WEBVTT 00:00:12.304 --> 00:00:13.904 position:50% align:middle Greetings, everyone. 00:00:13.904 --> 00:00:15.244 position:50% align:middle And thank you for the introduction. 00:00:15.244 --> 00:00:23.014 position:50% align:middle And I want to begin by just saying thank you to Colleen and to Michelle, for all their help in making 00:00:23.014 --> 00:00:25.764 position:50% align:middle this presentation possible. 00:00:25.764 --> 00:00:32.265 position:50% align:middle I want to just acknowledge the agenda here that I want to move through. 00:00:32.265 --> 00:00:37.095 position:50% align:middle We'll first of all talk about some strengths of the APRN workforce. 00:00:37.095 --> 00:00:43.125 position:50% align:middle You'll note that I'll be concentrating much of the time on nurse practitioners, 00:00:43.125 --> 00:00:46.415 position:50% align:middle this is because we have more data to work with. 00:00:46.415 --> 00:00:53.245 position:50% align:middle So, it's not that I'm ignoring the contributions of other APRNs, it's just we have more data to work 00:00:53.245 --> 00:00:55.395 position:50% align:middle with with nurse practitioners. 00:00:55.395 --> 00:01:02.856 position:50% align:middle We'll then also move into the challenges facing the workforce as we think about a post-pandemic world. 00:01:02.856 --> 00:01:07.566 position:50% align:middle And then hopefully, we'll have a few minutes for some conversation at the end. 00:01:07.566 --> 00:01:18.056 position:50% align:middle Now, I want to disclose the funders and my relationships with boards and other organizations. 00:01:18.056 --> 00:01:23.186 position:50% align:middle None of these relationships in my mind bias my comments. 00:01:23.186 --> 00:01:30.738 position:50% align:middle I'd also like to acknowledge my teammates from four different interdisciplinary research teams. 00:01:30.738 --> 00:01:37.328 position:50% align:middle And there's too many individuals to identify and name, so I'll just say thank you to all of them, 00:01:37.328 --> 00:01:38.898 position:50% align:middle and we'll move forward. 00:01:38.898 --> 00:01:42.678 position:50% align:middle So, here we are, the strengths of the APRN workforce. 00:01:42.678 --> 00:01:46.878 position:50% align:middle Now, there's five of them that I've listed here, we could add to those, 00:01:46.878 --> 00:01:51.908 position:50% align:middle but I wanted to pull out the five that really stand out in my mind. 00:01:51.908 --> 00:01:57.548 position:50% align:middle They're all listed on this one slide, but we're going to go through each of them one by one. 00:01:57.548 --> 00:02:02.759 position:50% align:middle Now, the first strength is that we have increasing numbers of APRNs. 00:02:02.759 --> 00:02:09.139 position:50% align:middle These are data taken from "The Future of Nursing" report, 2020 to 2030. 00:02:09.139 --> 00:02:20.589 position:50% align:middle And it's a little difficult in a way to provide numbers of APRNs, because so many are prepared in more 00:02:20.589 --> 00:02:21.939 position:50% align:middle than one role. 00:02:21.939 --> 00:02:32.224 position:50% align:middle So, I've listed both at the top all APRNs prepared in a single role, and then added those that have other 00:02:32.224 --> 00:02:33.254 position:50% align:middle roles as well. 00:02:33.254 --> 00:02:42.704 position:50% align:middle And you can see that by 2018, we have a considerable number of APRNs, around 373,000. 00:02:42.704 --> 00:02:46.984 position:50% align:middle That number is probably pretty close to 400,000 today. 00:02:46.984 --> 00:02:55.454 position:50% align:middle And then at the bottom half of the slide you can see the numbers of NPs, clinical nurse specialists, 00:02:55.454 --> 00:02:57.694 position:50% align:middle certified registered nurse anesthetist. 00:02:57.694 --> 00:03:05.497 position:50% align:middle And I forgot to put in certified nurse midwives, but that number is right around 12,500. 00:03:05.497 --> 00:03:15.530 position:50% align:middle The workforce is projected to grow rapidly as we move through this decade. 00:03:15.530 --> 00:03:23.000 position:50% align:middle This is some data that we published in the "New England Journal of Medicine" a few years ago. 00:03:23.000 --> 00:03:32.934 position:50% align:middle And you can see the rapid growth of nurse practitioners from 2010 through 2016. 