may have just taken the reins as President of the American Academy of Physician Assistants (AAPA), but he is no stranger to leadership roles. His extensive resume includes tenures as President of the Society for PAs in Pediatrics and as the AAPA Liaison to the American Academy of Pediatrics. But for Killeen, one of the significant highlights was serving as President of the Student Academy of AAPA (in 1986-1987): “Without that,” he says, “I don’t think I would have continued in the track that I did.”

As he commences his newest role, Killeen found time to answer a few questions for Clinician Reviews.  

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency?

Killeen: The past year was all about health care reform. Like no other year previously, that was the hot issue. So what I learned is that we have to be very, very organized as a profession, in order to be at the table and not “on the table,” as people say. If you’re not sitting there talking about your profession, then your profession may not be noted. In the past year, in my opinion at least, the Academy has done a great job promoting what the PA profession should be doing within health care reform, without talking about the Democratic or Republican side, but rather in reference to how PAs should practice.

[On a more personal note,] Steve Hanson, the current Immediate Past President, gave me some great advice in reference to looking at the future. It was “Do everything you need to do in the moment, because the big picture is overwhelming.” And it’s really true. When you look at everything you have to do as a profession, oh my gosh, it’s so much work to be done. But if you live in the moment to get done what you need to do right now or be at the table you need to be sitting at today, you’re going to make great progress. That’s probably the best advice he gave me.

CR: What impact do you foresee health care reform having on your profession? How might PA practice change as a result?

Killeen: It’s going to be about primary care. The Obama administration just announced that about $250 million will be going to health care reform in the primary care workforce. And we know that 15%, or about $32 million, of that is going to go to PA education, and that’s going to focus on primary care.

To me, it’s amazing that PAs are already recognized, with other providers such as nurse practitioners, as being primary care providers in a medical home or chronic care management model. Those are things that weren’t acknowledged at the federal level prior to health care reform. For the PA profession, it’s placed us with a great opportunity to make an impact in primary care.

When you talk about throwing 32 million [previously uninsured] people into the primary care pool and looking at where they are getting their care—no longer, hopefully, in emergency rooms—I think PAs, NPs, MDs, and DOs are really going to have to look at their patient mix—and reimbursement has to be appropriate for that patient mix…. So for right now, I think the focus is going to be on looking at increasing the patient load and looking at appropriate reimbursement.

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Killeen: For me there are two things, the first being the implementation of health care reform and all the different venues we have to look at. That’s probably our biggest thing, because again, if we’re not at the table, we’re not going to be the people who are able to implement changes.

And the second thing is research on the PA profession. I’m excited about working to develop extensive research on how PAs impact patient care, patient care outcomes, compliance to medications, compliance to smoking cessation and obesity interventions. Those are the types of things that we really need to look at. The PA profession has some of that information. But if you were to ask, “Is there one study that tells everything you need to know, or one great study that’s kind of the blueprint [for the profession]?” that would be a hard one to pick. I think this research agenda will allow the profession to really target some areas of clinical expertise, in addition to how they affect patient outcomes.

Patients need to understand that they’re receiving quality care and that it’s effective and safe; those same issues can be noted by other health care providers, insurers, and people who are doing appropriate reimbursement for physician services [provided] by a PA—because you’re in a team. As always, PAs have talked about a team approach, an interdisciplinary approach, to care. And I think that component needs to really be pushed out there, how the team approach improves patient care. In reality, the PA profession, and NPs and other groups, talk about it, but is there one really great sentinel study? That would be a difficult thing for PAs or NPs, to promote one study or one topic area that made a big impact.

CR: How would you rate the current level of recognition the PA profession has with the public? How can we increase public awareness of PAs?

Killeen: We need to do more. But overall, when you look at the profession and its marketing and public relations component, with regard to patients, I would say that the profession has slowly increased that knowledge base within the past five years. And, partly because of health care reform, we have groups like Money magazine listing the PA profession as the second-best career and Forbes.com listing ours as the best master’s degree to receive. Those media pieces are huge for the profession. And it’s really exciting to see that finally come to fruition, so the public can see that information out there.

But it doesn’t mean that every patient you see has a full understanding about your profession and its all-encompassing components. We do have a way to go, but I think as a profession we’ve made some significant strides. When you look at the future of the profession, it’s very bright. We talk about PAs’ numbers increasing and about being noted by all these different organizations—I think that says a lot.

Now, we have to take all that information and bring it down to a patient care level. I think the Academy is great at creating coalitions with other health care organizations—like the American Med­ical Association, the American Academy of Family Practitioners, the American Academy of Pediatrics—and at getting the message out to legislators. But we need to take all that information and then filter that through to the general public as well.

CR: How can we increase collaboration between PAs and NPs at all levels (national, state, individual practice settings)?

Killeen: I think there are some great opportunities there. We know that PAs and NPs work very well together clinically. But I think we do have to reach across the aisle at the state and national levels, when we talk about how we can work in teams, when we talk about the team approach to medicine or the interprofessionalism of medicine for patient care.

I think that’s something that we need to improve on, because we’re all talking about the same thing: How do we approach patient care within a medical home? How are we going to get preventive care and information out there?…. There are some great areas regarding patient care and patient advocacy that we can partner on—obesity being one of them. What kind of programs on obesity are the NP state and national organizations working on? That affects so many other aspects of life, such as hypertension, cholesterol, etc. And those are the types of partnerships that I think our profession and the NP profession should be really looking at, some of those clinical practice issues where we really make a great impact on patient care.

CR: What other message(s) do you have for your colleagues?

Killeen: I think the biggest, and the most difficult, thing is to volunteer. It doesn’t matter if you’re an NP or a PA, you need to have some component of your life to volunteer. I don’t care if it’s with the United Way or a gay and lesbian medical association—some type of group that you work with, because as a PA or an NP you’ll make a huge impact with any type of volunteer [activity]. If it’s an hour a week, that’s a huge impact for some individuals—and the more you can give, the better impact you can make. And that can be at the state level, professional level, or national level.

That’s something I’ve always done; I sort of grew up with the thought that you volunteer, you help out at church, you do your activities, because it’s the right thing to do. I would like to see more people do what they think is the right thing, by volunteering in something that they’re really passionate about. It doesn’t have to be medicine. It could be hockey or some other sport or something. But volunteering for it, being the parent who does that, makes a big impact, in comparison to the parent who is unfortunately too busy or is overwhelmed with life and activities as well.

Patrick Killeen, MS, PA-C, may have just taken the reins as President of the American Academy of Physician Assistants (AAPA), but he is no stranger to leadership roles. His extensive resume includes tenures as President of the Society for PAs in Pediatrics and as the AAPA Liaison to the American Academy of Pediatrics. But for Killeen, one of the significant highlights was serving as President of the Student Academy of AAPA (in 1986-1987): “Without that,” he says, “I don’t think I would have continued in the track that I did.”

As he commences his newest role, Killeen found time to answer a few questions for Clinician Reviews.  

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency?

Killeen: The past year was all about health care reform. Like no other year previously, that was the hot issue. So what I learned is that we have to be very, very organized as a profession, in order to be at the table and not “on the table,” as people say. If you’re not sitting there talking about your profession, then your profession may not be noted. In the past year, in my opinion at least, the Academy has done a great job promoting what the PA profession should be doing within health care reform, without talking about the Democratic or Republican side, but rather in reference to how PAs should practice.

[On a more personal note,] Steve Hanson, the current Immediate Past President, gave me some great advice in reference to looking at the future. It was “Do everything you need to do in the moment, because the big picture is overwhelming.” And it’s really true. When you look at everything you have to do as a profession, oh my gosh, it’s so much work to be done. But if you live in the moment to get done what you need to do right now or be at the table you need to be sitting at today, you’re going to make great progress. That’s probably the best advice he gave me.

CR: What impact do you foresee health care reform having on your profession? How might PA practice change as a result?

Killeen: It’s going to be about primary care. The Obama administration just announced that about $250 million will be going to health care reform in the primary care workforce. And we know that 15%, or about $32 million, of that is going to go to PA education, and that’s going to focus on primary care.

To me, it’s amazing that PAs are already recognized, with other providers such as nurse practitioners, as being primary care providers in a medical home or chronic care management model. Those are things that weren’t acknowledged at the federal level prior to health care reform. For the PA profession, it’s placed us with a great opportunity to make an impact in primary care.

When you talk about throwing 32 million [previously uninsured] people into the primary care pool and looking at where they are getting their care—no longer, hopefully, in emergency rooms—I think PAs, NPs, MDs, and DOs are really going to have to look at their patient mix—and reimbursement has to be appropriate for that patient mix…. So for right now, I think the focus is going to be on looking at increasing the patient load and looking at appropriate reimbursement.

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Killeen: For me there are two things, the first being the implementation of health care reform and all the different venues we have to look at. That’s probably our biggest thing, because again, if we’re not at the table, we’re not going to be the people who are able to implement changes.

And the second thing is research on the PA profession. I’m excited about working to develop extensive research on how PAs impact patient care, patient care outcomes, compliance to medications, compliance to smoking cessation and obesity interventions. Those are the types of things that we really need to look at. The PA profession has some of that information. But if you were to ask, “Is there one study that tells everything you need to know, or one great study that’s kind of the blueprint [for the profession]?” that would be a hard one to pick. I think this research agenda will allow the profession to really target some areas of clinical expertise, in addition to how they affect patient outcomes.

Patients need to understand that they’re receiving quality care and that it’s effective and safe; those same issues can be noted by other health care providers, insurers, and people who are doing appropriate reimbursement for physician services [provided] by a PA—because you’re in a team. As always, PAs have talked about a team approach, an interdisciplinary approach, to care. And I think that component needs to really be pushed out there, how the team approach improves patient care. In reality, the PA profession, and NPs and other groups, talk about it, but is there one really great sentinel study? That would be a difficult thing for PAs or NPs, to promote one study or one topic area that made a big impact.

CR: How would you rate the current level of recognition the PA profession has with the public? How can we increase public awareness of PAs?

Killeen: We need to do more. But overall, when you look at the profession and its marketing and public relations component, with regard to patients, I would say that the profession has slowly increased that knowledge base within the past five years. And, partly because of health care reform, we have groups like Money magazine listing the PA profession as the second-best career and Forbes.com listing ours as the best master’s degree to receive. Those media pieces are huge for the profession. And it’s really exciting to see that finally come to fruition, so the public can see that information out there.

But it doesn’t mean that every patient you see has a full understanding about your profession and its all-encompassing components. We do have a way to go, but I think as a profession we’ve made some significant strides. When you look at the future of the profession, it’s very bright. We talk about PAs’ numbers increasing and about being noted by all these different organizations—I think that says a lot.

Now, we have to take all that information and bring it down to a patient care level. I think the Academy is great at creating coalitions with other health care organizations—like the American Med­ical Association, the American Academy of Family Practitioners, the American Academy of Pediatrics—and at getting the message out to legislators. But we need to take all that information and then filter that through to the general public as well.

CR: How can we increase collaboration between PAs and NPs at all levels (national, state, individual practice settings)?

Killeen: I think there are some great opportunities there. We know that PAs and NPs work very well together clinically. But I think we do have to reach across the aisle at the state and national levels, when we talk about how we can work in teams, when we talk about the team approach to medicine or the interprofessionalism of medicine for patient care.

I think that’s something that we need to improve on, because we’re all talking about the same thing: How do we approach patient care within a medical home? How are we going to get preventive care and information out there?…. There are some great areas regarding patient care and patient advocacy that we can partner on—obesity being one of them. What kind of programs on obesity are the NP state and national organizations working on? That affects so many other aspects of life, such as hypertension, cholesterol, etc. And those are the types of partnerships that I think our profession and the NP profession should be really looking at, some of those clinical practice issues where we really make a great impact on patient care.

CR: What other message(s) do you have for your colleagues?

Killeen: I think the biggest, and the most difficult, thing is to volunteer. It doesn’t matter if you’re an NP or a PA, you need to have some component of your life to volunteer. I don’t care if it’s with the United Way or a gay and lesbian medical association—some type of group that you work with, because as a PA or an NP you’ll make a huge impact with any type of volunteer [activity]. If it’s an hour a week, that’s a huge impact for some individuals—and the more you can give, the better impact you can make. And that can be at the state level, professional level, or national level.

That’s something I’ve always done; I sort of grew up with the thought that you volunteer, you help out at church, you do your activities, because it’s the right thing to do. I would like to see more people do what they think is the right thing, by volunteering in something that they’re really passionate about. It doesn’t have to be medicine. It could be hockey or some other sport or something. But volunteering for it, being the parent who does that, makes a big impact, in comparison to the parent who is unfortunately too busy or is overwhelmed with life and activities as well.

Picture it: Kansas City, 1984. At a meeting sponsored by the American Nurses Association (ANA), conversation among the NP attendees from across the United States focuses on the widely perceived need for “common representation” of their distinct interests. Who among the existing nursing organizations has the time, money, and/or inclination to serve as the voice of all NPs, providing a conduit for communication and leadership in legislative efforts to remove barriers to practice?

As it will turn out, the answer is no one—at least, not in the way these NPs envision. So they ­decide to do something about that … and since the result of their collaborative vision is the American Academy of Nurse Practitioners (AANP), you have a pretty good idea how it worked out.

AANP is celebrating its 25th anniversary this year—a milestone its founders probably never doubted would be reached, although others initially questioned the viability of such an organization.

“The feeling was that if it was needed, it would grow, and if it wasn’t needed, it wouldn’t grow,” recalls Jan Towers, PhD, NP-C, CRNP, FAANP, a founding member and past president who continues to serve AANP as Director of Health Policy. “And indeed it grew—so I think we know what our answer was!”

A SEPARATE BUT EQUAL NEED
Of course, creating a new professional organization was not as simple as a group of individuals putting their heads together. And yet, in a certain sense, it was that easy.

Shortly after those initial discussions in Kansas City, there was another conference in Washington, DC. During a panel discussion with executives from the insurance and advertising industries, it became evident that the biggest issue for NPs was “no one knew who we were,” says Clinician Reviews NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP, also a founder and past president of AANP. Clearly, that situation needed to be remedied—but how?

At that time, many NPs were members of ANA (and, it should be noted, many still are). However, since ANA represents all of nursing, the bulk of its resources could not be devoted to NPs. The organization had created a Council of Primary Care NPs in 1974, but the “renegade” NPs of 1984 felt that structure didn’t provide the latitude they wanted in their representation.

“We needed a way to really work together and have our ­undivided attention focused on NP issues,” Towers says. Onieal adds, “We weren’t abandoning our ‘nursing-ness,’ but clearly we had separate and distinctly different issues at hand than did the general populace of the nursing profession.”

The fact that NPs from across the country—remember, this is pre-Internet—shared this viewpoint added strength to the argument. If dozens of people who didn’t really know one another could see the same need, it must be real—and therefore, it had to be addressed.

“The [NP] role had been around since 1965, but nursing faculty were just beginning to define what NP education ought to look like,” says Carole Kain, DNS, ARNP, PNP-BC, a founding member and the first president of AANP. (She was Carole Kerwin then.) “A lot of things were changing in the profession, and we all wanted to be part of defining what that change meant. It was everybody coming together with a skill set that set us on this course.”

The time was certainly ripe. In her files, Kain still has a copy of a document discussing a referendum the American Medical Association passed in 1984, in which “they said they were actually going to try to inhibit the practice of NPs, PAs, nurse-midwives, and pharmacists, as to prescribing and taking care of patients.”

In addition to that restrictive attitude—a cause to rally around for NPs nationwide—the NP profession had reached a tipping point in terms of growth. “Enough of us had been prepared, but we were still small enough to be spread out [across the country],” Towers says. “We needed some way to connect.”

By the time they left Washington, DC, a steering committee had been formed to explore the need for an organization representing the nation’s approximately 24,000 NPs. They were expected to report back to the ANA one year later, at a meeting in Chicago. And so, the hard work began.

SO, YOU WANT TO START AN ORGANIZATION?
For a group of virtual strangers who had never started an organization before, they went about their business in a methodical and logical way. Different task forces were created, including one to look into how to do articles of incorporation and other “legalese” pieces, and another to develop a list of reasons why a separate organization was needed.

Onieal recalls a good deal of traveling that she and some other NPs did “to every NP meeting, every NP gathering, across the US for a year. We had a petition, and I’d say, ‘All I want to know is whether you think we should start an NP organization.’” The list grew over the course of the year.

In the meantime, contact was made with the handful of existing NP organizations, to see if any of them could meet the needs of the profession at large: the National Association of Pediatric NPs (1973), the National Association of NPs in Reproductive Health (which became the National Association of NPs in Women’s Health; 1980), and the National Conference of Gerontological NPs (1981). But obviously, since these groups had been tasked by their members with representing the interests of NPs in specific fields, their responses boiled down to “We can’t help you—but we wish you well.”

By the time the Chicago meeting rolled around in May 1985, about the only thing left to do was announce the new organization’s formation. Bylaws had already been drafted, and Onieal’s (now former) address in Lowell, Massachusetts, had been chosen as the original headquarters of the organization. (Trivia: AANP was originally incorporated in Lowell, before relocating to Austin, Texas.)

