Running Head: POLICY PROJECT 1

Policy Project Plan

Amy Angell

Delaware Technical Community College

2/18/19
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Increasing Age of the United States population creating a physician shortage

The United States is experiencing a shift in the population people older than 65 years

now outnumber those younger than 5 ( Landers, Madigan, Leff, Rosati, Mccann, Hornbake, . . .

Breese, 2016). This aging population has also increased the number of Americans that are

living with multiple chronic conditions such as diabetes, congestive heart failure, dementia or

functional disabilities. One of the greatest health challenges is meeting these needs of the patient

and helping them to remain independent in the home. One way to do this is by offering home

health services. These services can include skilled nursing, occupational health, or therapy a

physician can only order these services according to Medicare regulations. This aging population

has created a shortage of primary care physicians. Around 58 million American live in areas in

which the number of primary care physician does not meet federal standards related to the proper

ratio of providers to patients ( Landers et al., 2016). This means more of the primary care of the

patient is failing to the nurse practitioner, and an important role is providing home care services

for those with chronic disease to prevent rehospitalization and continued education. Under

current Medicare law to qualify for coverage of home health services, a patient’s physician must

certify that the patient is confined to his or her home and in need of skilled care on an

intermittent basis (Landers et al., 2016). A physician can only complete this certification of care.

This is a problem because millions of American live in areas in which the number of primary

care physicians does not meet federal standards related to the proper ratio of providers to patients

(Wolff-Bake, 2018). This means more of the primary care of the patient is failing to the nurse

practitioner, and an important role is providing home care services for those with chronic disease

to prevent rehospitalization and continued education. But, under Medicare guidelines, this can
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only be ordered by a physician. In many cases, this requires a patient to be seen by a physician

that is not the patient’s primary care providers and delays needed treatment.

Proposed Bill to solve this problem

To alleviate the delay in care for patients needing home care, there is a bill called the

Home Health Care Planning Improvement Act of 2017. This bill would

allow home health services to be ordered by a nurse practitioner, a clinical nurse specialist,

certified nurse-midwife or a physician assistant (United States Congress, 2017). This bill will

amend title XVIII of the Social Security Act to ensure more timely access to home health

services for Medicare beneficiaries under the Medicare program, and other purposes. By

permitting the nurse practitioner to certify Medicare eligibility it allows certification of home

care to be completed by the practitioner caring for the patient (United States Congress, 2017). It

would allow the continuation of care by the practitioner and no longer be necessary for another

physician to sign home care orders. By permitting nurse practitioners to sign home care orders, it

will allow for a smoother transition to community care and prevent delays in services. This bill

seeks to allow non-physician providers to certify a patient’s eligibility for the Medicare Home

Health Benefit.

Talking point to discuss addressing concerns of the Legislation to Law Makers

Medicare was started as part of the Social Security Act of 1965 before Nurse practitioners

being able to practice as primary care providers (Wolff-Bake, 2018). It was not until the Balance

Budget act of 1997 that Nurse Practitioners were granted provider status that has since

authorized them to bill to Medicare directly for services (Wolff-Bake, 2018).

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Much of the wording in the Social Security Act still reflects the wording of the physician

only in providing care to the patient. With increasing aging population and shortage of primary

care physician, many American’s primary care providers are non-physician providers. Nurse

practitioners have full practice rights in 21 states and the District of Columbia that allow

independent practice for nurse practitioners (Heath, 2018). They are allowed to assess, diagnose,

interpret diagnostic tests, and prescribe medications independently yet under Medicare

guidelines they cannot sign home care orders. This still requires a handoff to a physician which

delays treatment and care for patients in need of home care. Nurse Practitioners are already

allowed and also have the ability to write orders for skilled nursing care, physical therapy,

speech therapy or social worker service in the outpatient setting, acute care setting and long term

care facilities just not when it comes to home health care (Wolff-Bake, 2018).

There is an increasing shortage of primary care physicians (PCP). The primary care

physician shortage currently affects approximately 13 percent of all of the United States patients

with patients in rural areas being five times more likely to face a primary care physician shortage

(Heath, 2018). There are not enough physicians choosing primary care with only 288,000 out of

869,000 physicians choosing the primary care route (Heath, 2018). By 2025, one-third of all

primary care providers will be over 65 years old and planning retirement (Heath, 2018). Patients

are also facing increasing chronic health challenges such as COPD, CHF, and diabetes with as

many as 43 million to 59 million by the year 2030 (Heath, 2018). Non-physician clinicians, such

as nurse practitioners and physician assistants can address this physician shortage. Many of these

providers are going to primary care office; it is estimated that 78% of nurse practitioners care

into primary care compared to just 33% of physicians (Heath, 2018). Medicare already allows

nurse practitioners to bill for Medicare services yet are not allowed to sign home care orders.
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Nurse practitioners can help solve the problem of a shortage of primary care physicians. This bill

would grant that right for nurse practitioners to sign home care orders allowing for a better

continuation of care without handoff to a physician (Wolf-Bake, 2018). Also, allowing for

greater independence of practice for Nurse Practitioners to manage the aging population with a

chronic illness that many times requires home health services.

