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Phase II contract with American Nurses' Association approved; legislative update given at Congress
JUNE 1987, VOL. 45, NO 6
AORN J O U R N A L
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Legislation Phase I1 contract with American Nurses’ Association approved; legislative update given at Congress
Phase I1 of the AORN contract with the American Nurses’ Assocation (ANA) for legislative monitoring and services was approved by the Board of Directors at its pre-Congress meeting in Atlanta. Kathy Michels, RN, JD, senior staff specialist, congressional and agency relations, ANA, Washington, DC, updated the Board on legislative issues, and spoke at the Congress Forum on Monday to update delegates on nursing issues. Under Phase I of the contract last year, the AORN Board of Directors met with the staff of the congressional and agency relations office in Washington, DC, in October for an update on legislative issues. The Phase I1 contract for 1987 includes: gathering information concerning policy considerations in Congress and the Executive Branch related to the legislative and regulatory priorities of AORN; preparation of draft testimony for congressional hearings; direct lobbying activities on behalf of AORN; and providing at least monthly reports from a designated ANA lobbyist to AORN Headquarters. In addressing the Forum, Michels identified reimbursement for RN first assistants as a top priority and one that ANA will help AORN to achieve. She reviewed the mechanism by which certain qualified physician assistants who assist at surgery can receive indirect reimbursement under Medicare (effective since Jan 1, 1987): payment will be made to the employer of the physician assistant at 65% of the amount that would be allowed if performed by a physician. The ANA will attempt to find a sponsor for legislation that would include RN first assistants in this indirect reimbursement mechanism, according to Michels. 1278
When the legislation has been introduced, a grass-roots effort to gain additional sponsors will be appropriate, said Michels. RN first assistants will need to show legislators why nurses in this role would improve access to care, contribute to quality patient care, and be cost-effective, she said. She stressed that the proposed reimbursement would be paid to the employer of the RN first assistant, would be predicated on the requirement of physician supervision, and would be at the 65% rate. Michels also gave an overview of the bills Congress is considering this year, which include: S 101, the Advanced Nursing Services in Nursing Homes Act, which would allow nurses to certify and recertify the need for patient care in nursing homes, H R 1161, the Medicare Community Nursing and Ambulatory Care Act, which would provide community-based nursing and ambulatory care services under Medicare Part B, and HR 913, the Military Selective Service Act Amendment, which would allow the Selective Service System to set up a system for registration of health care personnel in the event of a national emergency. Representatives from two schools of nursing have been appointed by Health and Human Services Secretary Otis R. Bowen to the National Advisory Council on Nurse Training. Appointees are Elizabeth T. Anderson, DPH, assistant dean and associate professor, College of Nursing, Texas Women’s University, Houston; Carol A. Linde-
JUNE 1987, VOL. 45. NO 6
AORN JOURNAL
man, PhD, dean, School of Nursing, University of Oregon Health Sciences Center, Portland; Cecelia H. Foxley, PhD, associate commissioner for academic affairs, Utah State Boad of Regents, Salt Lake City; and James E. Moon, administrator, University of Alabama Hospitals, Birmingham. The 19-member council includes 12 leaders in nursing and education, as well as representatives of hospitals and other institutions that provide nursing services. The council advises the Health and Human Services secretary on the administration of nursing education programs.