00:03:32.934 --> 00:03:41.756 position:50% align:middle But then as we project forward, that number will double from 157,000 in 2016 to almost 00:03:41.756 --> 00:03:45.363 position:50% align:middle 400,000 in 2030. 00:03:45.363 --> 00:03:49.574 position:50% align:middle So, this is a large increase in our NP workforce. 00:03:49.574 --> 00:03:56.681 position:50% align:middle These projections were done prior to the pandemic, but you can see NPs are projected to grow 00:03:56.681 --> 00:04:05.594 position:50% align:middle by about 6.8% annually compared to physicians at only 1.1% and physicians' 00:04:05.594 --> 00:04:08.204 position:50% align:middle assistants at 4.3%. 00:04:08.204 --> 00:04:12.684 position:50% align:middle So, strong numbers now and growing numbers in the future. 00:04:12.684 --> 00:04:19.924 position:50% align:middle A second strength of the APRN workforce and particularly with nurse practitioners is the 00:04:19.924 --> 00:04:21.245 position:50% align:middle growth in employment. 00:04:21.245 --> 00:04:29.984 position:50% align:middle And if you go back to 2010, to the left of the slide, you'll see that there was less than 100,000 nurse 00:04:29.984 --> 00:04:32.586 position:50% align:middle practitioners employed in the U.S. 00:04:32.586 --> 00:04:38.199 position:50% align:middle Today, that number is around 241,000, at least by 2020. 00:04:38.199 --> 00:04:42.516 position:50% align:middle This is a very rapid growth of the workforce. 00:04:42.516 --> 00:04:46.176 position:50% align:middle So, a pretty strong achievement here. 00:04:46.176 --> 00:04:53.176 position:50% align:middle The yellow line below the top blue line, that corresponds to nurse practitioners working 00:04:53.176 --> 00:04:59.886 position:50% align:middle in physicians' offices, so, about 110,000 NPs in that setting. 00:04:59.886 --> 00:05:03.610 position:50% align:middle Below that is the grey line which corresponds to hospitals. 00:05:03.610 --> 00:05:10.602 position:50% align:middle And you can see about 93,000 NPs working in hospitals as of 2020. 00:05:10.602 --> 00:05:18.030 position:50% align:middle And then the line at the bottom corresponds to all other settings where NPs are working, 00:05:18.030 --> 00:05:20.168 position:50% align:middle and that totals around 38,000. 00:05:20.168 --> 00:05:27.582 position:50% align:middle Let me provide a little bit more information on both hospital employed and non-hospital settings. 00:05:27.582 --> 00:05:31.390 position:50% align:middle I'll pause a little bit and have a drink of water while you take a look at the slide, 00:05:31.390 --> 00:05:40.570 position:50% align:middle and just get a feel for where our nurse practitioner workforce is employed. 00:05:40.570 --> 00:05:48.240 position:50% align:middle All right, so moving from employment, we'll look at inflation adjusted earnings. 00:05:48.240 --> 00:05:58.081 position:50% align:middle And this chart shows how earnings have increased from 2010 particularly up through 2015, 00:05:58.081 --> 00:06:02.395 position:50% align:middle nice inflation adjusted earnings growth. 00:06:02.395 --> 00:06:09.407 position:50% align:middle After 2015, you see that earnings have sort of plateaued, they haven't gone down. 00:06:09.407 --> 00:06:17.147 position:50% align:middle Had they decreased, that would be an indication that maybe the supply of NPs exceeded the demand, 00:06:17.147 --> 00:06:19.907 position:50% align:middle and therefore wages and earnings would fall. 00:06:19.907 --> 00:06:25.077 position:50% align:middle We're not seeing that, what we're seeing is a nice employment growth and that 00:06:25.077 --> 00:06:32.014 position:50% align:middle employers are finding the NPs that they need given current earnings. 00:06:32.014 --> 00:06:42.994 position:50% align:middle A third strength that I'd like to mention is the growth in the amount of care that NPs are providing 00:06:42.994 --> 00:06:45.544 position:50% align:middle to vulnerable populations. 00:06:45.544 --> 00:06:53.584 position:50% align:middle Now, I think you are aware that a number of studies has shown that compared to primary care physicians, 00:06:53.584 --> 00:06:59.494 position:50% align:middle primary care nurse practitioners are more likely to work and practice in rural areas. 