This bill has been brought in front of Congress several times yet has never been given a

Congressional budget office (CBO) cost estimate. This cost estimation for this bill would allow

for a clear picture of the cost of the final bill if passed. It would describe the budget impact of the

legislation and sometimes some information on premiums and coverage implication (Newkirk,

2017). It is believed by many lawmakers if this bill is passed that it would cause a dramatic

increase in cost from non-physician providers writing home care orders but with no CBO cost

estimate in place this cannot be determined (Heath, 2018). By allowing a formal cost estimate

on these changes, it would allow other members of Congress to vote for this change in Medicare

regulations.

This bill already has support from the Institute of Medicine that recommended the

removal of practice barriers including the proposal to the Center for Medicare and Medicaid

services to allow nurse practitioners to sign home care orders (Wolff-Bake, 2018). Also, many

leading nursing organizations have researched and found the benefits of allowing non-physician

providers to certify home care orders. In a letter address to Congress from the Nursing

Community coalition it urged support of this bill from 44 undersigned nursing organizations with

a wide range of profession from all aspect of nursing recognizing the need for support of the bill

(Wolff-Bake, 2018). Many of the registered nurse and advanced practice nurses that are apart of

these organizations can share personal stories on how home care services were delayed simply
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because a physician signature required. This bill would eliminate that need and allow non-

physician providers to provide the care needed to manage patients care without out delays in

care.

Key Stakeholders to contact on a State local and National level

Contact your state representative directly in the House at www.house.gov or Senator at

www.senate.gov websites and then use the member directories to find your legislators. You can

email or call directly to their Washington DC office. Call the U.S. Capitol Switchboard and ask

to be connected to the office of your Senators or Representative

Delaware U.S. Representative: Lisa Blunt Rochester not listed as co-sponsor. This

representative can be contacted by email or phone to show your support of this legislation

information on contact number can also be found at http://legis.delaware.gov/FindMyLegislator

Delaware U.S. Senator: Thomas Carpenter and Christopher Coons not listed as co-sponsor of

this bill email or phone call can be placed in support of this legislation

Contact your local state government State Senate and State House of Representative according to

your district this can be found on https://delaware.gov/topics/yourgovernment you can find their

email to make them aware of your support for giving full practice rights to Nurse Practitioners to

support no delays in-home care services for Delaware residents further.

Support the National Association of Home Care and Hospice on the website they have a

legislative action page that details Legislative that you can contact the representative of your

state to share your voice in support the website is https://p2a.co/zr0juwz.

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Reach out to other professional organizations in support of this bill share personal stories on how

this has affected your patients care, and you have seen delays caused by the Nurse Practitioners

unable to sign home care orders. A list of professional organizations can be found at

https://nurse.org/orgs.shtml

What goals do I hope to accomplish and how will further implement my goals

I would hope to gain support for The Home Health planning and Improvement act from

our state's representatives both the House Representative and the Senators. I could contact their

office directly or by email to further explain why this is needed. I could give personal stories of

patients home care orders being placed on hold while they wait for an appointment from a

physician or the patients that have to see another physician just because of there primary care

provider in a nurse practitioner. This causes delays in care that can be avoided if non-physicians

were able to signs orders to certify homecare. I am also attending a Cardiac Conference at

Christiana Hospital on March 2 where Chris Coons our Delaware Senator will be speaking

directly on current policy in healthcare. This should be the perfect opportunity to voice my

support on this bill and hear directly what his views are on health care policy. I would plan to

have this completed in the next 90 days, and I would hope this bill could gain support from our

local legislators so the bill could at least get the cost estimation to be able to be voted on in the

Senate and the House of Representative.

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References

Landers, S., Madigan, E., Leff, B., Rosati, R. J., Mccann, B. A., Hornbake, R., . . . Breese, E.

(2016). The future of home health care. Home Health Care Management & Practice,

28(4), 262-278. doi:10.1177/1084822316666368

Newkirk, V. R. (2017, May 04). How does the CBO measure the costs of health-care legislation?

Retrieved from https://www.theatlantic.com/politics/archive/2017/05/cbo-interview-ahca-

effects/525420/

Wolff-Bake, D. (2018, January 31). Nurse practitioners and Medicare certification of home

health services. Retrieved from https://www.gapna.org/publications/gapna-

newsletter/n/18spr/ha

Heath, S. (2018, September 13). NPs, PAs Could reduce primary care physician shortage nearly

70%. Retrieved from https://patientengagementhit.com/news/nps-pas-could-reduce-

primary-care-physician-shortage-nearly-70

United States Congress (2017) H.R.1825 - 115th Congress (2017-2018): Home Health Care

Planning Improvement Act of 2017. Retrieved from https://www.congress.gov/bill/115th-

congress/house-bill/1825
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