Small rural hospitals could convert to outpatient surgery, emergency, or home care centers with funding from the federal government if legislation introduced in the Senate becomes law. Sen David Durenberger (R-Minn) sponsored the Rural Health Services Transition Act introduced in March. The bill would provide grants of up to $50,000 per year for two years for hospital conversion into “more appropriate and cost-effective health care services,’’ according to American Medical News. Durenberger said the program would allow struggling hospitals with fewer than 100 beds to assess services and determine how best to serve the health needs of the community and provide high-quality care. Durenberger said statistics from the American Hospital Association indicate that the average occupancy rate in rural hospitals with fewer than 50 beds is 34% and the average length of stay is five days. In support of the bill, Sen Robert Dole (RKan) said, “Many hospitals who understand the reasons for altering their services, but who have been unable to do so because of financial restraints, will now have an opportunity to do so. This bill is an important step in assisting our rural hospitals to provide health care in a manner most appropriate for each individualized community.” The cost would be $15 million per year for two years. The bill is before the Senate Committee on Labor and Human Resources. Certain hospices can obtain a waiver of the requirement to provide nursing services
Kathy Michels, RN, JD, senior staff specialist, congressional and agency relations office, ANA, Washington, DC, updates delegates on legislative issues at the first Forum at Congress. directly, according to a final Medicare regulation published in the March 1 1 issue of the Federal Register. Hospices located in areas “that are not urbanized” can request a waiver of the requirement from the Health Care Financing Administration. The previous rule of Dec 16, 1983, required that a hospice provide nursing care and services “by or under the supervision of a registered nurse.’’ The regulations stated that these services were “routinely to be provided directly by hospice employees.” A hospice could use contracted staff to meet the “core service” needs of its patients, but only when necessary to supplement hospice employees during periods of peak patient loads or under extraordinary circumstances. Because rural hospitals reported difficulty in hiring enough nurses to provide hospice care and questioned the cost-effectiveness of directly employing nurses in rural areas where hospice use is relatively low, the new regulation was proposed on March 3, 1986, and took effect on 1279
JUNE 1987, VOL. 45. NO 6
AORN J O U R N A L
April 10, 1987. Hospices that are in nonurban areas and were operational on or before Jan 1, 1983, may be granted a waiver of the requirement that nursing services by provided directly if they can demonstrate that they made a “good faith effort to hire nurses.” The waiver may include nursing
services throughout the hospice service area, or for a hospice that functions in a large nonurban area where the availability of nurses differs from one location to another, only a part of the hospice service area may be waived. DEBORAH J. COMBS ASSOCtATE EDITOR
Organ Transplants May Be Cost-Effective
Program Offers Nursing Home Care at Home
Although the cost of organ transplants is highup to $238,000 for a liver transplant-it may cost less per year than the alternative treatments, according to Roger W. Evans, PhD, Health and Population Research Center, Battelle Human Affairs Research Centers, Seattle. At a presentation during the Cornell Medical College conference, “Medicine and society,” held Feb 26 and 27 in New York City, Dr Evans said he based his estimates of cost on pretransplant treatment, evaluation, and screening; cost of the transplant; and cost of postoperative care. His study estimated that the cost of liver transplants ranged from $68,000 to $238,000 and averaged $130,000. Heart transplants cost from $57,000 to $1 10,000 ($95,000 average) and kidney transplants cost from $25,000 to $45,000 ($35,000 average). Dr Evans estimates the cost per year of life gained by transplants was $23,500 for heart recipients, $14,250 for kidney recipients, and $38,000 for liver recipients. In comparison, patients with end-stage cardiac disease that are transplant candidates may incur costs of $6,000 or more per month, according to Dr Evans. Kidney transplant candidates who need dialysis incur bills of $25,000 per year, he said. To estimate costs of liver transplant candidates, Dr Evans used figures taken from a 1980 study that showed medical costs for patients who hemorrhage from acute esophageal varices averaged $35,000 per case. “The critical difference,” Dr Evans said, “occurs on the effectiveness side of the equation. The nonrecipients died, while the majority of recipients are likely to live.”
In Hawaii, Medicaid patients can receive nursing home care without leaving their homes, according to the January issue of the Journal of Gerontological Nursing. Developed by the State Department of Social Services and Housing, Nursing Home Without Walls (NHWW) helps prevent or delay placing an elderly patient into an institution. A registered nurse, medical social worker, and social services aide assess ways to meet the variety of health and social problems that long-term care patients face. Among the services NHWW provides are: case management, day health care, emergency alarm response system, environmental modifications, habilitation services, home maintenance, homemaking, home-delivered meals, nutritional counseling, personal care, respite care, skilled nurse care, and transportation. The services provided by NHWW cannot exceed 75% of the average cost to Medicaid of institutional nursing home care, according to the article. For example, if the cost of a nursing home bed averages $72 a day in Hawaii, the services provided to an NHWW patient cannot cost more than $54 a day. A study was conducted comparing the patient outcomes between NHWW patients and nursing home patients. The NHWW patients improved in more activities of daily living and mobility than nursing home patients. The NHWW patients were happier because they were more likely to have a private room and have contact with their family.
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AORN J O U R N A L
7
1
..
Legislation Phase I1 contract with American Nurses’ Association approved; legislative update given at Congress
Phase I1 of the AORN contract with the American Nurses’ Assocation (ANA) for legislative monitoring and services was approved by the Board of Directors at its pre-Congress meeting in Atlanta. Kathy Michels, RN, JD, senior staff specialist, congressional and agency relations, ANA, Washington, DC, updated the Board on legislative issues, and spoke at the Congress Forum on Monday to update delegates on nursing issues. Under Phase I of the contract last year, the AORN Board of Directors met with the staff of the congressional and agency relations office in Washington, DC, in October for an update on legislative issues. The Phase I1 contract for 1987 includes: gathering information concerning policy considerations in Congress and the Executive Branch related to the legislative and regulatory priorities of AORN; preparation of draft testimony for congressional hearings; direct lobbying activities on behalf of AORN; and providing at least monthly reports from a designated ANA lobbyist to AORN Headquarters. In addressing the Forum, Michels identified reimbursement for RN first assistants as a top priority and one that ANA will help AORN to achieve. She reviewed the mechanism by which certain qualified physician assistants who assist at surgery can receive indirect reimbursement under Medicare (effective since Jan 1, 1987): payment will be made to the employer of the physician assistant at 65% of the amount that would be allowed if performed by a physician. The ANA will attempt to find a sponsor for legislation that would include RN first assistants in this indirect reimbursement mechanism, according to Michels. 1278
When the legislation has been introduced, a grass-roots effort to gain additional sponsors will be appropriate, said Michels. RN first assistants will need to show legislators why nurses in this role would improve access to care, contribute to quality patient care, and be cost-effective, she said. She stressed that the proposed reimbursement would be paid to the employer of the RN first assistant, would be predicated on the requirement of physician supervision, and would be at the 65% rate. Michels also gave an overview of the bills Congress is considering this year, which include: S 101, the Advanced Nursing Services in Nursing Homes Act, which would allow nurses to certify and recertify the need for patient care in nursing homes, H R 1161, the Medicare Community Nursing and Ambulatory Care Act, which would provide community-based nursing and ambulatory care services under Medicare Part B, and HR 913, the Military Selective Service Act Amendment, which would allow the Selective Service System to set up a system for registration of health care personnel in the event of a national emergency. Representatives from two schools of nursing have been appointed by Health and Human Services Secretary Otis R. Bowen to the National Advisory Council on Nurse Training. Appointees are Elizabeth T. Anderson, DPH, assistant dean and associate professor, College of Nursing, Texas Women’s University, Houston; Carol A. Linde-
JUNE 1987, VOL. 45. NO 6
AORN JOURNAL
man, PhD, dean, School of Nursing, University of Oregon Health Sciences Center, Portland; Cecelia H. Foxley, PhD, associate commissioner for academic affairs, Utah State Boad of Regents, Salt Lake City; and James E. Moon, administrator, University of Alabama Hospitals, Birmingham. The 19-member council includes 12 leaders in nursing and education, as well as representatives of hospitals and other institutions that provide nursing services. The council advises the Health and Human Services secretary on the administration of nursing education programs.