00:06:59.494 --> 00:07:04.693 position:50% align:middle This is an area where we are getting increasingly concerned about the physician, 00:07:04.693 --> 00:07:07.213 position:50% align:middle the adequacy of the physician workforce. 00:07:07.213 --> 00:07:16.723 position:50% align:middle And we know that there are many, many vulnerabilities among rural populations, 00:07:16.723 --> 00:07:25.293 position:50% align:middle including insurance, low insurance levels, isolation, loneliness, mental behavioral health, 00:07:25.293 --> 00:07:28.419 position:50% align:middle older populations, etc. 00:07:28.419 --> 00:07:36.556 position:50% align:middle We also know that primary care NPs are more likely than physicians to take care of other 00:07:36.556 --> 00:07:44.836 position:50% align:middle vulnerable populations, women, people of color, the poor, the disabled, 00:07:44.836 --> 00:07:52.604 position:50% align:middle people who have no insurance or very low amounts of insurance, and those individuals who are qualified 00:07:52.604 --> 00:08:01.642 position:50% align:middle for both Medicare and Medicaid, the dual eligibles, very poor individuals, often with very complicated, 00:08:01.642 --> 00:08:07.715 position:50% align:middle numerous comorbid conditions that are difficult and expensive to take care of. 00:08:07.715 --> 00:08:15.936 position:50% align:middle I've got a reference here at the bottom of the screen, that at the end of the presentation I've included three 00:08:15.936 --> 00:08:24.072 position:50% align:middle or four slides that list the references to studies that backup this third strength, 00:08:24.072 --> 00:08:26.772 position:50% align:middle and also this fourth strength. 00:08:26.772 --> 00:08:30.738 position:50% align:middle Well, we'll get to the fourth strength, I've got one more slide before there. 00:08:30.738 --> 00:08:38.658 position:50% align:middle This is data from the "National Sample Survey of Registered Nurses" that was conducted in 2017 by the 00:08:38.658 --> 00:08:46.768 position:50% align:middle Health Resources Services Administration, and the Census Bureau. 00:08:46.768 --> 00:08:55.108 position:50% align:middle So, what was found is that NPs, 71% reported that at least a quarter of their patient 00:08:55.108 --> 00:08:59.788 position:50% align:middle panel were among racial and ethnic minority groups. 00:08:59.788 --> 00:09:07.971 position:50% align:middle That was the terms that were used in this study, so I've just provided them here to be as completely 00:09:07.971 --> 00:09:09.881 position:50% align:middle accurate as possible. 00:09:09.881 --> 00:09:16.201 position:50% align:middle Twenty percent of NPs said that at least 75% of their patient panels were from racial or 00:09:16.201 --> 00:09:18.331 position:50% align:middle ethnic minority groups. 00:09:18.331 --> 00:09:27.121 position:50% align:middle And then about a little more than a quarter of NPs said that 25% or more of their patient panel had 00:09:27.121 --> 00:09:29.751 position:50% align:middle limited English proficiency. 00:09:29.751 --> 00:09:37.146 position:50% align:middle So again, NPs providing a lot of care to vulnerable populations. 00:09:37.146 --> 00:09:40.226 position:50% align:middle Here's the other strength that I wanted to note. 00:09:40.226 --> 00:09:45.586 position:50% align:middle And I wanted to bring this information to your attention. 00:09:45.586 --> 00:09:53.846 position:50% align:middle It's been my experience that when you talk with APRNs, and particularly nurse practitioners, 00:09:53.846 --> 00:10:00.126 position:50% align:middle they're well versed around the strength and evidence around quality of care. 00:10:00.126 --> 00:10:09.035 position:50% align:middle And I wanted to just, you know, kind of provide some other information that expands our 00:10:09.035 --> 00:10:14.005 position:50% align:middle awareness of the contributions of nurse practitioners beyond quality. 00:10:14.005 --> 00:10:15.165 position:50% align:middle So, I want to go through these. 00:10:15.165 --> 00:10:22.445 position:50% align:middle And again, you'll see these slides will be referenced at the end of the presentation. 