During a panel session in Chicago, Kain and Onieal told the assembled crowd, “This is what we need: We need to be heard as independent providers. We need to have some say in how our practice is regulated. We need … an organization that will allow us to learn from each other across the country,” as Kain recalls.

The official press release announcing AANP’s creation reads: “The overall purpose of the AANP is to promote high standards of health care as delivered by nurse practitioners and to act as a forum to enhance the identity and continuity of nurse practitioners. It is nationwide in scope and welcomes all nurse practitioners, regardless of specialty. The first year’s focus will be on networking and communications.”

AANP’s first elected officers were Kain (President), Towers (President-Elect), Onieal (Treasurer), Madeline D. Wiley, MSN, ARNP (Recording Secretary), and Robert T. Smithing, MSN, ARNP (Communications Secretary). Annual membership dues were $60.

25 YEARS OF PROGRESS
The leaders and members of the newly formed AANP wasted little time in setting out to accomplish their organizational goals. As Onieal says, “When we started, we had a five-year plan and a 10-year plan. And in five years, we got through all of that.”

With the initial focus on networking and communications, 10 geographical regions were established, based on the National Health Service Corps regions, and regional directors were found. So were individual reps from every state, each of whom then “started talking to people within their state,” Kain says.

For Towers, the focus was on legislative and regulatory issues, just as it is today. “One of the first things we started doing was finding ways to influence policy, both in Washington and in our states,” she says. “Early on, we started working on reimbursement.”

An early victory was getting NPs reimbursement through the Federal Employees Health Benefits Program (1986-1987). On the Medicare front, AANP had a significant impact in securing reimbursement for NPs working in rural areas and in long-term care facilities (1989-1990). Additional milestones include mandated Medicare payment for family and pediatric NPs regardless of supervision status (the early ’90s) and direct Medicare reimbursement for NPs regardless of setting (1997).

Seeing all that has been accomplished in 25 years is still a little amazing, even to the people who set the wheels in motion. “We’re funding research, and we have a foundation that gives scholarships,” Kain says. “Those are things we talked about as ‘someday’ dreams, but now they’re actualizations.”

She’s greeted every day by signs of how much has changed since 1985. “I can remember the initial discussions about having a certification program, talking to the psychometricians about how we’d start up the exam and which criteria we’d use,” she reflects. “And now, the NPs that I’m teaching are using that certification exam to get their licensure!”

As much as Onieal appreciates all the services that AANP has grown to offer its members, she also recognizes the core value of the organization. “One of our primary purposes was to let people know what NPs are all about—to clarify that we’re not LPNs, we’re not students, we’re not people who couldn’t go to medical school and decided to do this instead; this was our chosen profession,” she says. “I think we’ve been successful in doing that.”

THE ULTIMATE COLLABORATION
The founders of AANP never doubted that forming the organization was the right thing to do, which probably confirms that they were the best people to do the job. Instead of expending energy on doubts or infighting, they figured out what needed to be done and moved forward. 

Kain still has a “vivid mental picture” of the early days in Kansas City and Washington, DC, when there was no organization and therefore no budget, so meetings were held in someone’s hotel room. “There would be people sitting on the bed, on the floor, standing up; we’re all crammed into the room,” she remembers with a laugh. “And people are talking, and we’re polite to one another, we’re respectful of one another. We’re passionate. We’re talking about the difficulties and why we need this. And if you could put that into a bottle, you could start a new organization right now!”

That spirit of collaboration is still a viable part of the organization, one that Onieal is proud of. “If anybody ever had an interest in doing something or being something within the organization, the doors were open,” she says. “Early on, a couple of students said, ‘But we have needs, too,’ so we said, ‘Fine, we’ll start a student special interest group. No problem.’” The point, after all, had always been to learn from one another.

If there is one lesson the AANP founders hope to pass along to future generations, it’s that great change can be brought about by a small group of (seemingly) ordinary people with extraordinary determination. They don’t want statues erected in their honor, but they do want others to be inspired to take an active role in the continuous evolution of the NP profession—especially since, as Towers observes, “There is still work to be done.”

“We need to get all the state practice acts on a level playing field,” she notes, “which we’re well on the way to doing now with our consensus document and the model rules and regulations. We need to have recognition within all the payment systems, and remove barriers within existing laws that prevent NPs from practicing to their fullest capability.”

The significant changes that have been brought about in the past 25 years can be difficult to fathom for those who did not witness them. In 2010, the NP profession is well established. (The same is true for PAs.) Students deciding their future choose these professions in part because of all they will be able to do and accomplish within their roles.

What they don’t always recognize is that it took hard work and continued vigilance on the part of those who have preceded them to achieve the privileges that today’s clinicians—and perhaps tomorrow’s—run the risk of taking for granted.

“We’re not done, and I don’t want anyone to think they can rest on the laurels of what has gone before or think that without their involvement it will continue,” says Kain. “It won’t. We need them. We need new blood, new thoughts, new ideas, to face the new challenges.”

When she reflects on how a group of near-strangers got together and made a mark on the history of their profession, she concludes, simply, “Others can do the same thing. They just have to want to, and see the need.”

Picture it: Kansas City, 1984. At a meeting sponsored by the American Nurses Association (ANA), conversation among the NP attendees from across the United States focuses on the widely perceived need for “common representation” of their distinct interests. Who among the existing nursing organizations has the time, money, and/or inclination to serve as the voice of all NPs, providing a conduit for communication and leadership in legislative efforts to remove barriers to practice?

As it will turn out, the answer is no one—at least, not in the way these NPs envision. So they ­decide to do something about that … and since the result of their collaborative vision is the American Academy of Nurse Practitioners (AANP), you have a pretty good idea how it worked out.

AANP is celebrating its 25th anniversary this year—a milestone its founders probably never doubted would be reached, although others initially questioned the viability of such an organization.

“The feeling was that if it was needed, it would grow, and if it wasn’t needed, it wouldn’t grow,” recalls Jan Towers, PhD, NP-C, CRNP, FAANP, a founding member and past president who continues to serve AANP as Director of Health Policy. “And indeed it grew—so I think we know what our answer was!”

A SEPARATE BUT EQUAL NEED
Of course, creating a new professional organization was not as simple as a group of individuals putting their heads together. And yet, in a certain sense, it was that easy.

Shortly after those initial discussions in Kansas City, there was another conference in Washington, DC. During a panel discussion with executives from the insurance and advertising industries, it became evident that the biggest issue for NPs was “no one knew who we were,” says Clinician Reviews NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP, also a founder and past president of AANP. Clearly, that situation needed to be remedied—but how?

At that time, many NPs were members of ANA (and, it should be noted, many still are). However, since ANA represents all of nursing, the bulk of its resources could not be devoted to NPs. The organization had created a Council of Primary Care NPs in 1974, but the “renegade” NPs of 1984 felt that structure didn’t provide the latitude they wanted in their representation.

“We needed a way to really work together and have our ­undivided attention focused on NP issues,” Towers says. Onieal adds, “We weren’t abandoning our ‘nursing-ness,’ but clearly we had separate and distinctly different issues at hand than did the general populace of the nursing profession.”

The fact that NPs from across the country—remember, this is pre-Internet—shared this viewpoint added strength to the argument. If dozens of people who didn’t really know one another could see the same need, it must be real—and therefore, it had to be addressed.

“The [NP] role had been around since 1965, but nursing faculty were just beginning to define what NP education ought to look like,” says Carole Kain, DNS, ARNP, PNP-BC, a founding member and the first president of AANP. (She was Carole Kerwin then.) “A lot of things were changing in the profession, and we all wanted to be part of defining what that change meant. It was everybody coming together with a skill set that set us on this course.”

The time was certainly ripe. In her files, Kain still has a copy of a document discussing a referendum the American Medical Association passed in 1984, in which “they said they were actually going to try to inhibit the practice of NPs, PAs, nurse-midwives, and pharmacists, as to prescribing and taking care of patients.”

In addition to that restrictive attitude—a cause to rally around for NPs nationwide—the NP profession had reached a tipping point in terms of growth. “Enough of us had been prepared, but we were still small enough to be spread out [across the country],” Towers says. “We needed some way to connect.”

By the time they left Washington, DC, a steering committee had been formed to explore the need for an organization representing the nation’s approximately 24,000 NPs. They were expected to report back to the ANA one year later, at a meeting in Chicago. And so, the hard work began.

SO, YOU WANT TO START AN ORGANIZATION?
For a group of virtual strangers who had never started an organization before, they went about their business in a methodical and logical way. Different task forces were created, including one to look into how to do articles of incorporation and other “legalese” pieces, and another to develop a list of reasons why a separate organization was needed.

Onieal recalls a good deal of traveling that she and some other NPs did “to every NP meeting, every NP gathering, across the US for a year. We had a petition, and I’d say, ‘All I want to know is whether you think we should start an NP organization.’” The list grew over the course of the year.

In the meantime, contact was made with the handful of existing NP organizations, to see if any of them could meet the needs of the profession at large: the National Association of Pediatric NPs (1973), the National Association of NPs in Reproductive Health (which became the National Association of NPs in Women’s Health; 1980), and the National Conference of Gerontological NPs (1981). But obviously, since these groups had been tasked by their members with representing the interests of NPs in specific fields, their responses boiled down to “We can’t help you—but we wish you well.”

By the time the Chicago meeting rolled around in May 1985, about the only thing left to do was announce the new organization’s formation. Bylaws had already been drafted, and Onieal’s (now former) address in Lowell, Massachusetts, had been chosen as the original headquarters of the organization. (Trivia: AANP was originally incorporated in Lowell, before relocating to Austin, Texas.)

During a panel session in Chicago, Kain and Onieal told the assembled crowd, “This is what we need: We need to be heard as independent providers. We need to have some say in how our practice is regulated. We need … an organization that will allow us to learn from each other across the country,” as Kain recalls.

The official press release announcing AANP’s creation reads: “The overall purpose of the AANP is to promote high standards of health care as delivered by nurse practitioners and to act as a forum to enhance the identity and continuity of nurse practitioners. It is nationwide in scope and welcomes all nurse practitioners, regardless of specialty. The first year’s focus will be on networking and communications.”

AANP’s first elected officers were Kain (President), Towers (President-Elect), Onieal (Treasurer), Madeline D. Wiley, MSN, ARNP (Recording Secretary), and Robert T. Smithing, MSN, ARNP (Communications Secretary). Annual membership dues were $60.

25 YEARS OF PROGRESS
The leaders and members of the newly formed AANP wasted little time in setting out to accomplish their organizational goals. As Onieal says, “When we started, we had a five-year plan and a 10-year plan. And in five years, we got through all of that.”

With the initial focus on networking and communications, 10 geographical regions were established, based on the National Health Service Corps regions, and regional directors were found. So were individual reps from every state, each of whom then “started talking to people within their state,” Kain says.

For Towers, the focus was on legislative and regulatory issues, just as it is today. “One of the first things we started doing was finding ways to influence policy, both in Washington and in our states,” she says. “Early on, we started working on reimbursement.”

An early victory was getting NPs reimbursement through the Federal Employees Health Benefits Program (1986-1987). On the Medicare front, AANP had a significant impact in securing reimbursement for NPs working in rural areas and in long-term care facilities (1989-1990). Additional milestones include mandated Medicare payment for family and pediatric NPs regardless of supervision status (the early ’90s) and direct Medicare reimbursement for NPs regardless of setting (1997).

Seeing all that has been accomplished in 25 years is still a little amazing, even to the people who set the wheels in motion. “We’re funding research, and we have a foundation that gives scholarships,” Kain says. “Those are things we talked about as ‘someday’ dreams, but now they’re actualizations.”

She’s greeted every day by signs of how much has changed since 1985. “I can remember the initial discussions about having a certification program, talking to the psychometricians about how we’d start up the exam and which criteria we’d use,” she reflects. “And now, the NPs that I’m teaching are using that certification exam to get their licensure!”

As much as Onieal appreciates all the services that AANP has grown to offer its members, she also recognizes the core value of the organization. “One of our primary purposes was to let people know what NPs are all about—to clarify that we’re not LPNs, we’re not students, we’re not people who couldn’t go to medical school and decided to do this instead; this was our chosen profession,” she says. “I think we’ve been successful in doing that.”

THE ULTIMATE COLLABORATION
The founders of AANP never doubted that forming the organization was the right thing to do, which probably confirms that they were the best people to do the job. Instead of expending energy on doubts or infighting, they figured out what needed to be done and moved forward. 

Kain still has a “vivid mental picture” of the early days in Kansas City and Washington, DC, when there was no organization and therefore no budget, so meetings were held in someone’s hotel room. “There would be people sitting on the bed, on the floor, standing up; we’re all crammed into the room,” she remembers with a laugh. “And people are talking, and we’re polite to one another, we’re respectful of one another. We’re passionate. We’re talking about the difficulties and why we need this. And if you could put that into a bottle, you could start a new organization right now!”

That spirit of collaboration is still a viable part of the organization, one that Onieal is proud of. “If anybody ever had an interest in doing something or being something within the organization, the doors were open,” she says. “Early on, a couple of students said, ‘But we have needs, too,’ so we said, ‘Fine, we’ll start a student special interest group. No problem.’” The point, after all, had always been to learn from one another.

If there is one lesson the AANP founders hope to pass along to future generations, it’s that great change can be brought about by a small group of (seemingly) ordinary people with extraordinary determination. They don’t want statues erected in their honor, but they do want others to be inspired to take an active role in the continuous evolution of the NP profession—especially since, as Towers observes, “There is still work to be done.”

“We need to get all the state practice acts on a level playing field,” she notes, “which we’re well on the way to doing now with our consensus document and the model rules and regulations. We need to have recognition within all the payment systems, and remove barriers within existing laws that prevent NPs from practicing to their fullest capability.”

The significant changes that have been brought about in the past 25 years can be difficult to fathom for those who did not witness them. In 2010, the NP profession is well established. (The same is true for PAs.) Students deciding their future choose these professions in part because of all they will be able to do and accomplish within their roles.

What they don’t always recognize is that it took hard work and continued vigilance on the part of those who have preceded them to achieve the privileges that today’s clinicians—and perhaps tomorrow’s—run the risk of taking for granted.

“We’re not done, and I don’t want anyone to think they can rest on the laurels of what has gone before or think that without their involvement it will continue,” says Kain. “It won’t. We need them. We need new blood, new thoughts, new ideas, to face the new challenges.”

When she reflects on how a group of near-strangers got together and made a mark on the history of their profession, she concludes, simply, “Others can do the same thing. They just have to want to, and see the need.”

Picture it: Kansas City, 1984. At a meeting sponsored by the American Nurses Association (ANA), conversation among the NP attendees from across the United States focuses on the widely perceived need for “common representation” of their distinct interests. Who among the existing nursing organizations has the time, money, and/or inclination to serve as the voice of all NPs, providing a conduit for communication and leadership in legislative efforts to remove barriers to practice?

As it will turn out, the answer is no one—at least, not in the way these NPs envision. So they ­decide to do something about that … and since the result of their collaborative vision is the American Academy of Nurse Practitioners (AANP), you have a pretty good idea how it worked out.

AANP is celebrating its 25th anniversary this year—a milestone its founders probably never doubted would be reached, although others initially questioned the viability of such an organization.

“The feeling was that if it was needed, it would grow, and if it wasn’t needed, it wouldn’t grow,” recalls Jan Towers, PhD, NP-C, CRNP, FAANP, a founding member and past president who continues to serve AANP as Director of Health Policy. “And indeed it grew—so I think we know what our answer was!”

A SEPARATE BUT EQUAL NEED
Of course, creating a new professional organization was not as simple as a group of individuals putting their heads together. And yet, in a certain sense, it was that easy.

Shortly after those initial discussions in Kansas City, there was another conference in Washington, DC. During a panel discussion with executives from the insurance and advertising industries, it became evident that the biggest issue for NPs was “no one knew who we were,” says Clinician Reviews NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP, also a founder and past president of AANP. Clearly, that situation needed to be remedied—but how?

At that time, many NPs were members of ANA (and, it should be noted, many still are). However, since ANA represents all of nursing, the bulk of its resources could not be devoted to NPs. The organization had created a Council of Primary Care NPs in 1974, but the “renegade” NPs of 1984 felt that structure didn’t provide the latitude they wanted in their representation.

“We needed a way to really work together and have our ­undivided attention focused on NP issues,” Towers says. Onieal adds, “We weren’t abandoning our ‘nursing-ness,’ but clearly we had separate and distinctly different issues at hand than did the general populace of the nursing profession.”

The fact that NPs from across the country—remember, this is pre-Internet—shared this viewpoint added strength to the argument. If dozens of people who didn’t really know one another could see the same need, it must be real—and therefore, it had to be addressed.

“The [NP] role had been around since 1965, but nursing faculty were just beginning to define what NP education ought to look like,” says Carole Kain, DNS, ARNP, PNP-BC, a founding member and the first president of AANP. (She was Carole Kerwin then.) “A lot of things were changing in the profession, and we all wanted to be part of defining what that change meant. It was everybody coming together with a skill set that set us on this course.”

The time was certainly ripe. In her files, Kain still has a copy of a document discussing a referendum the American Medical Association passed in 1984, in which “they said they were actually going to try to inhibit the practice of NPs, PAs, nurse-midwives, and pharmacists, as to prescribing and taking care of patients.”

In addition to that restrictive attitude—a cause to rally around for NPs nationwide—the NP profession had reached a tipping point in terms of growth. “Enough of us had been prepared, but we were still small enough to be spread out [across the country],” Towers says. “We needed some way to connect.”

By the time they left Washington, DC, a steering committee had been formed to explore the need for an organization representing the nation’s approximately 24,000 NPs. They were expected to report back to the ANA one year later, at a meeting in Chicago. And so, the hard work began.

SO, YOU WANT TO START AN ORGANIZATION?
For a group of virtual strangers who had never started an organization before, they went about their business in a methodical and logical way. Different task forces were created, including one to look into how to do articles of incorporation and other “legalese” pieces, and another to develop a list of reasons why a separate organization was needed.

Onieal recalls a good deal of traveling that she and some other NPs did “to every NP meeting, every NP gathering, across the US for a year. We had a petition, and I’d say, ‘All I want to know is whether you think we should start an NP organization.’” The list grew over the course of the year.

In the meantime, contact was made with the handful of existing NP organizations, to see if any of them could meet the needs of the profession at large: the National Association of Pediatric NPs (1973), the National Association of NPs in Reproductive Health (which became the National Association of NPs in Women’s Health; 1980), and the National Conference of Gerontological NPs (1981). But obviously, since these groups had been tasked by their members with representing the interests of NPs in specific fields, their responses boiled down to “We can’t help you—but we wish you well.”

By the time the Chicago meeting rolled around in May 1985, about the only thing left to do was announce the new organization’s formation. Bylaws had already been drafted, and Onieal’s (now former) address in Lowell, Massachusetts, had been chosen as the original headquarters of the organization. (Trivia: AANP was originally incorporated in Lowell, before relocating to Austin, Texas.)

During a panel session in Chicago, Kain and Onieal told the assembled crowd, “This is what we need: We need to be heard as independent providers. We need to have some say in how our practice is regulated. We need … an organization that will allow us to learn from each other across the country,” as Kain recalls.

The official press release announcing AANP’s creation reads: “The overall purpose of the AANP is to promote high standards of health care as delivered by nurse practitioners and to act as a forum to enhance the identity and continuity of nurse practitioners. It is nationwide in scope and welcomes all nurse practitioners, regardless of specialty. The first year’s focus will be on networking and communications.”

AANP’s first elected officers were Kain (President), Towers (President-Elect), Onieal (Treasurer), Madeline D. Wiley, MSN, ARNP (Recording Secretary), and Robert T. Smithing, MSN, ARNP (Communications Secretary). Annual membership dues were $60.

25 YEARS OF PROGRESS
The leaders and members of the newly formed AANP wasted little time in setting out to accomplish their organizational goals. As Onieal says, “When we started, we had a five-year plan and a 10-year plan. And in five years, we got through all of that.”

With the initial focus on networking and communications, 10 geographical regions were established, based on the National Health Service Corps regions, and regional directors were found. So were individual reps from every state, each of whom then “started talking to people within their state,” Kain says.

For Towers, the focus was on legislative and regulatory issues, just as it is today. “One of the first things we started doing was finding ways to influence policy, both in Washington and in our states,” she says. “Early on, we started working on reimbursement.”

An early victory was getting NPs reimbursement through the Federal Employees Health Benefits Program (1986-1987). On the Medicare front, AANP had a significant impact in securing reimbursement for NPs working in rural areas and in long-term care facilities (1989-1990). Additional milestones include mandated Medicare payment for family and pediatric NPs regardless of supervision status (the early ’90s) and direct Medicare reimbursement for NPs regardless of setting (1997).

Seeing all that has been accomplished in 25 years is still a little amazing, even to the people who set the wheels in motion. “We’re funding research, and we have a foundation that gives scholarships,” Kain says. “Those are things we talked about as ‘someday’ dreams, but now they’re actualizations.”

She’s greeted every day by signs of how much has changed since 1985. “I can remember the initial discussions about having a certification program, talking to the psychometricians about how we’d start up the exam and which criteria we’d use,” she reflects. “And now, the NPs that I’m teaching are using that certification exam to get their licensure!”

As much as Onieal appreciates all the services that AANP has grown to offer its members, she also recognizes the core value of the organization. “One of our primary purposes was to let people know what NPs are all about—to clarify that we’re not LPNs, we’re not students, we’re not people who couldn’t go to medical school and decided to do this instead; this was our chosen profession,” she says. “I think we’ve been successful in doing that.”

THE ULTIMATE COLLABORATION
The founders of AANP never doubted that forming the organization was the right thing to do, which probably confirms that they were the best people to do the job. Instead of expending energy on doubts or infighting, they figured out what needed to be done and moved forward. 

Kain still has a “vivid mental picture” of the early days in Kansas City and Washington, DC, when there was no organization and therefore no budget, so meetings were held in someone’s hotel room. “There would be people sitting on the bed, on the floor, standing up; we’re all crammed into the room,” she remembers with a laugh. “And people are talking, and we’re polite to one another, we’re respectful of one another. We’re passionate. We’re talking about the difficulties and why we need this. And if you could put that into a bottle, you could start a new organization right now!”

That spirit of collaboration is still a viable part of the organization, one that Onieal is proud of. “If anybody ever had an interest in doing something or being something within the organization, the doors were open,” she says. “Early on, a couple of students said, ‘But we have needs, too,’ so we said, ‘Fine, we’ll start a student special interest group. No problem.’” The point, after all, had always been to learn from one another.

If there is one lesson the AANP founders hope to pass along to future generations, it’s that great change can be brought about by a small group of (seemingly) ordinary people with extraordinary determination. They don’t want statues erected in their honor, but they do want others to be inspired to take an active role in the continuous evolution of the NP profession—especially since, as Towers observes, “There is still work to be done.”

“We need to get all the state practice acts on a level playing field,” she notes, “which we’re well on the way to doing now with our consensus document and the model rules and regulations. We need to have recognition within all the payment systems, and remove barriers within existing laws that prevent NPs from practicing to their fullest capability.”

The significant changes that have been brought about in the past 25 years can be difficult to fathom for those who did not witness them. In 2010, the NP profession is well established. (The same is true for PAs.) Students deciding their future choose these professions in part because of all they will be able to do and accomplish within their roles.

What they don’t always recognize is that it took hard work and continued vigilance on the part of those who have preceded them to achieve the privileges that today’s clinicians—and perhaps tomorrow’s—run the risk of taking for granted.

“We’re not done, and I don’t want anyone to think they can rest on the laurels of what has gone before or think that without their involvement it will continue,” says Kain. “It won’t. We need them. We need new blood, new thoughts, new ideas, to face the new challenges.”

When she reflects on how a group of near-strangers got together and made a mark on the history of their profession, she concludes, simply, “Others can do the same thing. They just have to want to, and see the need.”

Since joining the American Academy of Physician Assistants (AAPA) in February 2008 as Executive Vice President and CEO, Bill Leinweber has brought positive energy and a new focus to the organization. Despite his busy schedule, Leinweber recently found time to speak with Clinician Reviews about AAPA’s goals and priorities, the impact of health care reform on the direction of the profession, and efforts to raise PAs’ public profile.

Clinician Reviews: When you joined AAPA, what was your assessment of the profession’s needs?

Leinweber: My observation and experience was, from a PA perspective, a very high level of enthusiasm and commitment by PAs about the profession, and a strong desire for the profession to take its rightful, prominent place in health care. I really sensed a hunger, in those who make up the profession, for recognition, of wanting to be perceived as truly a player in the delivery of health care and the policy that accompanies that delivery.

CR: Of the changes implemented at AAPA in the past two years, which for you is the most significant and/or satisfying?

Leinweber: What jumps to mind is shifting the real focus and the work of the Board of Directors of the Academy from that of an operational board to a strategic board. What are the truly big issues and major priorities that the board needs to focus their time and attention on and allocate the organization’s resources to address? As we become more strategically focused, you’ll see continuity in terms of the goals that we’re working to achieve and the resources we’re putting behind achieving those goals.

We have also worked hard to shift—and this continues; I don’t want to suggest it’s completed—from a very process-driven organization to one that really wants to look at outcomes. You need some level of process, but if you have a lot of process but not the outcomes that really move the ball forward, then you’re not serving your members.

That said, there will be things that individuals or groups of individuals in the profession believe should be a priority that aren’t. I want to be clear that even in moving to a strategic focus and direction, everybody doesn’t get everything they want addressed all the time. That’s a challenge.

CR: What are your immediate and ongoing priorities for AAPA?

Leinweber: Our policymakers just passed historic health care reform legislation. There are clearly, even within our profession, varying points of view across the political spectrum in support for or opposition to health care reform.

The Academy had no position per se on any bill in its entirety. What we focused on was to ensure that as any and all legislation began to take shape, PAs were prominently and appropriately identified as key to the success of any reform effort.

I believe we made huge headway there. PAs are called out by name in the legislation, in terms of being critical to the success of the expansion of primary care and in a number of other ways.

That has implications in terms of priorities. The country will now move from a legislative process to the implementation of many of the provisions in the reform legislation over the next several years. That will have bearing on some of our work and some of our priorities. What will this mean for us as a profession? What does it mean for us as an Academy, and how do we respond?

Certainly the number of PAs in primary care today is not what it once was. We feel an obligation to really be looking for strategies to help grow, to the fullest degree possible, interest and commitment to primary care—and to do that in a way that doesn’t detract from the important contributions PAs in specialties are making.

I look at this as, how do we grow the whole “pie” of PAs exponentially, so that we can contribute larger numbers to the critical need in primary care, in addition to having PAs filling needs in surgery, surgical subspecialties, internal medicine, etc?

We continue to move forward with the development of a research agenda for the profession. In that regard, we hosted a research summit in early March, which was very well attended. We’ll be putting out a proceedings paper from that summit soon, which will outline the steps we will take to formulate a research agenda for the profession.

Also, we’re undertaking a lot of work on the governance front of the Academy. Over the next year, we’ll be looking at the relationship AAPA has with its state chapters and with its specialty organizations. The way those relationships have been chartered and have worked hasn’t really changed in 30 or 40 years, and I think the world in that time has changed dramatically.

The profession has grown dramatically, and it’s time for us to sit down with representatives of our constituent organizations and make sure that we’re working in the best model that we can to have the fullest impact at the local and the national level.

CR: How will AAPA address the increased movement by PAs from primary to specialty care?

Leinweber: If you step back and look at primary health care in its totality, the reality is that the demand for PAs continues to outstrip the supply. When you look at health care reform and the strong focus on primary care, I don’t think we’re necessarily going to see any immediate lessening of demand for PAs in specialty areas at the expense of growth in the primary care arena. So our challenge will be to grow that pie in totality.

We worked to have incentives built into the health care reform legislation that would encourage PA programs to participate in grant programs and other efforts that would really reward them for growing the number of PAs who choose primary care as their specialty, and to incentivize students who choose that path by increasing opportunities through the National Health Service Corps and loan forgiveness programs. Those things matter.

When you look at the primary care challenges of the country, the challenges that MDs or DOs face in terms of trying to grow the cadre of individuals going into primary care aren’t all that different from what we face. It comes down to quality of life, the compensation that’s tied to that particular kind of medicine, opportunities for advancement, flexibility.

Those are all issues that we’re going to have to address. We’ve begun to do that, but we’re going to have to work with organized medicine to continue to push for a shift in how the country rewards and positions primary care.

CR: How will AAPA provide support to PAs in specialties, while maintaining its commitment to primary care?

Leinweber: There are 24 specialty organizations that have a charter agreement with AAPA and are represented in our House of Delegates. We work closely with our specialty organizations; we collaborate with them, increasingly, on continuing medical education (CME) programs that they provide to their members.

The AAPA will work with the Society of PAs in Pediatrics, for example, and work to bring the American Academy of Pediatrics to the table so that we can contribute to shaping the delivery of programs that are of value to PAs in particular specialty fields. I certainly see us continuing to do that.

We completely recognize that the demographic has shifted. Our statistics now show that 35.7% of PAs identify themselves as practicing in primary care. So, that means almost 65% are in a specialized field. That’s a reality that we look at and we shape our services accordingly.

But considering how things are moving nationwide, relative to a reformed health care system, we very much feel the need, the pressure, and the obligation to do everything we can to grow those primary care numbers.

CR: What opportunities do you see for PAs to partner with NPs?

Leinweber: We are doing some partnering now in the form of joint CME programs that we’ve conducted in the past couple of years with the American Academy of Nurse Practitioners and various doctor specialty groups. For instance, there was a boot camp last August with the Society for Hospital Medicine. We will collaboratively put on programs that are designed to serve the CME needs of PAs and NPs primarily, although physicians can participate as well. Those have been tremendously successful. We certainly want to continue to do that.

On the legislative front, I think there is value in PAs and NPs working collaboratively wherever we can at the federal level. Wherever we have common messages that support our various legislative goals, we’re certainly open to that. I think when you start to look at the state level and where health care is delivered, on the front lines, things become a little more challenging because we don’t answer to the same regulatory body at that level.

But our philosophy is, the country has an enormous need in terms of individuals requiring care from qualified, competent providers. We need many more PAs, we need more NPs; there are very important and distinct roles that we play. And wherever we can work together to bring the wherewithal of our respective professions to improve health care and health care delivery, I think we need to be open to that and look for those opportunities.

CR: NPs have been touted for significantly raising their public profile, while many PAs feel their profession has lagged behind in this area. How is AAPA approaching the public perception and marketing of the profession?

Leinweber: First of all, I think it’s accurate to say that the NPs have been ahead of us from a policymaker and a public recognition/perception point of view. But I think we’ve made some significant strides over the past couple of years with the PA profession.

We have been very targeted in our approach. We made a conscious decision that it was critical to elevate the presence and the positioning of the profession first and foremost among policymakers and thought leaders who have the authority to impact how the profession is practiced. So, much of our work has focused on building understanding and awareness among members of Congress, among the administration, among state leaders, elected and appointed officials.

We have undertaken a variety of initiatives that we have not done before: briefings, roundtables, advertising that we’re doing in targeted publications, such as Congressional Daily, Politico, Roll Call. Some of these ads have really made a difference in terms of the role that we were invited to play in shaping health care reform. We were very much at the table. We were invited to the White House continually and invited to meetings with Congressional leaders throughout the drafting of health care reform legislation. So I think we’ve made some real strides there.

We’re not ignoring the public. But in an organization with limited resources, it’s been our feeling and our belief that the best service we can provide to our members and the best return we can put on their investment, in terms of their membership dues, is to make certain that policies are put in place that allow PAs to really practice to the full degree that they’re equipped to practice and to remove any barriers we can that prevent that.

We are beginning to make some inroads, from a public perception standpoint. Increasingly, as debate and understanding around health care reform begins to trickle across the country, we hear from and are engaging more and more folks from the mainstream media, such as MSNBC, Newsweek, the Wall Street Journal, and others.

They’re seeing, from a legislative point of view, multiple references to this profession called “physician assistants,” and they want to talk to us. They want to know about the profession so they can inform consumers on how to access and utilize PAs.

So I’m really proud of the work we’ve accomplished there. We have a long way to go—and really that work will never stop. But I think we have been on target in terms of how we have focused our resources, and we need to continue that very strongly in the future.

CR: What other messages do you have for PAs and their NP colleagues?

Leinweber: From a professional point of view, I can’t imagine a more well-positioned, exciting, and thriving profession at this point in history than the physician assistant profession. We are really poised to play the leadership role that some may argue we have played for decades quietly, but I think [now] much more visibly and with much more recognition. I just think there’s a level of relevance and consideration about the profession that hasn’t existed before. That’s very exciting, and it bodes very well for the future of the profession.

Relative to our work with our NP colleagues, there is an enormous amount of work needed by NPs and PAs across the country and across the health care spectrum. PAs and NPs work extremely well together and often seamlessly on the clinical level, and my hope would be to leverage every opportunity we can at the national level to make sure patients have access to the best quality of care, to the best providers, when they need it.

Since joining the American Academy of Physician Assistants (AAPA) in February 2008 as Executive Vice President and CEO, Bill Leinweber has brought positive energy and a new focus to the organization. Despite his busy schedule, Leinweber recently found time to speak with Clinician Reviews about AAPA’s goals and priorities, the impact of health care reform on the direction of the profession, and efforts to raise PAs’ public profile.

Clinician Reviews: When you joined AAPA, what was your assessment of the profession’s needs?

Leinweber: My observation and experience was, from a PA perspective, a very high level of enthusiasm and commitment by PAs about the profession, and a strong desire for the profession to take its rightful, prominent place in health care. I really sensed a hunger, in those who make up the profession, for recognition, of wanting to be perceived as truly a player in the delivery of health care and the policy that accompanies that delivery.

CR: Of the changes implemented at AAPA in the past two years, which for you is the most significant and/or satisfying?

Leinweber: What jumps to mind is shifting the real focus and the work of the Board of Directors of the Academy from that of an operational board to a strategic board. What are the truly big issues and major priorities that the board needs to focus their time and attention on and allocate the organization’s resources to address? As we become more strategically focused, you’ll see continuity in terms of the goals that we’re working to achieve and the resources we’re putting behind achieving those goals.

We have also worked hard to shift—and this continues; I don’t want to suggest it’s completed—from a very process-driven organization to one that really wants to look at outcomes. You need some level of process, but if you have a lot of process but not the outcomes that really move the ball forward, then you’re not serving your members.

That said, there will be things that individuals or groups of individuals in the profession believe should be a priority that aren’t. I want to be clear that even in moving to a strategic focus and direction, everybody doesn’t get everything they want addressed all the time. That’s a challenge.

CR: What are your immediate and ongoing priorities for AAPA?

Leinweber: Our policymakers just passed historic health care reform legislation. There are clearly, even within our profession, varying points of view across the political spectrum in support for or opposition to health care reform.

The Academy had no position per se on any bill in its entirety. What we focused on was to ensure that as any and all legislation began to take shape, PAs were prominently and appropriately identified as key to the success of any reform effort.

I believe we made huge headway there. PAs are called out by name in the legislation, in terms of being critical to the success of the expansion of primary care and in a number of other ways.

That has implications in terms of priorities. The country will now move from a legislative process to the implementation of many of the provisions in the reform legislation over the next several years. That will have bearing on some of our work and some of our priorities. What will this mean for us as a profession? What does it mean for us as an Academy, and how do we respond?

Certainly the number of PAs in primary care today is not what it once was. We feel an obligation to really be looking for strategies to help grow, to the fullest degree possible, interest and commitment to primary care—and to do that in a way that doesn’t detract from the important contributions PAs in specialties are making.

I look at this as, how do we grow the whole “pie” of PAs exponentially, so that we can contribute larger numbers to the critical need in primary care, in addition to having PAs filling needs in surgery, surgical subspecialties, internal medicine, etc?

We continue to move forward with the development of a research agenda for the profession. In that regard, we hosted a research summit in early March, which was very well attended. We’ll be putting out a proceedings paper from that summit soon, which will outline the steps we will take to formulate a research agenda for the profession.

Also, we’re undertaking a lot of work on the governance front of the Academy. Over the next year, we’ll be looking at the relationship AAPA has with its state chapters and with its specialty organizations. The way those relationships have been chartered and have worked hasn’t really changed in 30 or 40 years, and I think the world in that time has changed dramatically.

The profession has grown dramatically, and it’s time for us to sit down with representatives of our constituent organizations and make sure that we’re working in the best model that we can to have the fullest impact at the local and the national level.

CR: How will AAPA address the increased movement by PAs from primary to specialty care?

Leinweber: If you step back and look at primary health care in its totality, the reality is that the demand for PAs continues to outstrip the supply. When you look at health care reform and the strong focus on primary care, I don’t think we’re necessarily going to see any immediate lessening of demand for PAs in specialty areas at the expense of growth in the primary care arena. So our challenge will be to grow that pie in totality.

We worked to have incentives built into the health care reform legislation that would encourage PA programs to participate in grant programs and other efforts that would really reward them for growing the number of PAs who choose primary care as their specialty, and to incentivize students who choose that path by increasing opportunities through the National Health Service Corps and loan forgiveness programs. Those things matter.

When you look at the primary care challenges of the country, the challenges that MDs or DOs face in terms of trying to grow the cadre of individuals going into primary care aren’t all that different from what we face. It comes down to quality of life, the compensation that’s tied to that particular kind of medicine, opportunities for advancement, flexibility.

Those are all issues that we’re going to have to address. We’ve begun to do that, but we’re going to have to work with organized medicine to continue to push for a shift in how the country rewards and positions primary care.

CR: How will AAPA provide support to PAs in specialties, while maintaining its commitment to primary care?

Leinweber: There are 24 specialty organizations that have a charter agreement with AAPA and are represented in our House of Delegates. We work closely with our specialty organizations; we collaborate with them, increasingly, on continuing medical education (CME) programs that they provide to their members.

The AAPA will work with the Society of PAs in Pediatrics, for example, and work to bring the American Academy of Pediatrics to the table so that we can contribute to shaping the delivery of programs that are of value to PAs in particular specialty fields. I certainly see us continuing to do that.

We completely recognize that the demographic has shifted. Our statistics now show that 35.7% of PAs identify themselves as practicing in primary care. So, that means almost 65% are in a specialized field. That’s a reality that we look at and we shape our services accordingly.

But considering how things are moving nationwide, relative to a reformed health care system, we very much feel the need, the pressure, and the obligation to do everything we can to grow those primary care numbers.

CR: What opportunities do you see for PAs to partner with NPs?

Leinweber: We are doing some partnering now in the form of joint CME programs that we’ve conducted in the past couple of years with the American Academy of Nurse Practitioners and various doctor specialty groups. For instance, there was a boot camp last August with the Society for Hospital Medicine. We will collaboratively put on programs that are designed to serve the CME needs of PAs and NPs primarily, although physicians can participate as well. Those have been tremendously successful. We certainly want to continue to do that.

On the legislative front, I think there is value in PAs and NPs working collaboratively wherever we can at the federal level. Wherever we have common messages that support our various legislative goals, we’re certainly open to that. I think when you start to look at the state level and where health care is delivered, on the front lines, things become a little more challenging because we don’t answer to the same regulatory body at that level.

But our philosophy is, the country has an enormous need in terms of individuals requiring care from qualified, competent providers. We need many more PAs, we need more NPs; there are very important and distinct roles that we play. And wherever we can work together to bring the wherewithal of our respective professions to improve health care and health care delivery, I think we need to be open to that and look for those opportunities.

CR: NPs have been touted for significantly raising their public profile, while many PAs feel their profession has lagged behind in this area. How is AAPA approaching the public perception and marketing of the profession?

Leinweber: First of all, I think it’s accurate to say that the NPs have been ahead of us from a policymaker and a public recognition/perception point of view. But I think we’ve made some significant strides over the past couple of years with the PA profession.

We have been very targeted in our approach. We made a conscious decision that it was critical to elevate the presence and the positioning of the profession first and foremost among policymakers and thought leaders who have the authority to impact how the profession is practiced. So, much of our work has focused on building understanding and awareness among members of Congress, among the administration, among state leaders, elected and appointed officials.

We have undertaken a variety of initiatives that we have not done before: briefings, roundtables, advertising that we’re doing in targeted publications, such as Congressional Daily, Politico, Roll Call. Some of these ads have really made a difference in terms of the role that we were invited to play in shaping health care reform. We were very much at the table. We were invited to the White House continually and invited to meetings with Congressional leaders throughout the drafting of health care reform legislation. So I think we’ve made some real strides there.

We’re not ignoring the public. But in an organization with limited resources, it’s been our feeling and our belief that the best service we can provide to our members and the best return we can put on their investment, in terms of their membership dues, is to make certain that policies are put in place that allow PAs to really practice to the full degree that they’re equipped to practice and to remove any barriers we can that prevent that.

We are beginning to make some inroads, from a public perception standpoint. Increasingly, as debate and understanding around health care reform begins to trickle across the country, we hear from and are engaging more and more folks from the mainstream media, such as MSNBC, Newsweek, the Wall Street Journal, and others.

They’re seeing, from a legislative point of view, multiple references to this profession called “physician assistants,” and they want to talk to us. They want to know about the profession so they can inform consumers on how to access and utilize PAs.

So I’m really proud of the work we’ve accomplished there. We have a long way to go—and really that work will never stop. But I think we have been on target in terms of how we have focused our resources, and we need to continue that very strongly in the future.

CR: What other messages do you have for PAs and their NP colleagues?

Leinweber: From a professional point of view, I can’t imagine a more well-positioned, exciting, and thriving profession at this point in history than the physician assistant profession. We are really poised to play the leadership role that some may argue we have played for decades quietly, but I think [now] much more visibly and with much more recognition. I just think there’s a level of relevance and consideration about the profession that hasn’t existed before. That’s very exciting, and it bodes very well for the future of the profession.

Relative to our work with our NP colleagues, there is an enormous amount of work needed by NPs and PAs across the country and across the health care spectrum. PAs and NPs work extremely well together and often seamlessly on the clinical level, and my hope would be to leverage every opportunity we can at the national level to make sure patients have access to the best quality of care, to the best providers, when they need it.

Since joining the American Academy of Physician Assistants (AAPA) in February 2008 as Executive Vice President and CEO, Bill Leinweber has brought positive energy and a new focus to the organization. Despite his busy schedule, Leinweber recently found time to speak with Clinician Reviews about AAPA’s goals and priorities, the impact of health care reform on the direction of the profession, and efforts to raise PAs’ public profile.

Clinician Reviews: When you joined AAPA, what was your assessment of the profession’s needs?

Leinweber: My observation and experience was, from a PA perspective, a very high level of enthusiasm and commitment by PAs about the profession, and a strong desire for the profession to take its rightful, prominent place in health care. I really sensed a hunger, in those who make up the profession, for recognition, of wanting to be perceived as truly a player in the delivery of health care and the policy that accompanies that delivery.

CR: Of the changes implemented at AAPA in the past two years, which for you is the most significant and/or satisfying?

Leinweber: What jumps to mind is shifting the real focus and the work of the Board of Directors of the Academy from that of an operational board to a strategic board. What are the truly big issues and major priorities that the board needs to focus their time and attention on and allocate the organization’s resources to address? As we become more strategically focused, you’ll see continuity in terms of the goals that we’re working to achieve and the resources we’re putting behind achieving those goals.

We have also worked hard to shift—and this continues; I don’t want to suggest it’s completed—from a very process-driven organization to one that really wants to look at outcomes. You need some level of process, but if you have a lot of process but not the outcomes that really move the ball forward, then you’re not serving your members.

That said, there will be things that individuals or groups of individuals in the profession believe should be a priority that aren’t. I want to be clear that even in moving to a strategic focus and direction, everybody doesn’t get everything they want addressed all the time. That’s a challenge.

CR: What are your immediate and ongoing priorities for AAPA?

Leinweber: Our policymakers just passed historic health care reform legislation. There are clearly, even within our profession, varying points of view across the political spectrum in support for or opposition to health care reform.

The Academy had no position per se on any bill in its entirety. What we focused on was to ensure that as any and all legislation began to take shape, PAs were prominently and appropriately identified as key to the success of any reform effort.

I believe we made huge headway there. PAs are called out by name in the legislation, in terms of being critical to the success of the expansion of primary care and in a number of other ways.

That has implications in terms of priorities. The country will now move from a legislative process to the implementation of many of the provisions in the reform legislation over the next several years. That will have bearing on some of our work and some of our priorities. What will this mean for us as a profession? What does it mean for us as an Academy, and how do we respond?

Certainly the number of PAs in primary care today is not what it once was. We feel an obligation to really be looking for strategies to help grow, to the fullest degree possible, interest and commitment to primary care—and to do that in a way that doesn’t detract from the important contributions PAs in specialties are making.

I look at this as, how do we grow the whole “pie” of PAs exponentially, so that we can contribute larger numbers to the critical need in primary care, in addition to having PAs filling needs in surgery, surgical subspecialties, internal medicine, etc?

We continue to move forward with the development of a research agenda for the profession. In that regard, we hosted a research summit in early March, which was very well attended. We’ll be putting out a proceedings paper from that summit soon, which will outline the steps we will take to formulate a research agenda for the profession.

Also, we’re undertaking a lot of work on the governance front of the Academy. Over the next year, we’ll be looking at the relationship AAPA has with its state chapters and with its specialty organizations. The way those relationships have been chartered and have worked hasn’t really changed in 30 or 40 years, and I think the world in that time has changed dramatically.

The profession has grown dramatically, and it’s time for us to sit down with representatives of our constituent organizations and make sure that we’re working in the best model that we can to have the fullest impact at the local and the national level.

CR: How will AAPA address the increased movement by PAs from primary to specialty care?

Leinweber: If you step back and look at primary health care in its totality, the reality is that the demand for PAs continues to outstrip the supply. When you look at health care reform and the strong focus on primary care, I don’t think we’re necessarily going to see any immediate lessening of demand for PAs in specialty areas at the expense of growth in the primary care arena. So our challenge will be to grow that pie in totality.

We worked to have incentives built into the health care reform legislation that would encourage PA programs to participate in grant programs and other efforts that would really reward them for growing the number of PAs who choose primary care as their specialty, and to incentivize students who choose that path by increasing opportunities through the National Health Service Corps and loan forgiveness programs. Those things matter.

When you look at the primary care challenges of the country, the challenges that MDs or DOs face in terms of trying to grow the cadre of individuals going into primary care aren’t all that different from what we face. It comes down to quality of life, the compensation that’s tied to that particular kind of medicine, opportunities for advancement, flexibility.

Those are all issues that we’re going to have to address. We’ve begun to do that, but we’re going to have to work with organized medicine to continue to push for a shift in how the country rewards and positions primary care.

CR: How will AAPA provide support to PAs in specialties, while maintaining its commitment to primary care?

Leinweber: There are 24 specialty organizations that have a charter agreement with AAPA and are represented in our House of Delegates. We work closely with our specialty organizations; we collaborate with them, increasingly, on continuing medical education (CME) programs that they provide to their members.

The AAPA will work with the Society of PAs in Pediatrics, for example, and work to bring the American Academy of Pediatrics to the table so that we can contribute to shaping the delivery of programs that are of value to PAs in particular specialty fields. I certainly see us continuing to do that.

We completely recognize that the demographic has shifted. Our statistics now show that 35.7% of PAs identify themselves as practicing in primary care. So, that means almost 65% are in a specialized field. That’s a reality that we look at and we shape our services accordingly.

But considering how things are moving nationwide, relative to a reformed health care system, we very much feel the need, the pressure, and the obligation to do everything we can to grow those primary care numbers.

CR: What opportunities do you see for PAs to partner with NPs?

Leinweber: We are doing some partnering now in the form of joint CME programs that we’ve conducted in the past couple of years with the American Academy of Nurse Practitioners and various doctor specialty groups. For instance, there was a boot camp last August with the Society for Hospital Medicine. We will collaboratively put on programs that are designed to serve the CME needs of PAs and NPs primarily, although physicians can participate as well. Those have been tremendously successful. We certainly want to continue to do that.

On the legislative front, I think there is value in PAs and NPs working collaboratively wherever we can at the federal level. Wherever we have common messages that support our various legislative goals, we’re certainly open to that. I think when you start to look at the state level and where health care is delivered, on the front lines, things become a little more challenging because we don’t answer to the same regulatory body at that level.

But our philosophy is, the country has an enormous need in terms of individuals requiring care from qualified, competent providers. We need many more PAs, we need more NPs; there are very important and distinct roles that we play. And wherever we can work together to bring the wherewithal of our respective professions to improve health care and health care delivery, I think we need to be open to that and look for those opportunities.

CR: NPs have been touted for significantly raising their public profile, while many PAs feel their profession has lagged behind in this area. How is AAPA approaching the public perception and marketing of the profession?

Leinweber: First of all, I think it’s accurate to say that the NPs have been ahead of us from a policymaker and a public recognition/perception point of view. But I think we’ve made some significant strides over the past couple of years with the PA profession.

We have been very targeted in our approach. We made a conscious decision that it was critical to elevate the presence and the positioning of the profession first and foremost among policymakers and thought leaders who have the authority to impact how the profession is practiced. So, much of our work has focused on building understanding and awareness among members of Congress, among the administration, among state leaders, elected and appointed officials.

We have undertaken a variety of initiatives that we have not done before: briefings, roundtables, advertising that we’re doing in targeted publications, such as Congressional Daily, Politico, Roll Call. Some of these ads have really made a difference in terms of the role that we were invited to play in shaping health care reform. We were very much at the table. We were invited to the White House continually and invited to meetings with Congressional leaders throughout the drafting of health care reform legislation. So I think we’ve made some real strides there.

We’re not ignoring the public. But in an organization with limited resources, it’s been our feeling and our belief that the best service we can provide to our members and the best return we can put on their investment, in terms of their membership dues, is to make certain that policies are put in place that allow PAs to really practice to the full degree that they’re equipped to practice and to remove any barriers we can that prevent that.

We are beginning to make some inroads, from a public perception standpoint. Increasingly, as debate and understanding around health care reform begins to trickle across the country, we hear from and are engaging more and more folks from the mainstream media, such as MSNBC, Newsweek, the Wall Street Journal, and others.

They’re seeing, from a legislative point of view, multiple references to this profession called “physician assistants,” and they want to talk to us. They want to know about the profession so they can inform consumers on how to access and utilize PAs.

So I’m really proud of the work we’ve accomplished there. We have a long way to go—and really that work will never stop. But I think we have been on target in terms of how we have focused our resources, and we need to continue that very strongly in the future.

CR: What other messages do you have for PAs and their NP colleagues?

