nurse practitioners and certified nurse specialists to certify patients for home health services and for admission to hospice, and clarify that they are authorized to certify admission to a skilled nursing facility, and to perform the initial admitting assessment.

  • Medicare Hospital Conditions of Participation should be amended or clarified to facilitate APNs’ eligibility for clinical privileges and membership on the medical staff.

  • Nurse-Managed Health Clinics should be included in the regulatory definition of “essential community providers” that will be promulgated pursuant to the section of the Affordable Care Act that creates the Health Benefit Exchanges.


Almost every aspect of health care in the United States is in flux. The current reform debates include a seemingly endless (and ever-changing) number of proposals intended to reduce costs and improve access to quality health services. At the same time, modes of health care delivery continue to evolve synergistically at a breathtaking pace, with newly discovered biologics and pharmaceuticals, increasingly adept robotic interventions, personalized therapeutics, nanotechnology, interactive knowledge platforms, and computerized diagnostic and treatment aids that reduce the barriers of time and geography.

The end product of these developments is unknown. Health care reform, even when finalized, will not be fully implemented for several years, and the resulting ramifications on the efficiency and effectiveness of the delivery system will not be understood until even later. And the science and technology of health care delivery will continue to evolve.

In contrast, there are certain fundamental things that we do know.

  • The infrastructure necessary for the implementation of any conceivable reforms—and for the application of new assessment and treatment modalities—is deeply flawed, stuck in place and amazingly static.

  • More specifically, the framework for certifying to the public that an individual trained to provide care can do so competently is profoundly broken for the reasons I have described.

  • Notwithstanding the larger uncertainties, there are known problems with promising solutions which can be acted on immediately, and which will be helpful now and in the future regardless of the final contours of any reform legislation or further developments in the delivery of care.

In sum, the fundamental flaws in the regulatory framework that I have described are real, and they rob us as a nation of the full range of care options that our health care providers are capable of offering. This is particularly true of

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