• paid other than at differential rates (65, 75, or 85 percent of physician scale) by Medicaid, Medicare, or other payers and insurers;

  • paid directly by Medicaid;

  • certified as leading a patient-centered medical home or primary care home; or paid for services unless supervised by a physician.

A nurse may:

  • indirectly affect the eligibility of other providers for payment because

    • pharmacies cannot obtain payment from some private insurers unless the supervising or collaborating physician’s name is on the script, and

    • hospitals cannot bill for APRNs’ teaching or supervising of medical students and residents and advanced practice nursing students (as they can for physicians who provide those same services).

NPs. Of interest, this was the case even though the actual level of involvement by the physician may be the same in states where supervision is required as in states where it is not. Also of note is that Medicaid plans were more likely than any other category of insurer to credential NPs.

Although there is a movement away from a fee-for-service system, Table 3-2 shows the current payment structure for those providing primary care.

The Federal Government and Regulatory Reform16

Precisely because many of the problems described in this report are the result of a patchwork of state regulatory regimes, the federal government is especially well situated to promote effective reforms by collecting and disseminating best practices from across the country and incentivizing their adoption. The federal government has a compelling interest in the regulatory environment for health care professions because of its responsibility to patients covered by federal programs such as Medicare, Medicaid, the VA, and the Bureau of Indian Affairs. Equally important, however, is the federal government’s responsibility to all American taxpayers who fund the care provided under these and other programs to ensure that their tax dollars are spent efficiently and effectively. Federal actors already play a central role in a number of areas that would be essential to effective reform of nursing practice, especially that of APRNs. They pay for the majority of health care services delivered today, they pay for research on the safety and effectiveness of existing and innovative practice models and encourage


This section is based on a September 10, 2010, personal communication with Barbara J. Safriet, Lewis & Clark Law School.

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