November 2013

Volume 10, Issue 8

HEADLINES

House and Senate Continue Work on FY 2014 Spending Bills
FROM THE STATES . . .
SHORT . . .

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LINKS

NLN Government Affairs Action Center
NLN Public Policy

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House and Senate Continue Work on FY 2014 Spending Bills

2014 Budget Conference

The Budget Conference Committee, led by House Budget Committee chairman Paul Ryan (R-WI) and Senate Budget Committee chairwoman Patty Murray (D-WA), has been charged with finding a path forward on fiscal year (FY) 2014 spending and finding alternative ways to reduce the deficit to replace sequestration, which will continue through 2021 if Congress does not take action. Currently, the federal government is operating under a continuing resolution through January 15, 2014, that keeps the same spending levels that were in place before the shutdown.

While expectations are tempered, there seems to be little momentum for a "grand bargain." House and Senate leaders remain about $91 billion apart on FY 2014 spending, and finding areas of agreement on replacements for sequestration's automatic spending cuts will likely force lawmakers to have difficult discussions about politically sensitive issues, including:

• Tax reform
• Changes to Medicare, Medicaid, Social Security, and other mandatory programs
• Additional health care reforms
• More targeted spending cuts to defense and non-defense programs (which include many health related programs)

The conference committee has a self-imposed deadline of December 13 to send a conference report of recommendations to the full Congress. If they are unable to reach an agreement, House and Senate leadership is expected to take over negotiations to work out at least another short-term funding extension beyond January 15.

Potential 2014 CR

With the legislative days before the January 15 deadline dwindling, House and Senate appropriators are growing more concerned that they may end up piecing together yet another continuing resolution (CR). The top appropriators in both parties have asked the budget conference committee to negotiate a top-line budget number and to get it to them by Thanksgiving so they can work on spending bills using that number. But budget negotiators are nowhere near a framework for an agreement.

Appropriators may craft an omnibus spending package for the rest of the current 2014 fiscal year at the sequester level of $967 billion (the same level as the House budget resolution) while adhering to funding caps for defense and nondefense accounts stipulated under the 2011 Budget Control Act. That would avoid another set of automatic, across-the-board cuts scheduled to begin under sequestration, but it also would mean deciding to live with sequester-set levels of $469 billion for nondefense discretionary spending and $498 billion for defense spending. Senate Democrats set discretionary spending in their budget resolution at $1.058 trillion.

House appropriators say they still hope for an agreement out of the budget conference. If there is no budget deal for 2014, a CR - with the second round of the sequester taking an additional $20 billion bite out of defense programs compared to current funding levels - would be the most likely outcome. Some appropriators said the option of moving a 12-bill omnibus under the $967 billion cap would be difficult to accomplish.

More Timely National Workforce Data Needed

A General Accounting Office (GAO) report published September 30, 2013 examines the actions the Health Resources and Services Administration (HRSA) has taken to project the future supply of and demand for physicians, physician assistants (PA) and APRNs. Since publishing its 2008 report, HRSA awarded five contracts to research organizations to update national workforce projections. To date, none of these new reports have been published and the timeline that HRSA developed has been revised to reflect significant delays in the publication of these studies.

GAO REPORT — HRSA'S ORIGINAL AND REVISED TIMELINES FOR REPORT PUBLICATION

Reports	Original Goal for publication	Revised Goal for Publication
Primary care	No goal date	Fall 2013
Clinician specialty	December 2012	Summer 2014
Nursing workforce	September 2013	Fall 2014
Cross-occupations	2013	2014

One complicating factor in the production of these reports is the advent of the Patient Protection and Affordable Care Act (PPACA). The workforce projections significantly changed with PPACA's estimated 25 million new recipients of health insurance. This projection will have a large impact on the completion of the primary care report as well as the other reports. Completion of the reports is further complicated by challenges in estimating the number of APRNs, PAs, and primary care physicians needed to provide this care. While it is accepted that a team of primary care providers is needed, the ability to take into account the new models of care delivery emanating from PPACA and, thereby, forecast future workforce needs on largely untested delivery models, has slowed the work on HRSA's primary care report.

The GAO report also highlights other challenges HRSA has had with finalizing these reports. The lack of written procedures and tools to monitor report review to ensure timeline goals for publication has been problematic. HRSA noted its agreement with the GAO findings and will work to rectify the problems in order to facilitate prompt publication of all of the reports.

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FROM THE STATES . . .

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New Mexico Nursing Schools Adopt A Common Curriculum

New Mexico's state colleges and universities are moving to a common nursing curriculum to make it easier for students to complete their degrees. Governor Susana Martinez (R) and leaders of the New Mexico Nursing Education Consortium announced the alignment earlier this month. According to Martinez's office, the use of a common curriculum will make it easier and less expensive for students to transfer from one school to another. It also will allow nursing students at colleges in rural areas to be able to earn bachelor's degrees without having to leave their communities.