00:10:22.445 --> 00:10:30.377 position:50% align:middle But this first one, decrease in the number of payments made by physicians for malpractice rates. 00:10:30.377 --> 00:10:38.997 position:50% align:middle This is a study that Ben McMichaels did, that showed that in states that had less restricted 00:10:38.997 --> 00:10:45.417 position:50% align:middle scope of practice laws, the malpractice payments made by physicians decreased 00:10:45.417 --> 00:10:47.820 position:50% align:middle by as much as 31%. 00:10:47.820 --> 00:10:53.136 position:50% align:middle Tell that to our physician colleagues, that might get their attention. 00:10:53.136 --> 00:11:03.540 position:50% align:middle With regard to the lower rate of use of emergency departments, we knew that as the ACA was passed, 00:11:03.540 --> 00:11:08.962 position:50% align:middle and that states were going to expand their Medicaid coverage, that there was a chance, 00:11:08.962 --> 00:11:14.133 position:50% align:middle a good chance that use of emergency departments would increase. 00:11:14.133 --> 00:11:17.830 position:50% align:middle In fact, the studies have shown that's what happened. 00:11:17.830 --> 00:11:29.090 position:50% align:middle McMichaels shows that the increase in ED use was lower in states that had no restrictions placed 00:11:29.090 --> 00:11:30.535 position:50% align:middle on nurse practitioners. 00:11:30.535 --> 00:11:38.931 position:50% align:middle So, ED use went up across the board, but it was lower in the states without restrictions. 00:11:38.931 --> 00:11:47.332 position:50% align:middle Now, McMichaels also did an analysis of more than 70 million births in this country over the past 00:11:47.332 --> 00:11:58.461 position:50% align:middle 18 years and found that states without restrictions have lower caesarean rates. 00:11:58.461 --> 00:12:03.283 position:50% align:middle So, powerful information there. 00:12:03.283 --> 00:12:09.933 position:50% align:middle The fourth one on the slide about access to rural and vulnerable populations, 00:12:09.933 --> 00:12:11.843 position:50% align:middle we've talked a little bit about that already. 00:12:11.843 --> 00:12:24.177 position:50% align:middle But a study by Wendy Xu at Ohio State University was able to identify that the dual eligible population 00:12:24.177 --> 00:12:35.868 position:50% align:middle is clustered in southeastern states in rural counties, the very areas where there are physician shortages, 00:12:35.868 --> 00:12:44.798 position:50% align:middle and the most scope of practice restrictions on NPs. 00:12:44.798 --> 00:12:52.390 position:50% align:middle And finally, with regard to improvement in mental health, a study done by economists 00:12:52.390 --> 00:12:58.951 position:50% align:middle at the Federal Reserve Bank of Chicago, looking at 24 years of data, 00:12:58.951 --> 00:13:06.453 position:50% align:middle and identifying independent prescriptive practice authority by nurse practitioners, 00:13:06.453 --> 00:13:12.089 position:50% align:middle particularly those in psych and mental health, showed that in states that did not 00:13:12.089 --> 00:13:24.307 position:50% align:middle restrict the practice, the very favorable outcomes in terms of self-reported mental health was better. 00:13:24.307 --> 00:13:31.548 position:50% align:middle There was decreases in mental health-related mortality, including suicides. 00:13:31.548 --> 00:13:38.099 position:50% align:middle There was improvements in access to mental health services as well. 00:13:38.099 --> 00:13:46.293 position:50% align:middle So, these are some powerful examples of the full extent of contributions made by nurse practitioners, 00:13:46.293 --> 00:13:51.863 position:50% align:middle above and beyond that, of lower costs and higher quality. 00:13:51.863 --> 00:14:01.320 position:50% align:middle Now, a fifth strength is the comparative advantage that has developed for many nurse practitioners over their 00:14:01.320 --> 00:14:04.070 position:50% align:middle colleagues and primary care physicians. 00:14:04.070 --> 00:14:08.750 position:50% align:middle And the way to think about this is to think about value. 