Nurse pay mandate (HB 4010 ): Fastest way to drive up health care costs?

Nurse pay mandate (HB 4010 ): Fastest way to drive up health care costs?
By Taxpayer Association of Oregon

HB4010 mandates insurers to pay nurse practitioners at the same rate as physicians for the same services. This has to be among the fastest & most reckless ways politicians could drive up health care costs when looking at possible legislation across the nation. While other states are considering bills to lower health care costs, Oregon once again is charting a backwards course by raising costs which will do nothing but hurt poor Oregonians who cannot afford health insurance.

So expect the tragic lose-lose situation of Oregonians having to pay higher medical bills while paying higher taxes to cover the cost of more people enrolling into government programs who have been priced out.   Yet, politicians will tout this as a success.

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Posted by at 10:00 | Posted in Uncategorized | 65 Comments |Email This Post Email This Post |Print This Post Print This Post
  • Bob Clark

    Sorry, Nurses but Kitzhaber says he is going to save to $250 million from state healthcare expenses; and hiking your pay radically higher as in this proposed legislation would work against Kitzhaber’s promised savings.

    If you want doctor like pay, maybe you should become a good doctor.

    • Npguy

      Maybe You should think twice about the next time you bend over for a antobiotic shit

  • Oregon Engineer

    This legislature will pass the bill because it is a pay off
    to another union that got them elected.  That
    is the only reason for this bill.  The
    ONA is a very powerful union and the right to work in the state of Oregon does
    not exist,

    I would agree with you Bob but Gov Kitzgoober (yes I misspelled
    it on purpose) will bow to the union and sign it into law if it reaches his
    desk.  Do you really think he is capable
    of standing by what he said (cutting $250M from state healthcare expenses) to
    get elected, when it goes against a union?

  • JoelinPDX

    How in Hell does the government have anything to say about compensation…for physicians or nurse practitioners. This is just another example of government sticking its nose where it doesn’t belong and in the end costing people a whole lot more money.

    • valley person

      ” How in Hell does the government have anything to say about compensation”

      Government has a lot to say about compensation. Minimum wages, equal pay for equal work, workers comp, Davis Bacon….

  • Teacherman

    Nurses, like teachers, are underpaid. They must make a living wage.
    This will help.
    Thanks for looking out for us out here.

    • gumbojuice

      Nurse practitioners make $120k in Oregon.  Try again. 

  • Rupert in Springfield

    It’s not surprising. More government action equals less money I get to keep. In this case because my health insurance premiums will rise.

    What is surprising is the question – “Gee, why do you guys knock government so much?”

  • Mike Franz

    HB 4010 would mandate that all nurse practitioners be paid exactly the same as any physician in any specialty for providing a service using the same procedure code. This legislation is a misguided attempt to resolve a real problem — many nurse practitioners recently had their reimbursement rates cut unilaterally and without recourse by several commercial insurance companies. This has caused tremendous hardship on the nurses and has even created access problems as some of them find it difficult to stay in business. This must be fixed.
    However, HB 4010 is a major overreach full of very serious consequences on workforce development in health care. The bill implies that there is never a time when a physician specialist might provide services that could be of more value than those provided by a nurse practitioner. For example, a developmental pediatrician evaluating an autistic 3 year old with fetal alcohol effects, severe trauma and complex medical problems would be reimbursed the same as a family nurse practitioner using the same billing code. Does it matter that a physician might have 8 or 9 years of post-graduate rigorous training and education versus a nurse practitioner’s 2 year master program? Could one conceive that the pediatric specialist might provide more value for their service? Furthermore, why would anyone spend the additional 6-plus years in grueling training to become a physician specialist if they are deemed of no more value to society than an advanced practice nurse? This bill is not limited to primary care or any one specialty. Nurses mention outcome data to support their arguments but this is research is largely limited to low complexity primary care. This bill has no such limitations. It implies that we are wasting our resources sending people to medical school, residency and fellowships to train medical providers, especially specialists. By this logic, we should close down our medical schools and shift all training to the nursing programs. After all, the argument goes, Oregon nurse practitioners have the most liberal scope of practice in the nation and they can provide the exact same service so they should get the exact same pay.
    I hope we might take some time to further vet such a massive shift in workforce policy before this gets ramrodded through an abbreviated session in Salem. This is especially concerning given the lack of coordination of this bill with the medical transformation legislation that is one of the top priorities this month. Unfortunately, alternative amendments that would solve the nurses’ concern, including reversing recent rate cuts and developing regulations to prevent future unjust cuts, have been dismissed by the nursing lobby and many legislators. We can solve the nurses problem and maintain a medical education system that values expertise in treating our most complex and vulnerable patients. Let’s do it.

    • 3H

      My understanding is that the focus of a Nurse Practitioner is limited.   The reason we would have a physician would be to do all the other things that a Nurse Practitioner and presumably, they (physicians) would be compensated more highly for those other procedures and duties.

      I don’t think we should compensate doctor’s more highly for providing the same service as a Nurse Practitioner simply because they have more education.  Presumably the same service is being provided with the same quality and the same results.   

      “For example, a developmental pediatrician evaluating an autistic 3 year old with fetal alcohol effects, severe trauma and complex medical problems would be reimbursed the same as a family nurse practitioner using the same billing code.

      If they are providing the same service, yes.  Again, presumably, the developmental pediatrician would be compensated higher for procedures that require her expertise that would be beyond the ability of the Nurse Practitioner.

      I think it’s only fair to compensate for the service rendered – not the degree of the person giving the service.

      • Mike Franz

        One would think that a nurse practitioners scope would be more limited.  But Oregon has the most liberal scope of practice laws for NPs in the nation.  They function entirely independently and code almost any procedure except for some of the surgical and highly procedural specialties.  By Oregon law, there really isn’t much of a limit on what they are legally allowed to do — although whether or not that’s good medicine is another question.  

        Let me give you another example:
        I am a board certified child psychiatrist.  I went through 9 years of formal training AFTER I graduated from college:  4 years of medical school, 3 years of residency and 2 years of fellowship.  This was extremely rigorous training, much of it focused on a wide array of neuropsychiatric diagnoses and treatment.  

        In contrast, a psychiatric mental health nurse practitioner (PMHNP) completes a 2 years master’s nursing program.  

        By statute and regulations, we both must use exactly the same CPT codes when we see patients.  For example, a 90801 is a comprehensive psychiatric evaluation.  There is no coding to differentiate complexity of acuity.  So, I ask you, might there be more value in my assessment of a 5 year old child with Asperger’s, severe sexual trauma, co-morbid medical illness, etc versus that of a PMHNP with no formal training in pediatric psychiatry?  We are both allowed to “evaluate” this patient.  We both must use the same CPT code.  Should we both be reimbursed the same?  Are we providing the same service?  I think not.  

        Why on earth is anyone going to go to medical school plus 3-6 years of residency if our society says that this provides no more value to patient care than a nurse with a master’s degree?  With this legislation we will be shifting the training of our most expert workforce from medical school to nursing school.

        Plus, physicians continue to be held to a higher standard of care (as they should be) which results in significantly higher malpractice insurance.  Educational debt is on the order of a magnitude more for a physician than a nurse.  Plus there is the opportunity cost of not being in the workforce for a decade after college.

        This is very short-sighted legislation.  It is bad policy.  Let’s fix the cut in the nurses’ reimbursement but let’s not equate NPs with our most highly trained specialists.  Yes, we need to look at economics and workforce issues.  But let’s make reforms through a thoughtful, rationale process.  HB 4010 is not that.

        • NoNurseforMe

          Exactly. You are correct, sir! These morons in government are simply that.

        • Ronlgynn

          Right On Dr. Franz. I am a retired Parole and Probation Officer. I expect my doctors to be paid well because they have put in so much time and effort to be able to practice medicine. On the other hand, while I have had good services from NP, I do not expect them to receive the same rate of compensation since their education and training is way less.(I understand today, that person finishing medical school in Oregon may owe as much as $250,000 in student loans) Doctors have to go through so much, especially having to pay huges amounts of money for malpractice insurance. Sometimes, I wonder if doctors might just want to become  automobile mechanics instead and they could make high pay with a lot less headache.

        • Rupert in Springfield

           Look, this is fairly simple to resolve.

          The argument is that the nurse should be paid the same as the doctor if the service rendered, work involved. That seems to make some sense.  However, we have to completely ignore the doctors much higher level of training to reach this conclusion.

          But this is inconsistent with the arguments made just a post or two ago regarding closed shop workplaces.

          Union rules almost always will demand someone be paid based on seniority rather than work performed. Two people can be doing the exact same job but a union teacher with 20 years on the job will get paid higher than one with 5 years on the job, even if the latter is a better teacher.

          It’s a deer in the headlights moment. If equal pay for equal work is the thinking here, then bye bye any argument for union seniority contracts and closed shop rules.

          The point here is doctors go through much more training than a nurse and are held to a higher standard by virtue of what I would think are greater malpractice insurance costs. All that comes into play when you are treated by a doctor rather than a nurse even though the treatment may be exactly the same.

          • 3H

            Keep in mind we are talking about reimbursement rates from insurance companies, not wages.  They are two different things.   Insurance companies pay for services or procedures provided.  They do not pay wages.  You are comparing apples to oranges.

            Much of your post is meaningless as it is talking about wages.  

            Closed shop has nothing to do with rate of pay.  It has everything to do with either joining the union or paying fair share.  No inconsistency.  But again, you are fixated on wages.
            Unions negotiate wages based upon job duties and seniority.  Not just seniority.  Almost always.   It’s both, not one or the other.

            Malpractice is not based upon degree of education, but upon amount of harm that can be done to the patient.   Physicians with similar education will pay different rates based upon risk factors of their specialty.  I’m willing to bet that a Certified Registered Nurse Anesthetist pays more in malpractice than many physicians.

            I would think physicians would be in favor of this.  If NPs are reimbursed less for performing the same service, insurance companies could very well lower the reimbursement rate for everyone – including  physicians.  Why would an insurance company pay more to have a physician perform a service when they can pay less to have a Nurse Practitioner do the same job?

        • 3H

          So, in a private practice, would a doctor bill the insurance more if he set a broken arm than if her nurse set the broken arm?  Are there two codes for a broken arm — one for doctors, one for nurses?

          • Mike Franz

            I don’t think so.  And there may be some procedures  where there should be little, if any, differentiation.  However, HB 4010 applies to any shared procedure code in any specialty or subspecialty of medicine.

            But let me ask you this:
            Is it OK that an attorney gets reimbursed more than a paralegal if they both spend the same time (billable hours) preparing the same legal documents for a case before them?
            Is it OK for a master carpenter to receive more for his wooden chair than the amateur who sells a similar product on eBay?
            Is it OK that a RN with a bachelors in nursing receive more compensation for her time than the RN who never got her degree but performs the exact same service on the ward (the nursing lobby thinks they should be paid differently, by the way)?

          • 3H


             However, HB 4010 applies to any shared procedure code in any specialty or subspecialty of medicine.

            Are there any of the procedures that are shared, but that NP’s do not perform?  If there is, your argument is with insurance billing and coding. 

            However, if certain procedures or services should be paid less, then they should be paid less regardless of whether the person performing them is a physician or a NP.

            “Is it OK that an attorney gets reimbursed more than a paralegal if they both spend the same time (billable hours) preparing the same legal documents for a case before them?

            Depends… if it is a simple will, or a legal forms, then no, the attorney should not be paid more.  In fact, I think that is the case through EAP programs that will pay for employees to have a simple will drawn up: the amount reimbursed is the same regardless of who draws it up.

            “s it OK for a master carpenter to receive more for his wooden chair than the amateur who sells a similar product on eBay?

            You’re straying beyond the confines of the discussion.  Payment for items made on ebay is entirely up to buyer and seller.  Some people might.  Some people might not.  Depends upon the material and the quality of the craftsmanship.  If all things are equal, then I’d say no, the Master Carpenter shouldn’t receive more.  Especially if the quality of the chair wasn’t dependent upon the MC’s training and experience.   

            Is there a qualitative difference between the level of service and competence when a physician performs the same service or procedure as a Nurse Practitioner?   I go back to setting a broken arm.  Advanced training on the part of the physician will pertain to other skills, not the setting of an arm.  Yes?

            “Is it OK that a RN with a bachelors in nursing receive more compensation for her time than the RN who never got her degree but performs the exact same service on the ward (the nursing lobby thinks they should be paid differently, by the way)?