Leinweber: From a professional point of view, I can’t imagine a more well-positioned, exciting, and thriving profession at this point in history than the physician assistant profession. We are really poised to play the leadership role that some may argue we have played for decades quietly, but I think [now] much more visibly and with much more recognition. I just think there’s a level of relevance and consideration about the profession that hasn’t existed before. That’s very exciting, and it bodes very well for the future of the profession.

Relative to our work with our NP colleagues, there is an enormous amount of work needed by NPs and PAs across the country and across the health care spectrum. PAs and NPs work extremely well together and often seamlessly on the clinical level, and my hope would be to leverage every opportunity we can at the national level to make sure patients have access to the best quality of care, to the best providers, when they need it.

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”                            

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”                            

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”                            

Just two weeks after Breast Cancer Awareness Month ended, the US Preventive Services Task Force (USPSTF) dropped a bombshell on patients and health care providers across the country. The Task Force now recommends against routine screening mammography for breast cancer in average-risk women ages 40 to 49.

The American Cancer Society (ACS) promptly issued a statement from Chief Medical Officer Otis W. Brawley, MD: "The [ACS]continues to recommend annual screening using mammography ... for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. "

Almost instantly, the debate began. Which set of guidelines will clinicians follow? How confusing will the conflicting recommendations be for patients? And perhaps most alarming—and least controllable—which guidelines will insurers base their coverage on?

USPSTF Assessment
"The decision to start regular, biennial screening mammography before the age of 50," the USPSTF says, "should be an individual one and [should] take patient context into account, including the patient's values regarding specific benefits and harms." The Task Force based its recommendation on "convincing evidence" that while mammography reduces breast cancer mortality, the absolute reduction is greater in women ages 50 to 74 than in those ages 40 to 49. Furthermore, the USPSTF says there is "moderate certainty" that the net benefit of mammography screening in the younger age-group is small.

Nelson et al performed a systematic literature review for the USPSTF (Ann Intern Med. 2009; 151[10]:727-737). This analysis revealed a pooled relative risk for breast cancer mortality among women screened with mammography of 0.85 in those ages 40 to 49 and 0.86 in those ages 50 to 59. The researchers also found a "number needed to invite [for screening] to prevent one breast cancer death" of 1,904 for women ages 39 to 49 and 1,339 for those ages 50 to 59. The latter data show, according to the USPSTF, that "the absolute risk reduction ... is greater" for women in the older age-group.

Also published in the same issue of Annals of Internal Medicine were results from a related study by the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (2009;151[10]:738-747). Mandelblatt et al used six models to predict the benefits and harms of 20 different mammography screening strategies (with various ages of initiation and cessation, as well as different screening frequencies [annual or biennial]).

The Working Group found that "screening every other year from ages 50 to 69 ... is an efficient strategy for reducing breast cancer mortality." Beginning to screen at age 40 provided "additional, albeit small, reductions" that equated to a median one additional breast cancer–related death averted per 1,000 women screened on an annual basis. Annual screening beginning at age 40 also provided a median 33 life-years gained per 1,000 women screened. The Working Group also reported, however, that the rate of false-positive results for annual screening of women from age 40 through 69 was 2,250 per 1,000 women screened.

Based on these and other findings, the USPSTF concluded that "the additional benefit gained by starting screening at age 40 ... rather than at age 50 ... is small, and that moderate harms from screening remain at any age."

The Backlash
According to Brawley's statement, the ACS is aware that "the overall effectiveness of mammography increases with increasing age." However, he added, screening women starting at age 40 does save lives.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age[s] 40 to 49 saves lives; just not enough of them," Brawley stated.

The ACS statement cites recent data indicating that about 17% of breast cancer deaths occur in women diagnosed during their 40s, and 22% occur in those diagnosed during their 50s. Brawley said that ACS staff, members, and supporters "overwhelmingly believe the benefits of screening women ages 40 to 49 outweigh its limitations."

In his online cancer blog (www .cancer.org/aspx/blog), J. Leonard Lichtenfeld, MD, MACP, Deputy Chief Medical Officer of ACS, wrote at length about the new recommendations from USPSTF. He referenced the modeling study by Mandelblatt and colleagues (among other research), noting that depending on which model was used, breast cancer mortality was reduced by as much as 54% when women were screened annually between ages 40 and 84; by comparison, the reduction was 28% when women ages 50 to 74 were screened every two years. Other models revealed little or no difference, he acknowledged.

Lichtenfeld summarized the research this way: "You could get somewhere between 70% and 99% of the benefit of screening mammograms (that is, reducing deaths from breast cancer) while reducing the harms by about 50% if you started screening at age 50 and did it every two years, as compared to starting at age 40 and doing it every year."

However, he added, ACS "[does not] agree that 70% of the benefit from screening mammograms is the right way to go.... We should not forget that the 'benefit' in this situation is reducing deaths from breast cancer. A 30% reduction in saving lives in not acceptable."

Several patients posted comments to Lichtenfeld's blog, writing in essence that if they had followed what these guidelines propose, they "would be dead at 50." While the USPSTF has stated that the decision to screen at earlier ages should be based on the patient's and provider's judgment, there is concern that insurance companies will adhere to these guidelines, making it more difficult, or more expensive, for women to receive mammograms in their 40s, or on an annual rather than biennial basis.

One patient also expressed frustration with the lack of attention to women who are diagnosed with breast cancer in their 20s and 30s, saying, "If it's going to become more difficult for women in their 40s to get a mammogram, what is that going to do for women in their 20s and 30s, who already get blown off by their health care providers when they come in with a lump?"

There will undoubtedly be ongoing debate and discussion as to what impact the USPSTF recommendations will have, and clinicians will need to be prepared to answer questions from concerned (or even angry) patients. Lichtenfeld perhaps said it best in this blog posting: "These changes are bound to confuse women and health care professionals who must now make a professional and a personal choice as to which recommendations to follow. The worst outcome would be if the confusion leads women to do nothing, since the experts can't seem to make up their minds."

Just two weeks after Breast Cancer Awareness Month ended, the US Preventive Services Task Force (USPSTF) dropped a bombshell on patients and health care providers across the country. The Task Force now recommends against routine screening mammography for breast cancer in average-risk women ages 40 to 49.

The American Cancer Society (ACS) promptly issued a statement from Chief Medical Officer Otis W. Brawley, MD: "The [ACS]continues to recommend annual screening using mammography ... for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. "

Almost instantly, the debate began. Which set of guidelines will clinicians follow? How confusing will the conflicting recommendations be for patients? And perhaps most alarming—and least controllable—which guidelines will insurers base their coverage on?

USPSTF Assessment
"The decision to start regular, biennial screening mammography before the age of 50," the USPSTF says, "should be an individual one and [should] take patient context into account, including the patient's values regarding specific benefits and harms." The Task Force based its recommendation on "convincing evidence" that while mammography reduces breast cancer mortality, the absolute reduction is greater in women ages 50 to 74 than in those ages 40 to 49. Furthermore, the USPSTF says there is "moderate certainty" that the net benefit of mammography screening in the younger age-group is small.

Nelson et al performed a systematic literature review for the USPSTF (Ann Intern Med. 2009; 151[10]:727-737). This analysis revealed a pooled relative risk for breast cancer mortality among women screened with mammography of 0.85 in those ages 40 to 49 and 0.86 in those ages 50 to 59. The researchers also found a "number needed to invite [for screening] to prevent one breast cancer death" of 1,904 for women ages 39 to 49 and 1,339 for those ages 50 to 59. The latter data show, according to the USPSTF, that "the absolute risk reduction ... is greater" for women in the older age-group.

Also published in the same issue of Annals of Internal Medicine were results from a related study by the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (2009;151[10]:738-747). Mandelblatt et al used six models to predict the benefits and harms of 20 different mammography screening strategies (with various ages of initiation and cessation, as well as different screening frequencies [annual or biennial]).

The Working Group found that "screening every other year from ages 50 to 69 ... is an efficient strategy for reducing breast cancer mortality." Beginning to screen at age 40 provided "additional, albeit small, reductions" that equated to a median one additional breast cancer–related death averted per 1,000 women screened on an annual basis. Annual screening beginning at age 40 also provided a median 33 life-years gained per 1,000 women screened. The Working Group also reported, however, that the rate of false-positive results for annual screening of women from age 40 through 69 was 2,250 per 1,000 women screened.

Based on these and other findings, the USPSTF concluded that "the additional benefit gained by starting screening at age 40 ... rather than at age 50 ... is small, and that moderate harms from screening remain at any age."

The Backlash
According to Brawley's statement, the ACS is aware that "the overall effectiveness of mammography increases with increasing age." However, he added, screening women starting at age 40 does save lives.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age[s] 40 to 49 saves lives; just not enough of them," Brawley stated.

The ACS statement cites recent data indicating that about 17% of breast cancer deaths occur in women diagnosed during their 40s, and 22% occur in those diagnosed during their 50s. Brawley said that ACS staff, members, and supporters "overwhelmingly believe the benefits of screening women ages 40 to 49 outweigh its limitations."

In his online cancer blog (www .cancer.org/aspx/blog), J. Leonard Lichtenfeld, MD, MACP, Deputy Chief Medical Officer of ACS, wrote at length about the new recommendations from USPSTF. He referenced the modeling study by Mandelblatt and colleagues (among other research), noting that depending on which model was used, breast cancer mortality was reduced by as much as 54% when women were screened annually between ages 40 and 84; by comparison, the reduction was 28% when women ages 50 to 74 were screened every two years. Other models revealed little or no difference, he acknowledged.

Lichtenfeld summarized the research this way: "You could get somewhere between 70% and 99% of the benefit of screening mammograms (that is, reducing deaths from breast cancer) while reducing the harms by about 50% if you started screening at age 50 and did it every two years, as compared to starting at age 40 and doing it every year."

However, he added, ACS "[does not] agree that 70% of the benefit from screening mammograms is the right way to go.... We should not forget that the 'benefit' in this situation is reducing deaths from breast cancer. A 30% reduction in saving lives in not acceptable."

Several patients posted comments to Lichtenfeld's blog, writing in essence that if they had followed what these guidelines propose, they "would be dead at 50." While the USPSTF has stated that the decision to screen at earlier ages should be based on the patient's and provider's judgment, there is concern that insurance companies will adhere to these guidelines, making it more difficult, or more expensive, for women to receive mammograms in their 40s, or on an annual rather than biennial basis.

One patient also expressed frustration with the lack of attention to women who are diagnosed with breast cancer in their 20s and 30s, saying, "If it's going to become more difficult for women in their 40s to get a mammogram, what is that going to do for women in their 20s and 30s, who already get blown off by their health care providers when they come in with a lump?"

There will undoubtedly be ongoing debate and discussion as to what impact the USPSTF recommendations will have, and clinicians will need to be prepared to answer questions from concerned (or even angry) patients. Lichtenfeld perhaps said it best in this blog posting: "These changes are bound to confuse women and health care professionals who must now make a professional and a personal choice as to which recommendations to follow. The worst outcome would be if the confusion leads women to do nothing, since the experts can't seem to make up their minds."

Just two weeks after Breast Cancer Awareness Month ended, the US Preventive Services Task Force (USPSTF) dropped a bombshell on patients and health care providers across the country. The Task Force now recommends against routine screening mammography for breast cancer in average-risk women ages 40 to 49.

The American Cancer Society (ACS) promptly issued a statement from Chief Medical Officer Otis W. Brawley, MD: "The [ACS]continues to recommend annual screening using mammography ... for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. "

Almost instantly, the debate began. Which set of guidelines will clinicians follow? How confusing will the conflicting recommendations be for patients? And perhaps most alarming—and least controllable—which guidelines will insurers base their coverage on?

USPSTF Assessment
"The decision to start regular, biennial screening mammography before the age of 50," the USPSTF says, "should be an individual one and [should] take patient context into account, including the patient's values regarding specific benefits and harms." The Task Force based its recommendation on "convincing evidence" that while mammography reduces breast cancer mortality, the absolute reduction is greater in women ages 50 to 74 than in those ages 40 to 49. Furthermore, the USPSTF says there is "moderate certainty" that the net benefit of mammography screening in the younger age-group is small.

Nelson et al performed a systematic literature review for the USPSTF (Ann Intern Med. 2009; 151[10]:727-737). This analysis revealed a pooled relative risk for breast cancer mortality among women screened with mammography of 0.85 in those ages 40 to 49 and 0.86 in those ages 50 to 59. The researchers also found a "number needed to invite [for screening] to prevent one breast cancer death" of 1,904 for women ages 39 to 49 and 1,339 for those ages 50 to 59. The latter data show, according to the USPSTF, that "the absolute risk reduction ... is greater" for women in the older age-group.

Also published in the same issue of Annals of Internal Medicine were results from a related study by the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (2009;151[10]:738-747). Mandelblatt et al used six models to predict the benefits and harms of 20 different mammography screening strategies (with various ages of initiation and cessation, as well as different screening frequencies [annual or biennial]).

The Working Group found that "screening every other year from ages 50 to 69 ... is an efficient strategy for reducing breast cancer mortality." Beginning to screen at age 40 provided "additional, albeit small, reductions" that equated to a median one additional breast cancer–related death averted per 1,000 women screened on an annual basis. Annual screening beginning at age 40 also provided a median 33 life-years gained per 1,000 women screened. The Working Group also reported, however, that the rate of false-positive results for annual screening of women from age 40 through 69 was 2,250 per 1,000 women screened.

Based on these and other findings, the USPSTF concluded that "the additional benefit gained by starting screening at age 40 ... rather than at age 50 ... is small, and that moderate harms from screening remain at any age."

The Backlash
According to Brawley's statement, the ACS is aware that "the overall effectiveness of mammography increases with increasing age." However, he added, screening women starting at age 40 does save lives.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age[s] 40 to 49 saves lives; just not enough of them," Brawley stated.

The ACS statement cites recent data indicating that about 17% of breast cancer deaths occur in women diagnosed during their 40s, and 22% occur in those diagnosed during their 50s. Brawley said that ACS staff, members, and supporters "overwhelmingly believe the benefits of screening women ages 40 to 49 outweigh its limitations."

In his online cancer blog (www .cancer.org/aspx/blog), J. Leonard Lichtenfeld, MD, MACP, Deputy Chief Medical Officer of ACS, wrote at length about the new recommendations from USPSTF. He referenced the modeling study by Mandelblatt and colleagues (among other research), noting that depending on which model was used, breast cancer mortality was reduced by as much as 54% when women were screened annually between ages 40 and 84; by comparison, the reduction was 28% when women ages 50 to 74 were screened every two years. Other models revealed little or no difference, he acknowledged.

Lichtenfeld summarized the research this way: "You could get somewhere between 70% and 99% of the benefit of screening mammograms (that is, reducing deaths from breast cancer) while reducing the harms by about 50% if you started screening at age 50 and did it every two years, as compared to starting at age 40 and doing it every year."

However, he added, ACS "[does not] agree that 70% of the benefit from screening mammograms is the right way to go.... We should not forget that the 'benefit' in this situation is reducing deaths from breast cancer. A 30% reduction in saving lives in not acceptable."

Several patients posted comments to Lichtenfeld's blog, writing in essence that if they had followed what these guidelines propose, they "would be dead at 50." While the USPSTF has stated that the decision to screen at earlier ages should be based on the patient's and provider's judgment, there is concern that insurance companies will adhere to these guidelines, making it more difficult, or more expensive, for women to receive mammograms in their 40s, or on an annual rather than biennial basis.

One patient also expressed frustration with the lack of attention to women who are diagnosed with breast cancer in their 20s and 30s, saying, "If it's going to become more difficult for women in their 40s to get a mammogram, what is that going to do for women in their 20s and 30s, who already get blown off by their health care providers when they come in with a lump?"

There will undoubtedly be ongoing debate and discussion as to what impact the USPSTF recommendations will have, and clinicians will need to be prepared to answer questions from concerned (or even angry) patients. Lichtenfeld perhaps said it best in this blog posting: "These changes are bound to confuse women and health care professionals who must now make a professional and a personal choice as to which recommendations to follow. The worst outcome would be if the confusion leads women to do nothing, since the experts can't seem to make up their minds."

Regular readers of “Malpractice Chronicle” know that all types of cases—from instances of clear-cut negligence to those of obvious noncompliance by the patient—find their way into the legal system. It often seems that there is no rhyme or reason to how a verdict is decided or how high the judgment or settlement is. In light of this unpredictability, protecting yourself—with liability insurance acquired through your practice or on your own—seems like a no-brainer.

Always There for You
It’s hard to imagine any clinician “going bare” and having no liability coverage at all. At the very least, most will be covered by their employer’s policy. But there are advantages to having your own malpractice insurance.

For one thing, it’s portable—wherever you practice, the policy goes with you—and it covers all aspects of professional liability. “It protects you 24 hours a day, so if you’re moonlighting, if you’re volunteering, you’re protected,” says Rebecca S. Crosby, Vice President of Marsh, the insurance brokerage for the American Academy of Nurse Practitioners (AANP). “It also protects you if you give advice—friends and family sue, too.” The policies offered through AANP and the American Academy of Physician Assistants (AAPA) also provide coverage for policyholders who are called before their state licensing board.