00:14:08.750 --> 00:14:18.013 position:50% align:middle And value is really, from an economic perspective, sort of, the outcomes that are achieved by patients, 00:14:18.013 --> 00:14:23.243 position:50% align:middle divided by their cost, the cost of resources to produce those outcomes. 00:14:23.243 --> 00:14:26.828 position:50% align:middle So, you think of what are the outcomes, how much did it cost. 00:14:26.828 --> 00:14:34.628 position:50% align:middle And what we see from the studies and that you're well aware of is that the outcomes produced by nurse 00:14:34.628 --> 00:14:41.360 position:50% align:middle practitioners are as good or better than those of physicians but at lower costs. 00:14:41.360 --> 00:14:49.203 position:50% align:middle So, this gives nurse practitioners a comparative advantage over many primary care physicians. 00:14:49.203 --> 00:14:58.973 position:50% align:middle So, that is a set of strengths that I feel is important for us to be aware of as we move our mindset forward 00:14:58.973 --> 00:15:02.148 position:50% align:middle into a post, past pandemic future. 00:15:02.148 --> 00:15:09.688 position:50% align:middle These are all strengths that are just blowing wind at the back of our workforce, and they're important, 00:15:09.688 --> 00:15:13.378 position:50% align:middle and we should leverage them to the full extent that we can. 00:15:13.378 --> 00:15:17.778 position:50% align:middle Now, on to the challenges, I've listed six. 00:15:17.778 --> 00:15:23.628 position:50% align:middle Some of these are not new, and you'll see what I'm talking about in a moment. 00:15:23.628 --> 00:15:29.058 position:50% align:middle All six are listed on this one slide, and we'll take them one at a time. 00:15:29.058 --> 00:15:34.761 position:50% align:middle So, the first one is really about a more racially diverse APRN workforce. 00:15:34.761 --> 00:15:43.351 position:50% align:middle Now, I'm not going to go into this because I know that Margo will be coming on a little later this morning or 00:15:43.351 --> 00:15:49.431 position:50% align:middle this afternoon, and talking about this in depth, so I won't go into her topic. 00:15:49.431 --> 00:15:54.311 position:50% align:middle However, I do want to say that if you look at the registered nurse workforce, 00:15:54.311 --> 00:16:01.584 position:50% align:middle and you compare that to the APRN workforce, you'll see that the RN workforce is more racially 00:16:01.584 --> 00:16:03.884 position:50% align:middle diverse than the APRN workforce. 00:16:03.884 --> 00:16:06.424 position:50% align:middle So, we do have work to do there. 00:16:06.424 --> 00:16:15.274 position:50% align:middle At the same time, I would just also ask that we remember that the APRN workforce that we have is taking 00:16:15.274 --> 00:16:23.924 position:50% align:middle care of a lot of individuals, people of color, and other vulnerable populations. 00:16:23.924 --> 00:16:31.550 position:50% align:middle Now, the second challenge is what I would say is sort of closing gaps in our preparation. 00:16:31.550 --> 00:16:46.590 position:50% align:middle The NPs were asked in the 2018 "National Survey of Registered Nurses" about what topics would have helped 00:16:46.590 --> 00:16:50.170 position:50% align:middle them do their jobs better, if they could look back and say, 00:16:50.170 --> 00:16:57.470 position:50% align:middle "What were the topics that I wish I had more of that would have enabled me to do my job better?" 00:16:57.470 --> 00:17:05.556 position:50% align:middle And nurses working in public health and community health, ED and long-term care settings, 00:17:05.556 --> 00:17:11.026 position:50% align:middle selected the following areas would have helped them do their jobs better. 00:17:11.026 --> 00:17:16.926 position:50% align:middle Social determinants of health, mental health, working in underserved communities, 00:17:16.926 --> 00:17:21.396 position:50% align:middle and providing care for medically complex/specialty needs patients. 00:17:21.396 --> 00:17:30.186 position:50% align:middle So, our own workforce is identifying we need help in these areas. 