            Now we’re talking about wages, and that is different than a discussion on how much a NP or a Physician should be compensated for specific procedures that both are equally qualified, and competent, to perform.  

            It is up to the employer to determine whether your two RNs should be paid differently.  They very well because the additional training of the BA-RN gives them more skills and that there are things that they can do that the other RN cannot.  Just as Nurse Practitioners are not paid, for the most part, as well as physicians.  Even if there are things that the NP can do as well (or better) than the physician.  That is where you’re more intensive training pays off.  That, and the supervisory role that physicians play.

            Now, is it fair that a newly minted physician should be able to bill more for the same procedure as a NP with 30 years of experience and training?

            Or…  how about a Family Practice doctor who doesn’t have specialty training… should that doctor be compensated the same as another doctor with more years of training?  

  • Like Mike, I am a general and child psychiatrist.  I now work in private practice doing psychotherapy combined with medication management.  I attended four years of medical school, four years of residency and two years of child psychiatry fellowship.  

    I think that the central point that people may be missing is that this bill mandates same payment for same CPT code, but the CPT code does not actually define much about what work is done during the allotted time.  If am doing a developmental assessment on an eight year old with multiple developmental discontinuities, attention deficit disorder and trauma I code the same CPT code as a nurse practitioner doing a medication evaluation. I assure you that there are aspects of the child’s functioning and development that I am evaluating that most nurse practitioners are not trained to assess.  But both would be coded under the 90801.

    To take a different example, CPT codes do not yield  the same reimbursement even among doctors.  Because of my child psychiatry training I receive higher rates for a 90801 than some of my colleagues who did not do a fellowship.

    To put yet another spin on this, if a new patient sees an internist or a cardiologist  for chest pain it may be coded as a 99201 (initial patient visit).  THe cardiologist will receive a larger fee to reflect his increased training and knowledge base in this area.  Because he has received more training there are things that he will be evaluating that the internist is likely unaware of.  Because HB 4010 is based on CPT codes, the result would be that a nurse practitioner would receive the same fee for an initial visit as both the internist and cardiologist.  In fact, one unintended consequence is that it seems that specialists will no longer be able to bill a higher fee than the internist.  It is all considered the same work and everyone gets the same fee.

    At this time increased knowledge has a monetary value in our payment system.  HB 4010 would essentially signify that our society puts no value on increased knowledge as it applies to medical evaluation.

    • 3H


      I am evaluating that most nurse practitioners are not trained to assess…

      But some would right?   I’ll bet that most physicians aren’t trained to assess that either.

      • It is possible that the nurse practitioner would, but only if the got substantial additional continuing education.  I would have no problem with the idea that continuing ed could be factored into the fee structures.  In fact, some insurance companies increase my fees with time, but give early career psychiatrists lower fees.  I assume that this is based on the idea that experience and continuing ed increase value.

        You are right that many physicians would not be trained to assess these elements in a psychiatric eval either, but that is why I can negotiate higher fees from the insurance companies based on my fellowship training.  As I said above, not all physicians get the same fee for the same CPT code.

        My issue with this bill has less to do with what nurse practitioners get paid than it does with the fact that by paying everyone the same fee I could not make a case with various companies for my value when I negotiate contracts.  It essentially ends the possibility of any market based system in private practice.  If we are going to kill the free market completely in medicine then we should just go to a single payer system.

        • 3H

          “…
          then we should just go to a single payer system.

          From your fingers to God’s eye.  😉

  • 3H

    Interestingly enough, the bill passed with a majority of Republicans voting for it…  and most Democrats voting against it.

    http://gov.oregonlive.com/bill/2012/HB4010/ 

    • 3H

      My mistake, it was voted to send the bill to the rules committee.  Never mind.  Nothing to see here. Move along.

      (see Rupert.. I can admit when I made a mistake.  I even caught it myself)

      • Well, a friend of mine who is very involved with the political process said to me “The house rules committee is where bills are sent to die.”  I don’t know if that is completely true, but he thought that it was a maneuver to kill the bill without taking political heat.  We’ll see.

        • 3H

          LOL.. I’ve heard that too.  But, my knowledge of the legislative process is more like the civics class kind – the theory more than the practice.

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