The policy is also 100% yours. “You are the only named person on the policy, so the limits are not shared,” says Ellen Rathfon, Senior Director of Professional Affairs for AAPA. “If you’re covered by your employer, the limits may be shared among several people—or a lot of people, depending on what kind of policy it is.”

In the event of a lawsuit, you will have your own legal representation. “There can be conflicts of interest between an employer or a supervising physician and the PA; they could be pointing fingers at each other,” says Gary M. McCammon, President of Professional Risk Advisors, Inc, the AAPA’s insurance broker. “And when a case is ultimately settled, or maybe it even goes to trial, the apportionment of liability can be greater if the PA is not in a position to negotiate his own liability.”

This can be important, because settlement information is reported to the National Practitioner Data Bank. Cases are often settled because it is ultimately less costly than taking a case to trial. Even a successful defense costs money, after all. But if a group of providers is named in the settlement, and they are covered by a single employer policy, the individual clinician may not be in a position to decide what portion of the settlement is his or her responsibility.

“Now, it doesn’t come out of their pocket, it comes out of the insurance,” Rathfon acknowledges. “But in the Data Bank, that clinician might have a high payment value.”

 ow Risk, High Cost?
You may think that PAs and NPs don’t get sued. Actually, they do. Not as often as physicians do, certainly, but even a small risk can carry a big price tag.

An analysis of data from the National Practitioner Data Bank, published earlier this year in the Journal of Medical Licensure and Discipline (a publication of the Federation of State Medical Boards), indicated that approximately 3% of active PAs and at least 1.5% of active APNs made a payment during the 17-year study period. However, while PAs and APNs accounted for 0.003% and 0.007%, respectively, of the $74 billion in malpractice payments made from 1991 to 2008, the mean/median payments for these providers were $173,128/$80,003 and $350,540/$190,898, respectively. The risk may be small, but is it one clinicians can afford?

“If you look at the spread of payments, some of them are really high,” Rathfon says. “And I think most people look at that and say, ‘I don’t want to take that risk.’”

In some cases, verdicts are exceeding even the limits of the defendant’s insurance, says Michele Kauffman, JD, PA-C, Chair of the Physician Assistant Department at Gannon University in Erie, Pennsylvania. This can open clinicians up to personal liability; while this hasn’t really happened yet, it’s a sobering possibility.

“Some states—Pennsylvania is one of them—now require PAs and NPs to have a minimum insurance, whether it’s through their employer or on their own,” Kauffman says. “In order to get their license, they have to prove that they have that insurance.”

Oh, and that old “deep pocket” argument—the idea that having liability insurance will just make you a target for litigation—is “a fallacy,” according to Crosby. “They’re going after everybody who even said ‘good morning’ to the patient. They don’t know if you have insurance until you’re in the discovery phase of the case.” By then, it’s too late to think about obtaining malpractice coverage.

Know Your Limits
Whether or not you opt for your own policy, know what coverage you do have. If you’re covered through your employer, make sure you have (at the very least) a copy of the declarations page, which will provide the name of the insurance company, the policy number, and the terms of coverage. McCammon suggests making it a condition of your employment that your employer will provide this information every year.

“People need to know their limits and know that they are individually named under those limits,” Rathfon says. “And they need to feel confident that there’s enough coverage, whatever the policy is, whether it’s their own or through their employer.”

Familiarize yourself with the type of policy you have: Is it occurrence-based or claims-made coverage? The former applies to any incident that occurs during the period of coverage, even if the claim is made years later. The latter covers claims filed during the life of the policy; people with this type of policy often purchase tail coverage to close any gaps that may occur. McCammon, who has authored a series of articles on liability insurance that can be found in the “Advocacy and Practice Resources” section on the AAPA Web site (www.aapa.org), says one type is not better than the other.

Occurrence-based coverage may be easier to manage; you file a copy for your records and hope you never need it. As Crosby says, “You can be retired and lying on the beach in Florida, and if there’s a lawsuit over something that happened in your last year of work, you would be covered.”

However, the economic downturn has highlighted one drawback to occurrence-based coverage: The company that covered you 10 or 20 years ago may not be in business by the time you have a claim. “Ten or 20 years ago, that was not a real issue,” McCammon says, “because companies just didn’t go under. But in this day and age, companies are getting out of the business or going out of business.”

That doesn’t mean you should avoid occurrence-based policies. But you might do a little extra homework on a company’s financial stability and longevity.

Rates depend on a number of factors, including geographic location and specialty of practice. AANP members can find information at www.proliability.com. AAPA members can contact AAPA Insurance Services at (877) 356-2272.

Regular readers of “Malpractice Chronicle” know that all types of cases—from instances of clear-cut negligence to those of obvious noncompliance by the patient—find their way into the legal system. It often seems that there is no rhyme or reason to how a verdict is decided or how high the judgment or settlement is. In light of this unpredictability, protecting yourself—with liability insurance acquired through your practice or on your own—seems like a no-brainer.

Always There for You
It’s hard to imagine any clinician “going bare” and having no liability coverage at all. At the very least, most will be covered by their employer’s policy. But there are advantages to having your own malpractice insurance.

For one thing, it’s portable—wherever you practice, the policy goes with you—and it covers all aspects of professional liability. “It protects you 24 hours a day, so if you’re moonlighting, if you’re volunteering, you’re protected,” says Rebecca S. Crosby, Vice President of Marsh, the insurance brokerage for the American Academy of Nurse Practitioners (AANP). “It also protects you if you give advice—friends and family sue, too.” The policies offered through AANP and the American Academy of Physician Assistants (AAPA) also provide coverage for policyholders who are called before their state licensing board.

The policy is also 100% yours. “You are the only named person on the policy, so the limits are not shared,” says Ellen Rathfon, Senior Director of Professional Affairs for AAPA. “If you’re covered by your employer, the limits may be shared among several people—or a lot of people, depending on what kind of policy it is.”

In the event of a lawsuit, you will have your own legal representation. “There can be conflicts of interest between an employer or a supervising physician and the PA; they could be pointing fingers at each other,” says Gary M. McCammon, President of Professional Risk Advisors, Inc, the AAPA’s insurance broker. “And when a case is ultimately settled, or maybe it even goes to trial, the apportionment of liability can be greater if the PA is not in a position to negotiate his own liability.”

This can be important, because settlement information is reported to the National Practitioner Data Bank. Cases are often settled because it is ultimately less costly than taking a case to trial. Even a successful defense costs money, after all. But if a group of providers is named in the settlement, and they are covered by a single employer policy, the individual clinician may not be in a position to decide what portion of the settlement is his or her responsibility.

“Now, it doesn’t come out of their pocket, it comes out of the insurance,” Rathfon acknowledges. “But in the Data Bank, that clinician might have a high payment value.”

 ow Risk, High Cost?
You may think that PAs and NPs don’t get sued. Actually, they do. Not as often as physicians do, certainly, but even a small risk can carry a big price tag.

An analysis of data from the National Practitioner Data Bank, published earlier this year in the Journal of Medical Licensure and Discipline (a publication of the Federation of State Medical Boards), indicated that approximately 3% of active PAs and at least 1.5% of active APNs made a payment during the 17-year study period. However, while PAs and APNs accounted for 0.003% and 0.007%, respectively, of the $74 billion in malpractice payments made from 1991 to 2008, the mean/median payments for these providers were $173,128/$80,003 and $350,540/$190,898, respectively. The risk may be small, but is it one clinicians can afford?

“If you look at the spread of payments, some of them are really high,” Rathfon says. “And I think most people look at that and say, ‘I don’t want to take that risk.’”

In some cases, verdicts are exceeding even the limits of the defendant’s insurance, says Michele Kauffman, JD, PA-C, Chair of the Physician Assistant Department at Gannon University in Erie, Pennsylvania. This can open clinicians up to personal liability; while this hasn’t really happened yet, it’s a sobering possibility.

“Some states—Pennsylvania is one of them—now require PAs and NPs to have a minimum insurance, whether it’s through their employer or on their own,” Kauffman says. “In order to get their license, they have to prove that they have that insurance.”

Oh, and that old “deep pocket” argument—the idea that having liability insurance will just make you a target for litigation—is “a fallacy,” according to Crosby. “They’re going after everybody who even said ‘good morning’ to the patient. They don’t know if you have insurance until you’re in the discovery phase of the case.” By then, it’s too late to think about obtaining malpractice coverage.

Know Your Limits
Whether or not you opt for your own policy, know what coverage you do have. If you’re covered through your employer, make sure you have (at the very least) a copy of the declarations page, which will provide the name of the insurance company, the policy number, and the terms of coverage. McCammon suggests making it a condition of your employment that your employer will provide this information every year.

“People need to know their limits and know that they are individually named under those limits,” Rathfon says. “And they need to feel confident that there’s enough coverage, whatever the policy is, whether it’s their own or through their employer.”

Familiarize yourself with the type of policy you have: Is it occurrence-based or claims-made coverage? The former applies to any incident that occurs during the period of coverage, even if the claim is made years later. The latter covers claims filed during the life of the policy; people with this type of policy often purchase tail coverage to close any gaps that may occur. McCammon, who has authored a series of articles on liability insurance that can be found in the “Advocacy and Practice Resources” section on the AAPA Web site (www.aapa.org), says one type is not better than the other.

Occurrence-based coverage may be easier to manage; you file a copy for your records and hope you never need it. As Crosby says, “You can be retired and lying on the beach in Florida, and if there’s a lawsuit over something that happened in your last year of work, you would be covered.”

However, the economic downturn has highlighted one drawback to occurrence-based coverage: The company that covered you 10 or 20 years ago may not be in business by the time you have a claim. “Ten or 20 years ago, that was not a real issue,” McCammon says, “because companies just didn’t go under. But in this day and age, companies are getting out of the business or going out of business.”

That doesn’t mean you should avoid occurrence-based policies. But you might do a little extra homework on a company’s financial stability and longevity.

Rates depend on a number of factors, including geographic location and specialty of practice. AANP members can find information at www.proliability.com. AAPA members can contact AAPA Insurance Services at (877) 356-2272.

Regular readers of “Malpractice Chronicle” know that all types of cases—from instances of clear-cut negligence to those of obvious noncompliance by the patient—find their way into the legal system. It often seems that there is no rhyme or reason to how a verdict is decided or how high the judgment or settlement is. In light of this unpredictability, protecting yourself—with liability insurance acquired through your practice or on your own—seems like a no-brainer.

Always There for You
It’s hard to imagine any clinician “going bare” and having no liability coverage at all. At the very least, most will be covered by their employer’s policy. But there are advantages to having your own malpractice insurance.

For one thing, it’s portable—wherever you practice, the policy goes with you—and it covers all aspects of professional liability. “It protects you 24 hours a day, so if you’re moonlighting, if you’re volunteering, you’re protected,” says Rebecca S. Crosby, Vice President of Marsh, the insurance brokerage for the American Academy of Nurse Practitioners (AANP). “It also protects you if you give advice—friends and family sue, too.” The policies offered through AANP and the American Academy of Physician Assistants (AAPA) also provide coverage for policyholders who are called before their state licensing board.

The policy is also 100% yours. “You are the only named person on the policy, so the limits are not shared,” says Ellen Rathfon, Senior Director of Professional Affairs for AAPA. “If you’re covered by your employer, the limits may be shared among several people—or a lot of people, depending on what kind of policy it is.”

In the event of a lawsuit, you will have your own legal representation. “There can be conflicts of interest between an employer or a supervising physician and the PA; they could be pointing fingers at each other,” says Gary M. McCammon, President of Professional Risk Advisors, Inc, the AAPA’s insurance broker. “And when a case is ultimately settled, or maybe it even goes to trial, the apportionment of liability can be greater if the PA is not in a position to negotiate his own liability.”

This can be important, because settlement information is reported to the National Practitioner Data Bank. Cases are often settled because it is ultimately less costly than taking a case to trial. Even a successful defense costs money, after all. But if a group of providers is named in the settlement, and they are covered by a single employer policy, the individual clinician may not be in a position to decide what portion of the settlement is his or her responsibility.

“Now, it doesn’t come out of their pocket, it comes out of the insurance,” Rathfon acknowledges. “But in the Data Bank, that clinician might have a high payment value.”

 ow Risk, High Cost?
You may think that PAs and NPs don’t get sued. Actually, they do. Not as often as physicians do, certainly, but even a small risk can carry a big price tag.

An analysis of data from the National Practitioner Data Bank, published earlier this year in the Journal of Medical Licensure and Discipline (a publication of the Federation of State Medical Boards), indicated that approximately 3% of active PAs and at least 1.5% of active APNs made a payment during the 17-year study period. However, while PAs and APNs accounted for 0.003% and 0.007%, respectively, of the $74 billion in malpractice payments made from 1991 to 2008, the mean/median payments for these providers were $173,128/$80,003 and $350,540/$190,898, respectively. The risk may be small, but is it one clinicians can afford?

“If you look at the spread of payments, some of them are really high,” Rathfon says. “And I think most people look at that and say, ‘I don’t want to take that risk.’”

In some cases, verdicts are exceeding even the limits of the defendant’s insurance, says Michele Kauffman, JD, PA-C, Chair of the Physician Assistant Department at Gannon University in Erie, Pennsylvania. This can open clinicians up to personal liability; while this hasn’t really happened yet, it’s a sobering possibility.

“Some states—Pennsylvania is one of them—now require PAs and NPs to have a minimum insurance, whether it’s through their employer or on their own,” Kauffman says. “In order to get their license, they have to prove that they have that insurance.”

Oh, and that old “deep pocket” argument—the idea that having liability insurance will just make you a target for litigation—is “a fallacy,” according to Crosby. “They’re going after everybody who even said ‘good morning’ to the patient. They don’t know if you have insurance until you’re in the discovery phase of the case.” By then, it’s too late to think about obtaining malpractice coverage.

Know Your Limits
Whether or not you opt for your own policy, know what coverage you do have. If you’re covered through your employer, make sure you have (at the very least) a copy of the declarations page, which will provide the name of the insurance company, the policy number, and the terms of coverage. McCammon suggests making it a condition of your employment that your employer will provide this information every year.

“People need to know their limits and know that they are individually named under those limits,” Rathfon says. “And they need to feel confident that there’s enough coverage, whatever the policy is, whether it’s their own or through their employer.”

Familiarize yourself with the type of policy you have: Is it occurrence-based or claims-made coverage? The former applies to any incident that occurs during the period of coverage, even if the claim is made years later. The latter covers claims filed during the life of the policy; people with this type of policy often purchase tail coverage to close any gaps that may occur. McCammon, who has authored a series of articles on liability insurance that can be found in the “Advocacy and Practice Resources” section on the AAPA Web site (www.aapa.org), says one type is not better than the other.

Occurrence-based coverage may be easier to manage; you file a copy for your records and hope you never need it. As Crosby says, “You can be retired and lying on the beach in Florida, and if there’s a lawsuit over something that happened in your last year of work, you would be covered.”

However, the economic downturn has highlighted one drawback to occurrence-based coverage: The company that covered you 10 or 20 years ago may not be in business by the time you have a claim. “Ten or 20 years ago, that was not a real issue,” McCammon says, “because companies just didn’t go under. But in this day and age, companies are getting out of the business or going out of business.”

That doesn’t mean you should avoid occurrence-based policies. But you might do a little extra homework on a company’s financial stability and longevity.

Rates depend on a number of factors, including geographic location and specialty of practice. AANP members can find information at www.proliability.com. AAPA members can contact AAPA Insurance Services at (877) 356-2272.

Call it the New Age of Transparency and Accountability: So far this year, two states—Massachusetts and Vermont—have enacted strict laws that codify and regulate the interactions between health care providers and pharmaceutical sales and marketing representatives. Whether you consider such legislation “draconian” (as some critics do) or essential, it appears to be part of a trend that advocates hope will continue.

While lauding Massachusetts and Vermont for “taking the lead” in these matters—going beyond other states’ laws that allow gifts and payments from pharmaceutical and device manufacturers to health care providers, as long as they are disclosed—Howard Brody, MD, PhD, Director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, laments that legislation has been necessary.

“I think it would really be ideal if professionally, we just decided among ourselves—doctors, nurse practitioners, physician assistants, and so on—that we would not accept this money,” Brody says. “Because it’s tainted money, really, and it compromises our commitment to our patients.”

Massachusetts: The Microcosm
The Massachusetts code of conduct—officially designated “105 CMR 970.000: Pharmaceutical and Medical Device Manufacturer Conduct”—is outlined in a 13-page document available at the Web site for the state’s Department of Public Health (www.mass.gov/dph). The code applies to industry interactions with any health care provider licensed to practice in Massachusetts—even if the encounter occurs in another state (say, at a national conference). Helpfully, there are three “frequently asked questions” sections in which the finer points of the regulations are explained, often with specific examples.

In a nutshell, the code prohibits gifts of entertainment or recreation (eg, trips, tickets to concerts or sporting events); complimentary branded items (eg, pens, mugs, calendars); and meals, unless certain circumstances are met. All provided meals must be “modest” and “occasional,” must take place in the practitioner’s office or hospital setting, and must be accompanied by an informational presentation. Items that have potential benefit to patients—such as drug samples or demonstration models of medical devices—are permissible under the new regulations.

