A requirement for insurance companies to make upfront payments to doctors enrolled in a state program cleared a legislative panel on Monday despite complaints from some critics that advanced-practice nurses aren't allowed to participate on the same footing as physicians.
The requirement, reviewed in an 8-5 vote by the Legislative Council's Administrative Rules and Regulations Subcommittee, is part of an expansion of the state's patient-centered medical home initiative, which is meant to slow the growth of health care spending in the state.
The state Medicaid program pays health care providers an average of $4 per month for each Medicaid recipient assigned to a team of providers.
In exchange, the providers agree to take steps such as expanding their use of electronic medical records, making sure patients get preventive health screenings and providing around-the-clock access to a medical professional.
The state Insurance Department rule reviewed by the committee Monday will require insurance companies to pay the providers a similar amount, starting Jan. 1, on behalf of patients who are enrolled in plans offered through the state's health insurance exchange.
The Medicaid program requires the provider teams receiving the payments to be led by physicians, a move that has drawn objections from the Arkansas Nurses Association, which wants advanced-practice registered nurses to be allowed to lead the teams.
Such nurses have completed postgraduate training and can prescribe medicine if they have a collaborative agreement with a physician.
"At a time of primary care physician shortage and the coverage of 250,000 newly insured Arkansas citizens, we believe we need to remove the barriers to ensure access to all health care providers," Darlene Byrd, a family nurse practitioner based in Cabot, told the committee.
Arkansas Surgeon General Joe Thompson said the program doesn't prohibit patients from seeing a nurse as their primary care provider.
A physician must lead the team, but doesn't have to treat all the patients, he said. Team members can have offices in different locations, he added.
"We're not changing the scope of practice definitions of what the primary care provider is," Thompson said. "We're defining what the team is."
Asking why nurses couldn't lead the teams, Rep. Andrea Lea, R-Russellville, said the state is "losing doctors all over, especially in rural areas, and the people filling that in are advanced-practice nurses."
Thompson said a study by the Arkansas Center for Health Improvement didn't show that nurses are filling gaps in rural areas. Instead, he said both doctors and nurses tend to practice in more populated areas.
He said physicians are better qualified.
"At some point, it may be that the nurse practitioner practice is equivalent to a primary care residence training and a three-year residence program" required for physicians, Thompson said. "I don't believe at this point in time, personally, that those are equivalent training experiences the day they come out of the training program."
The state's medical-home initiative began in October 2012, when more than 60 practices in Arkansas began receiving quarterly payments from Medicare, the insurance program for the elderly and disabled, under a pilot project known as Comprehensive Primary Care Initiative.
The state Medicaid program is also participating in the pilot project. Arkansas Blue Cross and Blue Shield, QualChoice Health Insurance and Humana have also contributed payments on behalf of customers enrolled in employer plans.
Since then, the state Medicaid program has begun enrolling additional practices in a similar initiative. As of earlier this month, it was making payments to 123 physician practices on behalf of almost 300,000 Medicaid recipients.
In addition to the up-front payments, both the pilot project and the Medicaid program will provide additional payments to practices that keep patients' overall health care costs low.
As of Dec. 15, plans offered through the exchange, which allows people to shop for coverage and apply for subsidies to help pay for it, covered more than 233,000 Arkansans, including more than 188,000 who received coverage through Medicaid-funded plans under the so-called private option.
The insurance companies would be required to contribute an average of $5 to participating practices on behalf of each patient enrolled in one of the company's plans offered through the exchange.
The Medicaid program's average payments are lower because most of the Medicaid recipients are children, who typically have lower health care costs than adults, officials have said.
Act 1498 of 2013, which created the private option, requires companies offering plans on the exchange to provide "support for patient-centered medical home."
An earlier version of the rule required insurance companies to pay participating "primary care provider practices," without specifying that the practice must be led by a physician.
In response to complaints by the Arkansas Medical Society and other physician groups, the rule was revised to say the payments must go to participating "primary care physician practices."
Senate President Pro Tempore Jonathan Dismang, R-Searcy and one of the sponsors of Act 1498, said the discussions about the law never included allowing providers other than physicians to lead the medical homes.
He added that "there was a push" to change the laws governing different types of health care providers, and "that did not pass."
Rep. Kim Hammer, R-Benton, said he was concerned that the rule would limit Arkansans' choice of primary care providers.
He voted against the rule along with Lea; the subcommittee chairman, Rep. Kelley Linck, R-Yellville; and Reps. Terry Rice, R-Waldron, and Greg Leding, D-Fayetteville.
Dismang voted in favor of the rule along with the vice chairman, Sen. Bruce Maloch, D-Magnolia; and Reps. Sheilla Lampkin, D-Monticello, Butch Wilkins, D-Bono, Ann Clemmer, R-Benton, Lane Jean, R-Magnolia, Jeff Wardlaw, D-Hermitage and Joe Jett, D-Success.
The subcommittee was originally scheduled to review the rule at its meeting Dec. 3, but Linck tabled the issue, saying not enough members were present to vote.
The Legislative Council agreed on Friday that the rules subcommittee's review on Monday would be final, Maloch said.
David Wroten, executive vice president of the Medical Society, said after the meeting that medical home initiative already has strong participation by the state's primary care practices. Contributions from the private companies will help those practices meet the program's requirements and help the program to attract additional practices, he said.
"Without those moneys, it would be very difficult particularly in rural areas, to get practices to be able to do this," Wroten said.
Metro on 12/23/2014