"The lack of a common curriculum for nursing students in New Mexico has put undue stress on our health care system, causing high costs and frustrating delays for many New Mexicans who seek to serve their state and communities as nursing professionals," the governor said in a statement. "When burdensome and dissimilar requirements hold back the training of nurses, New Mexico families and communities suffer. These important changes will allow more New Mexicans who aspire to serve their communities as nurses to realize their goals, as well as to ensure they are then able to serve in their own communities where their families live and work."

By the next academic year, officials say, 63 percent of nursing students will learn from the same curriculum, with that number rising to 100 percent by 2017.

But the California Medical Association remained the bill's biggest obstacle. In the first half of the year, the doctors' association spent nearly $1.2 million lobbying on scope-of-practice bills and other similar legislation. The group also has given more than $500,000 in campaign contributions; lawmakers sitting on committees that oversee health and professional licenses received more than $100,000 of that money.

Seventeen states and the District of Columbia allow nurse practitioners to work autonomously. Catherine Dower, associate director of the Center for Health Professions at UC San Francisco, said data and research from those states "show that the quality of care is the same as, if not better than, doctors' and that safety is not compromised."

Michigan State Votes To Expand Nurses' Scope of Practice

Michigan APRNs could soon practice without oversight by physicians and prescribe drugs under legislation that won narrow approval on November 13 from the state Senate despite opposition from the doctors' lobby. The bill passed 20-18 and has been sent to the Michigan House for its consideration.

Supporters say giving the practitioners a broader scope of practice would keep them in Michigan and help address impending doctor shortages as baby boomers retire and more residents qualify for insurance under the federal health law. But the medical establishment, fighting to protect its turf, said the move could endanger patients.

Under changes made to the legislation, APRNs looking to practice and prescribe medicine would need four years of supervision under a physician or another APRN. Another narrowly adopted amendment would hold APRNs not under the supervision of a physician to the higher standard of care for doctors in medical malpractice lawsuits.

Doctors and advanced nurses have competing studies on who better controls costs by not overprescribing drugs and not ordering unnecessary tests.

Many advanced nurses work in doctors' offices and that mostly would not change if the bill becomes law, Jansen said, noting it includes a provision designed to prevent them from starting their own independent offices.

The legislation's future in the House is unclear. "Lawmakers in the state House should do what the Senate wouldn't, reject this dangerous special interest legislation and instead put patients first," said Kenneth Elmassian, president of the Michigan State Medical Society.

Landmark Workforce Report Released By Wisconsin Center For Nursing

The Wisconsin Center for Nursing (WCN) recently released "The Wisconsin Nursing Workforce: Status and Recommendations." The report is based on survey data from more than 95,000 RNs and LPNs, and educational programs in Wisconsin, and identifies evidence-based nursing workforce issues.

Critical recommendations from this report will provide Wisconsin health care systems, educators, and policy makers with key strategies to avert a public health crisis from anticipated shortages in the nursing workforce. Currently, Wisconsin does not have much of a nursing shortage, but many older nurses are expected to retire soon as the economy improves. With nurses an average age of 48 and the general population requiring more care as it ages, the state is expected to be short 5,000 nurses by 2020 — and nearly 20,000 nurses by 2035, according to the report.

The Wisconsin report is unique in that it is framed using the recommendations of the IOM's The Future of Nursing. It recognizes that nurses offer untapped potential to transform health care delivery and improve access, customer satisfaction, cost effectiveness, and patient outcomes. The report calls for more than doubling the state's 3,100 annual nursing graduates by 2020, encouraging more nurses with associate degrees to get bachelor's degrees and training more APRNs.

The full report and executive summary are available here.

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IOM Workshop Summary - Transdisciplinary Proessionalis

On October 7, 2013, the Institute of Medicine (IOM) released a workshop summary report, "Establishing Transdisciplinary Professionalism for Improving Health Outcomes." This document contains summaries of the presentations, discussions, and opinions of those who attended or presented at the May 14-15, 2013 workshop, the IOM Global on Innovation in Health Professional Education. While there are no consensus findings or recommendations, the information in the publication provides a broad range of content that helps describe the issues and philosophic base of the concept of "transdisciplinary professionalism."

The health care professional's education and clinical environments are evolving rapidly in response to changes in the environment, limited health care dollars, new technologies and a new construct of health care delivery emanating from the Patient Protection and Affordable Care Act. These forces are requiring a change in the traditional approach to education and delivery of care. The IOM report presents discussions of this "new professionalism." It posits the theory that the concept of transdisciplinary professionalism may result in improved outcomes throughout health care systems and emphasizes professional responsibilities and accountabilities. This report is timely and can assist in developing a common language between professions for these issues.

The National League of Nursing was a sponsor of this report. Other nursing organizations that supported this work are the American Academy of Nurses, American Association of Colleges of Nursing, the American Association of Nurse Anesthetists, the American College of Nurse-Midwives, and the National Association for Associate Degree Nurses.