00:17:30.186 --> 00:17:44.575 position:50% align:middle Now, another challenge for our workforce is to deal with the growing challenges of providing 00:17:44.575 --> 00:17:46.115 position:50% align:middle rural health care. 00:17:46.115 --> 00:17:54.065 position:50% align:middle These challenges are going to grow as we see more physicians retiring over the decade. 00:17:54.065 --> 00:18:00.773 position:50% align:middle This is some data that was published from a study of ours, it was published in the "New England 00:18:00.773 --> 00:18:01.573 position:50% align:middle Journal of Medicine." 00:18:01.573 --> 00:18:04.723 position:50% align:middle A lot of lines and figures here. 00:18:04.723 --> 00:18:09.103 position:50% align:middle But the main thing to do is look at the right side of the slide, the top line. 00:18:09.103 --> 00:18:19.113 position:50% align:middle And this shows a projected decrease of 23% in the number of physicians per 10,000 population 00:18:19.113 --> 00:18:20.103 position:50% align:middle through this decade. 00:18:20.103 --> 00:18:25.349 position:50% align:middle This is because of a retiring, older physician workforce in rural areas, 00:18:25.349 --> 00:18:31.093 position:50% align:middle and not enough younger physicians being educated to replace them. 00:18:31.093 --> 00:18:37.160 position:50% align:middle So, we'll see a net decline in the physicians for rural population. 00:18:37.160 --> 00:18:41.642 position:50% align:middle This is an opportunity and a challenge for nurse practitioners. 00:18:41.642 --> 00:18:51.653 position:50% align:middle And fortunately, we have from HRSA a number of opportunities and grants to help increase the rural 00:18:51.653 --> 00:18:57.683 position:50% align:middle readiness of the APRN, and particularly the nurse practitioner workforce, 00:18:57.683 --> 00:19:01.505 position:50% align:middle which we need to take advantage of. 00:19:01.505 --> 00:19:08.855 position:50% align:middle But we're going to also need to deal with restrictions on our scope of practice. 00:19:08.855 --> 00:19:17.545 position:50% align:middle And here's some data that comes from a study that we published in 2015. 00:19:17.545 --> 00:19:28.642 position:50% align:middle And this, I think makes the case pretty clearly that we are aware of the top lines or top bar chart 00:19:28.642 --> 00:19:31.518 position:50% align:middle shows the restricted states. 00:19:31.518 --> 00:19:35.073 position:50% align:middle The middle bar is the reduced practice states. 00:19:35.073 --> 00:19:38.345 position:50% align:middle And the full practice states are at the bottom. 00:19:38.345 --> 00:19:43.948 position:50% align:middle And you can see that for the restricted practice states, people living in those states, 00:19:43.948 --> 00:19:49.858 position:50% align:middle about 34% say they have access to primary care. 00:19:49.858 --> 00:19:59.118 position:50% align:middle But when you get down to full practice states, you see that 63% of people living in those states have 00:19:59.118 --> 00:20:01.186 position:50% align:middle good access to primary care. 00:20:01.186 --> 00:20:09.980 position:50% align:middle So, we know that lifting these restrictions increases access to care. 00:20:09.980 --> 00:20:19.946 position:50% align:middle But I have to say, I'm getting a little tired of these maps, not because this is an outdated one, 00:20:19.946 --> 00:20:24.376 position:50% align:middle and I just decided the heck with it, I'm not going to update this because I'm getting tired 00:20:24.376 --> 00:20:25.776 position:50% align:middle of updating these maps. 00:20:25.776 --> 00:20:35.377 position:50% align:middle And I wonder, at what point will we have to be relying on these maps when we talk about our practice? 00:20:35.377 --> 00:20:37.487 position:50% align:middle I want to get rid of these maps. 00:20:37.487 --> 00:20:42.647 position:50% align:middle And look at this map, which is admittedly a little out of date. 00:20:42.647 --> 00:20:49.945 position:50% align:middle But the circled area is the southeast states, and extending into sort of the north central and east 00:20:49.945 --> 00:20:52.997 position:50% align:middle central portions as well. 00:20:52.997 --> 00:20:58.467 position:50% align:middle This is where Wendy Xu, who I mentioned before at Ohio State, 00:20:58.467 --> 00:21:07.012 position:50% align:middle identified the concentration of dual eligible beneficiaries in rural areas, 00:21:07.012 --> 00:21:11.852 position:50% align:middle and in states where there are concentrations of physician shortages, 00:21:11.852 --> 00:21:16.392 position:50% align:middle and the most restricted scope of practice restrictions. 