With regard to sponsorship of continuing medical education (CME) programs, the code stipulates that pharmaceutical and medical device manufacturers may not provide financial support for travel, lodging, meals, or personal expenses to nonfaculty health care providers attending such events. They are also prohibited from sponsoring or paying for CME that does not comply with the Standards for Commercial Support set forth by the Accreditation Council for Continuing Medical Education or an equivalent accrediting body. Further, companies are also barred from providing “any advice or guidance to the CME provider regarding the content or faculty for a particular CME program funded by the company.”

Pharmaceutical and medical device manufacturers are required to disclose “the value, nature, purpose, and particular recipient of any fee, payment, subsidy, or other economic benefit with a value of at least $50 to any covered recipient in connection with the company’s sales and marketing activities.” Disclosure reports must be filed by July 1 each year, beginning in 2010, and must be accompanied by a $2,000 fee. The first reports will cover the six-month period from the regulations’ implementation on July 1, 2009, through December 31, 2009. Subsequent annual reports will cover the entire previous calendar year.

While the demise of the “free lunch” has received the most media attention, it is the CME restrictions that may pose the biggest challenges to clinicians in Massachusetts. Both the NP and PA professional organizations in the state have already started planning how they will continue to provide CME opportunities to their members while complying with the code.

“Since the change in attitude toward pharmaceutical company funding of CME events, we have had to be more creative in how we provide CME to our members,” says David Probert, PA-C, the Massachusetts Association of Physician Assistants (MAPA) Delegate to the American Academy of Physician Assistants, who has served on MAPA’s CME committee. “The continued operation of our professional organization will rely more on member support—ie, dues—than in the past.” MAPA is applying for grants from nonpharmaceutical sources, including the AAPA, local hospitals, and other employers of PAs.

The Massachusetts Coalition of Nurse Practitioners (MCNP) is also working to develop educational programs in partnership with larger institutions and universities. “We’re looking at how we can develop quarterly educational offerings … that we could open to our members for a small fee,” says MCNP President Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP. “We haven’t had to charge them anything for their educational opportunities, but at this point, we’re going to have to start. It’s probably going to be a nominal fee, but it still has to cover the cost of putting on the program. Speakers for these programs typically get a large honorarium, and that’s where the pharmaceutical companies were helping us—paying that honorarium.”

O’Rourke also points out that the location restrictions, while understandable, may pose challenges for those who are not in major urban areas such as Boston. “If you’re practicing out in central or western Massachusetts, you might be 100 miles from the nearest hospital setting,” she points out. But the law is the law, as she observes, and “there are still ways that you can provide education—you just have to work within that structure.”

Industry, Police Thyself?
The Massachusetts code mirrors, to a large extent, the voluntary code established by the Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA actually updated its code last year, and the changes took effect on January 1, 2009. Among them was the banning of gifts that are either “reminder items” (eg, the pens and preprinted notepads that everyone used to collect in the exhibit halls at conferences) or items that are of benefit to the prescriber. The updated PhRMA code is also more explicit about the situations in which provision of meals is appropriate and about the need for disclosure of any relationship between a pharmaceutical company and a health care provider if the latter is involved in the development of CME programs, clinical practice guidelines, or formulary decisions.

This industry-wide code is part of the reason that PhRMA opposed the Massachusetts legislation. “We’ve said consistently that it is the most draconian law in the country,” says Marjorie Powell, Senior Assistant General Counsel for PhRMA. “We think it’s not necessary—in part, because of the PhRMA code. We think it doesn’t do anything to improve patient care. It simply involves everybody in the health care system in much more recordkeeping and potential disputes over potential violations.”

 All PhRMA member companies and some nonmember companies have agreed to comply with the organization’s code; the names of all the companies’ compliance officers are listed on the PhRMA Web site (www.phrma.org), making it easy, Powell says, for a clinician to report a potential violation to the appropriate party. She adds that this provides “a great deal of both peer pressure and public pressure” for company representatives to comply with the code of conduct.

There are those who would suggest that a voluntary code administered by a leading industry organization may not be effective enough; that’s why laws like the ones in Massachusetts and Vermont become necessary. While it is not an apples-to-apples comparison, no one has been very impressed with the financial industry’s efforts at policing itself.

Brody, who authored the book Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, says the effectiveness of the more robust PhRMA code will be proven if marketing expenses decrease. “If they’re not doing all those things anymore—the lavish dinners, giving out pens and notepads and so on—shouldn’t there be a reduction in cost somewhere?” he asks. “Until I see some hard numbers, I’m going to be skeptical. I’m going to look for some evidence that it actually is working. And I can see why a state would say, ‘Well, the track record being what it is, maybe your voluntary code will work, but maybe it won’t. Just in case, we’re going to have this law on the books.’”

But Powell points out that pharmaceutical and medical device manufacturers, like all health care companies, are subject to the federal Anti-Kickback Statute. The FDA reviews all materials that are presented to prescribers and surveys health care providers to determine what types of information sales reps have provided about medications and devices. And the Centers for Medicare and Medicaid Services, the Department of Justice, and state attorneys general all have enforcement authority.

“Frankly, they have very strong enforcement authority,” Powell says, “and they bring actions if they think companies either have been failing to abide by the federal requirements or have been lax in their own enforcement…. It’s sort of a misunderstanding to say that the only thing that regulates the industry is this voluntary code. 

And while other states—including Oregon, Texas, Connecticut, Colorado, Illinois, and Maryland—are considering legislation that would either ban gift-giving or require public disclosure of it, the real battleground on this issue may be the US Congress. The devil may end up being in the details, but all parties are watching to see what progress the Physician Payments Sunshine Act will make at the federal level.

“We have consistently said that we think transparency has a place in the health care system, but that if there is going to be that kind of transparency, national reporting—one uniform standard—makes much more sense than 55 different standards,” Powell says. “So we in fact supported last year’s [version of the bill] because it had a national uniformity provision. This year, [that] provision is much weaker; it allows states to have their own additional reporting requirements.”

Brody, on the other hand, will be among those watching to see whether industry influence waters down the bill to a degree that would render it ineffective. “The fact of the matter is that if you follow the track record of the pharmaceutical industry, they almost always get their way in Washington,” he observes. “And they don’t get their way by shouting and screaming and making noise…. So you always have to be very careful and very cautious with any legislation.”

Under the Influence?
The entire ethics debate begs the question: How much influence does a pen or a notepad—or even a slice of pizza—really have on a health care provider’s prescribing habits, anyway? Obviously, there are what Brody calls “high rollers,” the physicians (predominantly) who receive consulting fees totaling millions of dollars in exchange for lending their expertise as “key opinion leaders” on behalf of pharmaceutical companies. But what about the average clinician?

“It’s true that it’s a very large industry, and there are always kids who will throw spitballs in class,” Powell admits. “But it’s a bit like saying, ‘OK, we’ve all lost our recess for the week because Johnny misbehaved.’”

The Massachusetts law “does not convey a lot of faith in the people of these professions to prescribe based on the research and the standard of care,” in the opinion of MAPA President Jillian Crowley, PA-C. “Personally, I cannot think of anyone who would be influenced to prescribe a drug based on a pen—or even remember the pharmaceutical company that produces the drug!”

MCNP President O’Rourke echoes that assessment, calling the Massachusetts code “almost like a slap on the wrist and ‘Big Brother is watching’ kind of stuff.” Her professional viewpoint, she says, has always been to go with the evidence-based data, with the acknowledgment that “pharmaceutical studies are usually skewed in some way. So you take the information and you prescribe what’s appropriate for the patient—not because of the pharmaceutical rep. I think I could say that probably 99.9% of the NP and medical communities feel that way. I think the law didn’t take that into consideration.”

But Brody cautions against assuming that any individual is immune to marketing. He recalls a pharmacist colleague from the hospital where he taught in the family practice residency program, who used to say: “There’s never any doubt in my mind when a drug rep has just come through, because there’s a spike in the prescriptions for the drug that that guy markets.”

“Smart people, profitable people, don’t waste money to the tune of billions of dollars in the US with a marketing strategy that does not work,” Brody argues. “The point is to recognize that we’re all human and we’re all susceptible to these kinds of influences.”

Powell points out that the focus on the pharmaceutical industry overlooks other potentially influencing factors. “When you talk to prescribers, they consistently say that the largest influence on their prescribing decisions is the formulary that the patient’s health insurer establishes,” she says. “But nobody regulates their medical decisions. And in fact, some insurers are paying prescribers to switch patients’ medications, which for a pharmaceutical manufacturer would be a violation of the Anti-Kickback Statute.”

Powell also says that companies have “an obligation” to disseminate relevant information about medications to health care providers. “It’s vitally important that everybody in the health care system have the most current information about new medicines and medicine where there has been a change in the labeling,” she says. “Without that information, prescription medicines can’t be used effectively.”

Brody, on the other hand, says that every health care provider “should have a source of information they know they can go to and they can say, ‘I know that the drug companies are not controlling the information that I’m getting from this source.’”

Money Better Spent
Clearly, the conversation about interactions between pharmaceutical sales reps and health care providers will continue for the foreseeable future. But for PAs and NPs like Crowley and O’Rourke in Massachusetts, the bottom line is really that the money pharmaceutical companies (used to) spend on wining and dining them and their colleagues—an estimated $7 billion annually across the United States—could certainly be put to better use.

Crowley thinks there should be “some regulations on the amount of money [pharmaceutical companies] spend on advertising, so that we cut down on the costs that need to be relayed to the consumer… I think a balance needs to be obtained between the pharmaceutical companies and the state to achieve education for providers and marketing and the lowest cost of the drug to consumers.”

O’Rourke also sees more effective ways to use the thousands of dollars that would, in the past, have been spent to take a group of 20 or 25 NPs to dinner at a fancy restaurant in Boston and provide an expert speaker. “It’s an expensive proposition, and if you’re doing that across the country for many, many groups, you’re talking millions of dollars,” she says. “That money could absolutely go into research and development. It could clearly go to supporting the indigent drug programs for patients who don’t have any health insurance. Instead of being able to give them a sample pack of five pills, maybe they could get a month’s supply of their prescription.

“It has to come back to the patient. In health care, at some point, you lose sight of what’s right and what’s wrong for the patient.We have to bring health care back to that and have to focus on what’s good for patients and not necessarily what’s good for us.”        

Call it the New Age of Transparency and Accountability: So far this year, two states—Massachusetts and Vermont—have enacted strict laws that codify and regulate the interactions between health care providers and pharmaceutical sales and marketing representatives. Whether you consider such legislation “draconian” (as some critics do) or essential, it appears to be part of a trend that advocates hope will continue.

While lauding Massachusetts and Vermont for “taking the lead” in these matters—going beyond other states’ laws that allow gifts and payments from pharmaceutical and device manufacturers to health care providers, as long as they are disclosed—Howard Brody, MD, PhD, Director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, laments that legislation has been necessary.

“I think it would really be ideal if professionally, we just decided among ourselves—doctors, nurse practitioners, physician assistants, and so on—that we would not accept this money,” Brody says. “Because it’s tainted money, really, and it compromises our commitment to our patients.”

Massachusetts: The Microcosm
The Massachusetts code of conduct—officially designated “105 CMR 970.000: Pharmaceutical and Medical Device Manufacturer Conduct”—is outlined in a 13-page document available at the Web site for the state’s Department of Public Health (www.mass.gov/dph). The code applies to industry interactions with any health care provider licensed to practice in Massachusetts—even if the encounter occurs in another state (say, at a national conference). Helpfully, there are three “frequently asked questions” sections in which the finer points of the regulations are explained, often with specific examples.

In a nutshell, the code prohibits gifts of entertainment or recreation (eg, trips, tickets to concerts or sporting events); complimentary branded items (eg, pens, mugs, calendars); and meals, unless certain circumstances are met. All provided meals must be “modest” and “occasional,” must take place in the practitioner’s office or hospital setting, and must be accompanied by an informational presentation. Items that have potential benefit to patients—such as drug samples or demonstration models of medical devices—are permissible under the new regulations.

With regard to sponsorship of continuing medical education (CME) programs, the code stipulates that pharmaceutical and medical device manufacturers may not provide financial support for travel, lodging, meals, or personal expenses to nonfaculty health care providers attending such events. They are also prohibited from sponsoring or paying for CME that does not comply with the Standards for Commercial Support set forth by the Accreditation Council for Continuing Medical Education or an equivalent accrediting body. Further, companies are also barred from providing “any advice or guidance to the CME provider regarding the content or faculty for a particular CME program funded by the company.”

Pharmaceutical and medical device manufacturers are required to disclose “the value, nature, purpose, and particular recipient of any fee, payment, subsidy, or other economic benefit with a value of at least $50 to any covered recipient in connection with the company’s sales and marketing activities.” Disclosure reports must be filed by July 1 each year, beginning in 2010, and must be accompanied by a $2,000 fee. The first reports will cover the six-month period from the regulations’ implementation on July 1, 2009, through December 31, 2009. Subsequent annual reports will cover the entire previous calendar year.

While the demise of the “free lunch” has received the most media attention, it is the CME restrictions that may pose the biggest challenges to clinicians in Massachusetts. Both the NP and PA professional organizations in the state have already started planning how they will continue to provide CME opportunities to their members while complying with the code.

“Since the change in attitude toward pharmaceutical company funding of CME events, we have had to be more creative in how we provide CME to our members,” says David Probert, PA-C, the Massachusetts Association of Physician Assistants (MAPA) Delegate to the American Academy of Physician Assistants, who has served on MAPA’s CME committee. “The continued operation of our professional organization will rely more on member support—ie, dues—than in the past.” MAPA is applying for grants from nonpharmaceutical sources, including the AAPA, local hospitals, and other employers of PAs.

The Massachusetts Coalition of Nurse Practitioners (MCNP) is also working to develop educational programs in partnership with larger institutions and universities. “We’re looking at how we can develop quarterly educational offerings … that we could open to our members for a small fee,” says MCNP President Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP. “We haven’t had to charge them anything for their educational opportunities, but at this point, we’re going to have to start. It’s probably going to be a nominal fee, but it still has to cover the cost of putting on the program. Speakers for these programs typically get a large honorarium, and that’s where the pharmaceutical companies were helping us—paying that honorarium.”

O’Rourke also points out that the location restrictions, while understandable, may pose challenges for those who are not in major urban areas such as Boston. “If you’re practicing out in central or western Massachusetts, you might be 100 miles from the nearest hospital setting,” she points out. But the law is the law, as she observes, and “there are still ways that you can provide education—you just have to work within that structure.”

Industry, Police Thyself?
The Massachusetts code mirrors, to a large extent, the voluntary code established by the Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA actually updated its code last year, and the changes took effect on January 1, 2009. Among them was the banning of gifts that are either “reminder items” (eg, the pens and preprinted notepads that everyone used to collect in the exhibit halls at conferences) or items that are of benefit to the prescriber. The updated PhRMA code is also more explicit about the situations in which provision of meals is appropriate and about the need for disclosure of any relationship between a pharmaceutical company and a health care provider if the latter is involved in the development of CME programs, clinical practice guidelines, or formulary decisions.

This industry-wide code is part of the reason that PhRMA opposed the Massachusetts legislation. “We’ve said consistently that it is the most draconian law in the country,” says Marjorie Powell, Senior Assistant General Counsel for PhRMA. “We think it’s not necessary—in part, because of the PhRMA code. We think it doesn’t do anything to improve patient care. It simply involves everybody in the health care system in much more recordkeeping and potential disputes over potential violations.”

 All PhRMA member companies and some nonmember companies have agreed to comply with the organization’s code; the names of all the companies’ compliance officers are listed on the PhRMA Web site (www.phrma.org), making it easy, Powell says, for a clinician to report a potential violation to the appropriate party. She adds that this provides “a great deal of both peer pressure and public pressure” for company representatives to comply with the code of conduct.

There are those who would suggest that a voluntary code administered by a leading industry organization may not be effective enough; that’s why laws like the ones in Massachusetts and Vermont become necessary. While it is not an apples-to-apples comparison, no one has been very impressed with the financial industry’s efforts at policing itself.

Brody, who authored the book Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, says the effectiveness of the more robust PhRMA code will be proven if marketing expenses decrease. “If they’re not doing all those things anymore—the lavish dinners, giving out pens and notepads and so on—shouldn’t there be a reduction in cost somewhere?” he asks. “Until I see some hard numbers, I’m going to be skeptical. I’m going to look for some evidence that it actually is working. And I can see why a state would say, ‘Well, the track record being what it is, maybe your voluntary code will work, but maybe it won’t. Just in case, we’re going to have this law on the books.’”

But Powell points out that pharmaceutical and medical device manufacturers, like all health care companies, are subject to the federal Anti-Kickback Statute. The FDA reviews all materials that are presented to prescribers and surveys health care providers to determine what types of information sales reps have provided about medications and devices. And the Centers for Medicare and Medicaid Services, the Department of Justice, and state attorneys general all have enforcement authority.

