28 November 2013

The future of nursing practice

In its November issue, the journal Health Affairs explored how the healthcare workforce in the US could be redesigned to address the concerns of increased patient demand and physician shortages. One such solution is to expand the use of nurse practitioners (NPs) to provide patient care.

This approach appears to be supported by a recent survey by the American Association of Nurse Practitioners (AANP) demonstrating the public’s very favourable attitude towards NPs. If such an expansion does occur, is today’s medical professional coverage, underwriting and pricing keeping pace?

Varying NP authority

Currently, the scope of practice laws and regulations are a creature of state law and they define what services may or may not be provided by a professional licensed in the state. The legal framework sets forth the authority to provide care to patients, including diagnosing disease, treating illness, prescribing medication and determining the extent of educational training and practice supervision required, as well as licensure and discipline.

Sixteen states allow for NPs to practise fully under their licence with oversight by the state board of nursing. Twenty-one states have at least some restriction on what NPs may do under their licence, and 13 states restrict NPs practice altogether, requiring full supervision by a physician.

The Affordable Care Act, with its goal to expand availability of health insurance to an estimated 30 million people, will increase the demand for healthcare services and it is likely that restrictive NP scope of practice laws will come under pressure to be revisited and revised. In fact, between January 2011 and December 2012, 1,800 practice-act bills were proposed and nearly 20 percent were adopted, according to a database established by the National Conference for State Legislatures.

There are also those who forecast that the push to reduce costs will create additional pressure to revise the scope of practice laws. Take, for example, the rise of retail clinics. The first retail clinic opened in 2000 and by 2010 there were more than 1,200 operating in 45 states. Revisions to the scope of practice law, argue its supporters, would allow NPs to practise fully in these retail settings and reduce costs to patients.

Underwriting impact

So, if you are in a state whose laws may be undergoing a change or whose NPs practise in non-traditional locations such as retail clinics, what are the implications for your programme? Do your current medical professional underwriting, pricing and coverage need to be amended?

To prepare, you can take a page from the states who already have granted full practice rights to NPs. Gen Re follows how insurers are responding to this changing environment by examining the filings in states with full practice rights for NPs. This examination has revealed that some insurers are developing specific classifications, rates, and severity curves for these evolving classes of practitioners. These classifications also look to stratify the specific NP practice characteristics between lower risk (dermatology and geriatric medicine) and higher risk practices (critical care, obstetrics/gynaecology, and pain management).

If your programme is in a state where the laws have not yet changed, it will become essential that not only data regarding the areas of practice of NPs are captured, but the locations they serve as well. These data will assist in better underwriting, rating and covering this evolving healthcare group. In addition, as there is much less experience associated with these new practitioners than the industry has with physicians and surgeons, insurers will need to look to additional ways to price this business while at the same time continually reexamining the rates against the loss experience as it develops.

Being prepared

Like everything else in the healthcare landscape, transformational change is underway.  Our ‘top 10 game changers’ were highlighted in a recent Gen Re Viewpoint publication, but many more could be included. The bottom line is that the exposures you underwrote yesterday will not be those you underwrite tomorrow. Appreciating the difference is what we, as underwriters, need to do.

Being out in front of that change as it relates to your programme will help you weather the changes ahead.

Libby Benet is Gen Re’s casualty underwriting manager in North America. She can be contacted at: