Some allied health professionals see state laws as the biggest obstacle to team-based care.

May 17—The growing use of team-based care continues to run into legal and regulatory hurdles, industry advocates say.

Shawn Martin, senior vice president at the American Association of Family Physicians (AAFP), noted that health care—particularly primary care—is moving toward a team-based care approach and payment model.

“The transformation is taking hold, but there are regulations that prohibit teams from functioning at the highest level possible,” Martin said at a recent Washington, D.C., healthcare policy discussion.

Among the obstacles to team-based care are the Stark Law, which prohibits physician self-referral, and other regulations.

Hospitals have targeted the same obstacles. The American Hospital Association (AHA) said organizations cannot succeed in their efforts to coordinate care and participate in new payment models because of such “outdated” regulations. As part of the Trump administration’s promised rollback of redundant and outdated regulations, AHA in December wrote the incoming administration to urge creation of a new exception “that protects any arrangement that meets the terms of a newly created Anti-Kickback safe harbor for clinical integration arrangements.”

Scope of Practice

Some allied health professionals see a bigger obstacle in state laws.

Cindy Cooke, president of the American Association of Nurse Practitioners, cited state licensure laws on scope of practice for not keeping “pace with the education and expertise of everyone at the table.”

“There’s a cost with collaborative agreements or supervisory agreements that actually drive up the cost of health care,” Cooke said, referring to physician oversight requirements in 28 states. “In many instances, nurse practitioners are paying physicians a great sum of money in order to provide that collaborative or supervisory piece of paper.”

Other costs imposed by such restrictions, she said, include reduced access to care in rural and urban areas and reduced ability to provide the goods and services that keep patients from progressing to costly inpatient care.

Furthermore, state scope-of-practice requirements are echoed in many physician-centric Medicare rules.

“Right now, I can’t order diabetic shoes, again, because of these Medicare statutes,” Cooke said. “Because once the physician writes the prescription for their diabetic shoes, they actually have to assume the care of that diabetes, according to law.”

Ben Ippolito, a healthcare economist at the American Enterprise Institute, questioned whether the potential of scope-of-practice changes to reduce costs is overstated. Research indicates scope-of-practice expansions have “modestly” lowered price for services like well-family or well-child visits. But such changes do not lower total spending.

“The problem is the price may go down, the quantity may go up,” Ippolito said. “So we have better access, which is kind of a nice way of saying utilization goes up. And so it’s not necessarily true that cost is going to be lower on net.”

Team Costs

Fitch Ratings warned not-for-profit hospitals in April that improvement in the labor market is raising the demand for nurses and mid-level clinical staff, resulting in higher salary and benefits costs.

“The impact is more pronounced in areas with higher levels of hospital competition and population and economic growth,” the analysis stated.

Cooke agreed that utilization may increase with the greater access to care that comes with expanded scope of practice. But for patients with diabetes, for example, increased primary care access can reduce costly progression to amputation, diabetic retinopathy, or kidney disease.

“It’s hard to really enumerate that value in a concrete way,” Cooke said. “But we really can see the outcomes when we have that.”

Martin urged letting state legislatures remain the arbiters of scope of practice.

“State legislatures in general should take very seriously their obligation to ensure appropriate access to health care for their citizens and identify policies that promulgate the distribution of healthcare professionals of all types in all communities,” Martin said.

Martin also noted that various expansions of scope of practice, also known as open-practice laws, have not made an impact on federally designated health professional shortage areas or other population groups experiencing a shortage of providers.

“I cringe a little bit about saying, ‘We’re going to do X, and then all these people are going to go out in these rural counties because history and statistics just demonstrate that,’” Martin said. “Yes, that’s happened a little bit, but not to the rate that it’s really going to solve rural and urban access problems.”

A demonstrated benefit of such initiatives was seen in Arizona, which, five years after the adoption of full-practice authority, saw a 50 percent increase in nurse practitioners as more moved to the state and were licensed, Cooke noted.

“And actually, rural-classified counties actually saw the largest increase, with more than 70 percent of those rural counties seeing more nurse practitioners in practice, so it can happen,” Cooke said.

Such increases in mid-level healthcare personnel have come as increases in the number of physicians have slowed. The latest projections from the Association of American Medical Colleges (AAMC) estimate a shortage of up 104,900 physicians in the coming decade. To help alleviate that shortage, the AAMC supports a multipronged solution, including innovation in team-based care and better use of technology.

Martin described telemedicine as “a really big, important tool” in accomplishing cost-reduction goals.

However, a recent AAFP member survey found that although 70 percent want to use telehealth, only about 20 percent actually use it.

Among the reasons for the disconnect is a “regulatory structure of deploying [telehealth] in my practice that is so restrictive, I can’t do it,” Martin said.

AHA also urged the Trump administration to expand Medicare coverage of telehealth, such as by adding a presumption that Medicare-covered services also are covered when delivered via telehealth unless the Centers for Medicare & Medicaid Services determines on a case-by-case basis that such coverage is inappropriate.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Thursday, May 18, 2017