00:21:16.392 --> 00:21:18.862 position:50% align:middle This just has to change. 00:21:18.862 --> 00:21:27.032 position:50% align:middle And I feel that, you know, maybe we have reached a period as we are moving 00:21:27.032 --> 00:21:33.456 position:50% align:middle from the pandemic into a post-pandemic world, where we should pause, 00:21:33.456 --> 00:21:43.816 position:50% align:middle and maybe consider some different approaches to, you know, move more decisively in eliminating these 00:21:43.816 --> 00:21:48.826 position:50% align:middle barriers that are bringing about real harm and decreasing access to care. 00:21:48.826 --> 00:21:55.036 position:50% align:middle And it's not just the state scope of practice, but these barriers occur in our organizations, 00:21:55.036 --> 00:22:00.269 position:50% align:middle and healthcare delivery systems, and among payers. 00:22:00.269 --> 00:22:10.349 position:50% align:middle So, maybe we need to be looking at new models of care that are more cost effective and more in line with the 00:22:10.349 --> 00:22:13.559 position:50% align:middle care that can be provided by nurse practitioners. 00:22:13.559 --> 00:22:18.099 position:50% align:middle Maybe we need to be looking at different sorts of partnerships with local businesses, 00:22:18.099 --> 00:22:25.299 position:50% align:middle with local community organizations, with organizations that are very motivated to address 00:22:25.299 --> 00:22:30.556 position:50% align:middle social determinants and health equity. 00:22:30.556 --> 00:22:37.616 position:50% align:middle But there's something else I think we should be taking advantage of, is, as we know that during the emergency 00:22:37.616 --> 00:22:46.506 position:50% align:middle declarations declared by a number of states around removing the barriers to nurse practitioners, 00:22:46.506 --> 00:22:53.866 position:50% align:middle we could be at a point where now that those emergencies are leaving, or are no longer in existence, 00:22:53.866 --> 00:22:58.596 position:50% align:middle we could return back to imposing scope of practice restrictions. 00:22:58.596 --> 00:23:02.625 position:50% align:middle And this would be a really regressive move. 00:23:02.625 --> 00:23:13.605 position:50% align:middle And I would just simply say to you who may be in that situation to ask for the evidence where people were 00:23:13.605 --> 00:23:21.715 position:50% align:middle harmed or died as a consequence of nurse practitioners being allowed to practice without these restrictions 00:23:21.715 --> 00:23:24.501 position:50% align:middle during COVID shows that evidence. 00:23:24.501 --> 00:23:29.354 position:50% align:middle This was a natural experiment, and they won't be able to show that evidence. 00:23:29.354 --> 00:23:34.196 position:50% align:middle And so, why would we want to go backwards versus going forwards? 00:23:34.196 --> 00:23:43.748 position:50% align:middle So, I really think it may also be a time where the leaders of our APRN organizations and particularly 00:23:43.748 --> 00:23:55.158 position:50% align:middle nurse practitioners may want to develop some television advertising on this issue for national audiences, 00:23:55.158 --> 00:24:01.982 position:50% align:middle bringing in states that have had the benefit of lifting scope of practice restrictions to weigh 00:24:01.982 --> 00:24:05.972 position:50% align:middle in on the experiences, the positive experiences that they've enjoyed, 00:24:05.972 --> 00:24:08.902 position:50% align:middle why shouldn't this occur throughout the rest of the country? 00:24:08.902 --> 00:24:14.622 position:50% align:middle Maybe we need to sit down our leaders with the editors of "The New York Times" or 00:24:14.622 --> 00:24:23.192 position:50% align:middle the "Wall Street Journal" or the "Washington Post" or others and have a conversation about what's happening 00:24:23.192 --> 00:24:25.072 position:50% align:middle with the nurse practitioner workforce. 