“Frankly, they have very strong enforcement authority,” Powell says, “and they bring actions if they think companies either have been failing to abide by the federal requirements or have been lax in their own enforcement…. It’s sort of a misunderstanding to say that the only thing that regulates the industry is this voluntary code. 

And while other states—including Oregon, Texas, Connecticut, Colorado, Illinois, and Maryland—are considering legislation that would either ban gift-giving or require public disclosure of it, the real battleground on this issue may be the US Congress. The devil may end up being in the details, but all parties are watching to see what progress the Physician Payments Sunshine Act will make at the federal level.

“We have consistently said that we think transparency has a place in the health care system, but that if there is going to be that kind of transparency, national reporting—one uniform standard—makes much more sense than 55 different standards,” Powell says. “So we in fact supported last year’s [version of the bill] because it had a national uniformity provision. This year, [that] provision is much weaker; it allows states to have their own additional reporting requirements.”

Brody, on the other hand, will be among those watching to see whether industry influence waters down the bill to a degree that would render it ineffective. “The fact of the matter is that if you follow the track record of the pharmaceutical industry, they almost always get their way in Washington,” he observes. “And they don’t get their way by shouting and screaming and making noise…. So you always have to be very careful and very cautious with any legislation.”

Under the Influence?
The entire ethics debate begs the question: How much influence does a pen or a notepad—or even a slice of pizza—really have on a health care provider’s prescribing habits, anyway? Obviously, there are what Brody calls “high rollers,” the physicians (predominantly) who receive consulting fees totaling millions of dollars in exchange for lending their expertise as “key opinion leaders” on behalf of pharmaceutical companies. But what about the average clinician?

“It’s true that it’s a very large industry, and there are always kids who will throw spitballs in class,” Powell admits. “But it’s a bit like saying, ‘OK, we’ve all lost our recess for the week because Johnny misbehaved.’”

The Massachusetts law “does not convey a lot of faith in the people of these professions to prescribe based on the research and the standard of care,” in the opinion of MAPA President Jillian Crowley, PA-C. “Personally, I cannot think of anyone who would be influenced to prescribe a drug based on a pen—or even remember the pharmaceutical company that produces the drug!”

MCNP President O’Rourke echoes that assessment, calling the Massachusetts code “almost like a slap on the wrist and ‘Big Brother is watching’ kind of stuff.” Her professional viewpoint, she says, has always been to go with the evidence-based data, with the acknowledgment that “pharmaceutical studies are usually skewed in some way. So you take the information and you prescribe what’s appropriate for the patient—not because of the pharmaceutical rep. I think I could say that probably 99.9% of the NP and medical communities feel that way. I think the law didn’t take that into consideration.”

But Brody cautions against assuming that any individual is immune to marketing. He recalls a pharmacist colleague from the hospital where he taught in the family practice residency program, who used to say: “There’s never any doubt in my mind when a drug rep has just come through, because there’s a spike in the prescriptions for the drug that that guy markets.”

“Smart people, profitable people, don’t waste money to the tune of billions of dollars in the US with a marketing strategy that does not work,” Brody argues. “The point is to recognize that we’re all human and we’re all susceptible to these kinds of influences.”

Powell points out that the focus on the pharmaceutical industry overlooks other potentially influencing factors. “When you talk to prescribers, they consistently say that the largest influence on their prescribing decisions is the formulary that the patient’s health insurer establishes,” she says. “But nobody regulates their medical decisions. And in fact, some insurers are paying prescribers to switch patients’ medications, which for a pharmaceutical manufacturer would be a violation of the Anti-Kickback Statute.”

Powell also says that companies have “an obligation” to disseminate relevant information about medications to health care providers. “It’s vitally important that everybody in the health care system have the most current information about new medicines and medicine where there has been a change in the labeling,” she says. “Without that information, prescription medicines can’t be used effectively.”

Brody, on the other hand, says that every health care provider “should have a source of information they know they can go to and they can say, ‘I know that the drug companies are not controlling the information that I’m getting from this source.’”

Money Better Spent
Clearly, the conversation about interactions between pharmaceutical sales reps and health care providers will continue for the foreseeable future. But for PAs and NPs like Crowley and O’Rourke in Massachusetts, the bottom line is really that the money pharmaceutical companies (used to) spend on wining and dining them and their colleagues—an estimated $7 billion annually across the United States—could certainly be put to better use.

Crowley thinks there should be “some regulations on the amount of money [pharmaceutical companies] spend on advertising, so that we cut down on the costs that need to be relayed to the consumer… I think a balance needs to be obtained between the pharmaceutical companies and the state to achieve education for providers and marketing and the lowest cost of the drug to consumers.”

O’Rourke also sees more effective ways to use the thousands of dollars that would, in the past, have been spent to take a group of 20 or 25 NPs to dinner at a fancy restaurant in Boston and provide an expert speaker. “It’s an expensive proposition, and if you’re doing that across the country for many, many groups, you’re talking millions of dollars,” she says. “That money could absolutely go into research and development. It could clearly go to supporting the indigent drug programs for patients who don’t have any health insurance. Instead of being able to give them a sample pack of five pills, maybe they could get a month’s supply of their prescription.

“It has to come back to the patient. In health care, at some point, you lose sight of what’s right and what’s wrong for the patient.We have to bring health care back to that and have to focus on what’s good for patients and not necessarily what’s good for us.”        

Call it the New Age of Transparency and Accountability: So far this year, two states—Massachusetts and Vermont—have enacted strict laws that codify and regulate the interactions between health care providers and pharmaceutical sales and marketing representatives. Whether you consider such legislation “draconian” (as some critics do) or essential, it appears to be part of a trend that advocates hope will continue.

While lauding Massachusetts and Vermont for “taking the lead” in these matters—going beyond other states’ laws that allow gifts and payments from pharmaceutical and device manufacturers to health care providers, as long as they are disclosed—Howard Brody, MD, PhD, Director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, laments that legislation has been necessary.

“I think it would really be ideal if professionally, we just decided among ourselves—doctors, nurse practitioners, physician assistants, and so on—that we would not accept this money,” Brody says. “Because it’s tainted money, really, and it compromises our commitment to our patients.”

Massachusetts: The Microcosm
The Massachusetts code of conduct—officially designated “105 CMR 970.000: Pharmaceutical and Medical Device Manufacturer Conduct”—is outlined in a 13-page document available at the Web site for the state’s Department of Public Health (www.mass.gov/dph). The code applies to industry interactions with any health care provider licensed to practice in Massachusetts—even if the encounter occurs in another state (say, at a national conference). Helpfully, there are three “frequently asked questions” sections in which the finer points of the regulations are explained, often with specific examples.

In a nutshell, the code prohibits gifts of entertainment or recreation (eg, trips, tickets to concerts or sporting events); complimentary branded items (eg, pens, mugs, calendars); and meals, unless certain circumstances are met. All provided meals must be “modest” and “occasional,” must take place in the practitioner’s office or hospital setting, and must be accompanied by an informational presentation. Items that have potential benefit to patients—such as drug samples or demonstration models of medical devices—are permissible under the new regulations.

With regard to sponsorship of continuing medical education (CME) programs, the code stipulates that pharmaceutical and medical device manufacturers may not provide financial support for travel, lodging, meals, or personal expenses to nonfaculty health care providers attending such events. They are also prohibited from sponsoring or paying for CME that does not comply with the Standards for Commercial Support set forth by the Accreditation Council for Continuing Medical Education or an equivalent accrediting body. Further, companies are also barred from providing “any advice or guidance to the CME provider regarding the content or faculty for a particular CME program funded by the company.”

Pharmaceutical and medical device manufacturers are required to disclose “the value, nature, purpose, and particular recipient of any fee, payment, subsidy, or other economic benefit with a value of at least $50 to any covered recipient in connection with the company’s sales and marketing activities.” Disclosure reports must be filed by July 1 each year, beginning in 2010, and must be accompanied by a $2,000 fee. The first reports will cover the six-month period from the regulations’ implementation on July 1, 2009, through December 31, 2009. Subsequent annual reports will cover the entire previous calendar year.

While the demise of the “free lunch” has received the most media attention, it is the CME restrictions that may pose the biggest challenges to clinicians in Massachusetts. Both the NP and PA professional organizations in the state have already started planning how they will continue to provide CME opportunities to their members while complying with the code.

“Since the change in attitude toward pharmaceutical company funding of CME events, we have had to be more creative in how we provide CME to our members,” says David Probert, PA-C, the Massachusetts Association of Physician Assistants (MAPA) Delegate to the American Academy of Physician Assistants, who has served on MAPA’s CME committee. “The continued operation of our professional organization will rely more on member support—ie, dues—than in the past.” MAPA is applying for grants from nonpharmaceutical sources, including the AAPA, local hospitals, and other employers of PAs.

The Massachusetts Coalition of Nurse Practitioners (MCNP) is also working to develop educational programs in partnership with larger institutions and universities. “We’re looking at how we can develop quarterly educational offerings … that we could open to our members for a small fee,” says MCNP President Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP. “We haven’t had to charge them anything for their educational opportunities, but at this point, we’re going to have to start. It’s probably going to be a nominal fee, but it still has to cover the cost of putting on the program. Speakers for these programs typically get a large honorarium, and that’s where the pharmaceutical companies were helping us—paying that honorarium.”

O’Rourke also points out that the location restrictions, while understandable, may pose challenges for those who are not in major urban areas such as Boston. “If you’re practicing out in central or western Massachusetts, you might be 100 miles from the nearest hospital setting,” she points out. But the law is the law, as she observes, and “there are still ways that you can provide education—you just have to work within that structure.”

Industry, Police Thyself?
The Massachusetts code mirrors, to a large extent, the voluntary code established by the Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA actually updated its code last year, and the changes took effect on January 1, 2009. Among them was the banning of gifts that are either “reminder items” (eg, the pens and preprinted notepads that everyone used to collect in the exhibit halls at conferences) or items that are of benefit to the prescriber. The updated PhRMA code is also more explicit about the situations in which provision of meals is appropriate and about the need for disclosure of any relationship between a pharmaceutical company and a health care provider if the latter is involved in the development of CME programs, clinical practice guidelines, or formulary decisions.

This industry-wide code is part of the reason that PhRMA opposed the Massachusetts legislation. “We’ve said consistently that it is the most draconian law in the country,” says Marjorie Powell, Senior Assistant General Counsel for PhRMA. “We think it’s not necessary—in part, because of the PhRMA code. We think it doesn’t do anything to improve patient care. It simply involves everybody in the health care system in much more recordkeeping and potential disputes over potential violations.”

 All PhRMA member companies and some nonmember companies have agreed to comply with the organization’s code; the names of all the companies’ compliance officers are listed on the PhRMA Web site (www.phrma.org), making it easy, Powell says, for a clinician to report a potential violation to the appropriate party. She adds that this provides “a great deal of both peer pressure and public pressure” for company representatives to comply with the code of conduct.

There are those who would suggest that a voluntary code administered by a leading industry organization may not be effective enough; that’s why laws like the ones in Massachusetts and Vermont become necessary. While it is not an apples-to-apples comparison, no one has been very impressed with the financial industry’s efforts at policing itself.

Brody, who authored the book Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, says the effectiveness of the more robust PhRMA code will be proven if marketing expenses decrease. “If they’re not doing all those things anymore—the lavish dinners, giving out pens and notepads and so on—shouldn’t there be a reduction in cost somewhere?” he asks. “Until I see some hard numbers, I’m going to be skeptical. I’m going to look for some evidence that it actually is working. And I can see why a state would say, ‘Well, the track record being what it is, maybe your voluntary code will work, but maybe it won’t. Just in case, we’re going to have this law on the books.’”

But Powell points out that pharmaceutical and medical device manufacturers, like all health care companies, are subject to the federal Anti-Kickback Statute. The FDA reviews all materials that are presented to prescribers and surveys health care providers to determine what types of information sales reps have provided about medications and devices. And the Centers for Medicare and Medicaid Services, the Department of Justice, and state attorneys general all have enforcement authority.

“Frankly, they have very strong enforcement authority,” Powell says, “and they bring actions if they think companies either have been failing to abide by the federal requirements or have been lax in their own enforcement…. It’s sort of a misunderstanding to say that the only thing that regulates the industry is this voluntary code. 

And while other states—including Oregon, Texas, Connecticut, Colorado, Illinois, and Maryland—are considering legislation that would either ban gift-giving or require public disclosure of it, the real battleground on this issue may be the US Congress. The devil may end up being in the details, but all parties are watching to see what progress the Physician Payments Sunshine Act will make at the federal level.

“We have consistently said that we think transparency has a place in the health care system, but that if there is going to be that kind of transparency, national reporting—one uniform standard—makes much more sense than 55 different standards,” Powell says. “So we in fact supported last year’s [version of the bill] because it had a national uniformity provision. This year, [that] provision is much weaker; it allows states to have their own additional reporting requirements.”

Brody, on the other hand, will be among those watching to see whether industry influence waters down the bill to a degree that would render it ineffective. “The fact of the matter is that if you follow the track record of the pharmaceutical industry, they almost always get their way in Washington,” he observes. “And they don’t get their way by shouting and screaming and making noise…. So you always have to be very careful and very cautious with any legislation.”

Under the Influence?
The entire ethics debate begs the question: How much influence does a pen or a notepad—or even a slice of pizza—really have on a health care provider’s prescribing habits, anyway? Obviously, there are what Brody calls “high rollers,” the physicians (predominantly) who receive consulting fees totaling millions of dollars in exchange for lending their expertise as “key opinion leaders” on behalf of pharmaceutical companies. But what about the average clinician?

“It’s true that it’s a very large industry, and there are always kids who will throw spitballs in class,” Powell admits. “But it’s a bit like saying, ‘OK, we’ve all lost our recess for the week because Johnny misbehaved.’”

The Massachusetts law “does not convey a lot of faith in the people of these professions to prescribe based on the research and the standard of care,” in the opinion of MAPA President Jillian Crowley, PA-C. “Personally, I cannot think of anyone who would be influenced to prescribe a drug based on a pen—or even remember the pharmaceutical company that produces the drug!”

MCNP President O’Rourke echoes that assessment, calling the Massachusetts code “almost like a slap on the wrist and ‘Big Brother is watching’ kind of stuff.” Her professional viewpoint, she says, has always been to go with the evidence-based data, with the acknowledgment that “pharmaceutical studies are usually skewed in some way. So you take the information and you prescribe what’s appropriate for the patient—not because of the pharmaceutical rep. I think I could say that probably 99.9% of the NP and medical communities feel that way. I think the law didn’t take that into consideration.”

But Brody cautions against assuming that any individual is immune to marketing. He recalls a pharmacist colleague from the hospital where he taught in the family practice residency program, who used to say: “There’s never any doubt in my mind when a drug rep has just come through, because there’s a spike in the prescriptions for the drug that that guy markets.”

“Smart people, profitable people, don’t waste money to the tune of billions of dollars in the US with a marketing strategy that does not work,” Brody argues. “The point is to recognize that we’re all human and we’re all susceptible to these kinds of influences.”

Powell points out that the focus on the pharmaceutical industry overlooks other potentially influencing factors. “When you talk to prescribers, they consistently say that the largest influence on their prescribing decisions is the formulary that the patient’s health insurer establishes,” she says. “But nobody regulates their medical decisions. And in fact, some insurers are paying prescribers to switch patients’ medications, which for a pharmaceutical manufacturer would be a violation of the Anti-Kickback Statute.”

Powell also says that companies have “an obligation” to disseminate relevant information about medications to health care providers. “It’s vitally important that everybody in the health care system have the most current information about new medicines and medicine where there has been a change in the labeling,” she says. “Without that information, prescription medicines can’t be used effectively.”

Brody, on the other hand, says that every health care provider “should have a source of information they know they can go to and they can say, ‘I know that the drug companies are not controlling the information that I’m getting from this source.’”

Money Better Spent
Clearly, the conversation about interactions between pharmaceutical sales reps and health care providers will continue for the foreseeable future. But for PAs and NPs like Crowley and O’Rourke in Massachusetts, the bottom line is really that the money pharmaceutical companies (used to) spend on wining and dining them and their colleagues—an estimated $7 billion annually across the United States—could certainly be put to better use.

Crowley thinks there should be “some regulations on the amount of money [pharmaceutical companies] spend on advertising, so that we cut down on the costs that need to be relayed to the consumer… I think a balance needs to be obtained between the pharmaceutical companies and the state to achieve education for providers and marketing and the lowest cost of the drug to consumers.”

O’Rourke also sees more effective ways to use the thousands of dollars that would, in the past, have been spent to take a group of 20 or 25 NPs to dinner at a fancy restaurant in Boston and provide an expert speaker. “It’s an expensive proposition, and if you’re doing that across the country for many, many groups, you’re talking millions of dollars,” she says. “That money could absolutely go into research and development. It could clearly go to supporting the indigent drug programs for patients who don’t have any health insurance. Instead of being able to give them a sample pack of five pills, maybe they could get a month’s supply of their prescription.

“It has to come back to the patient. In health care, at some point, you lose sight of what’s right and what’s wrong for the patient.We have to bring health care back to that and have to focus on what’s good for patients and not necessarily what’s good for us.”