Small rural hospitals could convert to outpatient surgery, emergency, or home care centers with funding from the federal government if legislation introduced in the Senate becomes law. Sen David Durenberger (R-Minn) sponsored the Rural Health Services Transition Act introduced in March. The bill would provide grants of up to $50,000 per year for two years for hospital conversion into “more appropriate and cost-effective health care services,’’ according to American Medical News. Durenberger said the program would allow struggling hospitals with fewer than 100 beds to assess services and determine how best to serve the health needs of the community and provide high-quality care. Durenberger said statistics from the American Hospital Association indicate that the average occupancy rate in rural hospitals with fewer than 50 beds is 34% and the average length of stay is five days. In support of the bill, Sen Robert Dole (RKan) said, “Many hospitals who understand the reasons for altering their services, but who have been unable to do so because of financial restraints, will now have an opportunity to do so. This bill is an important step in assisting our rural hospitals to provide health care in a manner most appropriate for each individualized community.” The cost would be $15 million per year for two years. The bill is before the Senate Committee on Labor and Human Resources. Certain hospices can obtain a waiver of the requirement to provide nursing services
Kathy Michels, RN, JD, senior staff specialist, congressional and agency relations office, ANA, Washington, DC, updates delegates on legislative issues at the first Forum at Congress. directly, according to a final Medicare regulation published in the March 1 1 issue of the Federal Register. Hospices located in areas “that are not urbanized” can request a waiver of the requirement from the Health Care Financing Administration. The previous rule of Dec 16, 1983, required that a hospice provide nursing care and services “by or under the supervision of a registered nurse.’’ The regulations stated that these services were “routinely to be provided directly by hospice employees.” A hospice could use contracted staff to meet the “core service” needs of its patients, but only when necessary to supplement hospice employees during periods of peak patient loads or under extraordinary circumstances. Because rural hospitals reported difficulty in hiring enough nurses to provide hospice care and questioned the cost-effectiveness of directly employing nurses in rural areas where hospice use is relatively low, the new regulation was proposed on March 3, 1986, and took effect on 1279
JUNE 1987, VOL. 45. NO 6
AORN J O U R N A L
April 10, 1987. Hospices that are in nonurban areas and were operational on or before Jan 1, 1983, may be granted a waiver of the requirement that nursing services by provided directly if they can demonstrate that they made a “good faith effort to hire nurses.” The waiver may include nursing
services throughout the hospice service area, or for a hospice that functions in a large nonurban area where the availability of nurses differs from one location to another, only a part of the hospice service area may be waived. DEBORAH J. COMBS ASSOCtATE EDITOR
Organ Transplants May Be Cost-Effective
Program Offers Nursing Home Care at Home
Although the cost of organ transplants is highup to $238,000 for a liver transplant-it may cost less per year than the alternative treatments, according to Roger W. Evans, PhD, Health and Population Research Center, Battelle Human Affairs Research Centers, Seattle. At a presentation during the Cornell Medical College conference, “Medicine and society,” held Feb 26 and 27 in New York City, Dr Evans said he based his estimates of cost on pretransplant treatment, evaluation, and screening; cost of the transplant; and cost of postoperative care. His study estimated that the cost of liver transplants ranged from $68,000 to $238,000 and averaged $130,000. Heart transplants cost from $57,000 to $1 10,000 ($95,000 average) and kidney transplants cost from $25,000 to $45,000 ($35,000 average). Dr Evans estimates the cost per year of life gained by transplants was $23,500 for heart recipients, $14,250 for kidney recipients, and $38,000 for liver recipients. In comparison, patients with end-stage cardiac disease that are transplant candidates may incur costs of $6,000 or more per month, according to Dr Evans. Kidney transplant candidates who need dialysis incur bills of $25,000 per year, he said. To estimate costs of liver transplant candidates, Dr Evans used figures taken from a 1980 study that showed medical costs for patients who hemorrhage from acute esophageal varices averaged $35,000 per case. “The critical difference,” Dr Evans said, “occurs on the effectiveness side of the equation. The nonrecipients died, while the majority of recipients are likely to live.”
In Hawaii, Medicaid patients can receive nursing home care without leaving their homes, according to the January issue of the Journal of Gerontological Nursing. Developed by the State Department of Social Services and Housing, Nursing Home Without Walls (NHWW) helps prevent or delay placing an elderly patient into an institution. A registered nurse, medical social worker, and social services aide assess ways to meet the variety of health and social problems that long-term care patients face. Among the services NHWW provides are: case management, day health care, emergency alarm response system, environmental modifications, habilitation services, home maintenance, homemaking, home-delivered meals, nutritional counseling, personal care, respite care, skilled nurse care, and transportation. The services provided by NHWW cannot exceed 75% of the average cost to Medicaid of institutional nursing home care, according to the article. For example, if the cost of a nursing home bed averages $72 a day in Hawaii, the services provided to an NHWW patient cannot cost more than $54 a day. A study was conducted comparing the patient outcomes between NHWW patients and nursing home patients. The NHWW patients improved in more activities of daily living and mobility than nursing home patients. The NHWW patients were happier because they were more likely to have a private room and have contact with their family.
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