00:24:25.072 --> 00:24:34.065 position:50% align:middle I think we're just at an opportune time to make significant change, so that in a few years we won't 00:24:34.065 --> 00:24:39.815 position:50% align:middle have to be looking at these maps as we progress through this decade ahead. 00:24:39.815 --> 00:24:46.345 position:50% align:middle All right, the fifth challenge is a challenge that I think you're familiar with, 00:24:46.345 --> 00:24:55.565 position:50% align:middle and that is the challenge of growing demand for healthcare originating out amongst society, 00:24:55.565 --> 00:25:02.326 position:50% align:middle pressing in on our healthcare delivery systems, our physician workforce, all other workforces, 00:25:02.326 --> 00:25:05.756 position:50% align:middle including nurses, particularly. 00:25:05.756 --> 00:25:16.126 position:50% align:middle And sort of the basic point here is that we just don't have the numbers of APRNs, and for that matter, 00:25:16.126 --> 00:25:24.472 position:50% align:middle the nursing RN workforce who are trained in the right specialties and providing care where they 00:25:24.472 --> 00:25:26.386 position:50% align:middle are needed most. 00:25:26.386 --> 00:25:29.726 position:50% align:middle And this gap is not new. 00:25:29.726 --> 00:25:37.267 position:50% align:middle But I think we've not paid much attention to it with COVID, understandably, but now, here it comes again, 00:25:37.267 --> 00:25:43.497 position:50% align:middle and we need to be taking, I think, a more firm stance at addressing these gaps, 00:25:43.497 --> 00:25:51.387 position:50% align:middle because this will require some tough decisions that I want to just speak to a little bit about, 00:25:51.387 --> 00:25:55.354 position:50% align:middle which is that… 00:25:55.354 --> 00:25:58.789 position:50% align:middle Well, let me make the case a little further. 00:25:58.789 --> 00:26:07.788 position:50% align:middle First of all, on the growth in demand, we have 70-some million people in our population born 00:26:07.788 --> 00:26:11.798 position:50% align:middle in the baby boom generation or earlier who are ageing. 00:26:11.798 --> 00:26:18.858 position:50% align:middle And you can see some of the information here on medical visits that have increased over time. 00:26:18.858 --> 00:26:26.768 position:50% align:middle Before the pandemic, it was an estimated 40 million people had diagnosable 00:26:26.768 --> 00:26:29.628 position:50% align:middle conditions in mental behavioral health. 00:26:29.628 --> 00:26:34.417 position:50% align:middle I've seen estimates where that's doubled as a consequence of the pandemic. 00:26:34.417 --> 00:26:41.402 position:50% align:middle We have an estimated 80 million people without adequate access to primary care. 00:26:41.402 --> 00:26:50.944 position:50% align:middle And then, with regard to high maternal mortality, it was just beginning to drop a little bit 00:26:50.944 --> 00:26:55.344 position:50% align:middle before the pandemic, but I just saw some recent evidence that suggests 00:26:55.344 --> 00:26:58.104 position:50% align:middle that it increased again. 00:26:58.104 --> 00:27:06.873 position:50% align:middle Since then, so now, if you look at the supply of nurses, and I included RNs as well as NPs 00:27:06.873 --> 00:27:16.933 position:50% align:middle on this slide, you can see we're not able to provide the numbers of RNs or NPs 00:27:16.933 --> 00:27:25.353 position:50% align:middle in geriatrics, in mental or behavioral health, and in primary healthcare even though we've done 00:27:25.353 --> 00:27:27.822 position:50% align:middle a lot here, still not enough. 00:27:27.822 --> 00:27:35.848 position:50% align:middle And we have a slow growth of certified nurse midwives that we really need to ramp up as well. 00:27:35.848 --> 00:27:44.659 position:50% align:middle Now, I feel that we need to close these gaps. 00:27:44.659 --> 00:27:53.659 position:50% align:middle This is what societal health needs are going, and we are lagging behind. 00:27:53.659 --> 00:28:00.960 position:50% align:middle And I think to address these, we've got to look at what educators value. 00:28:00.960 --> 00:28:11.100 position:50% align:middle Do we value producing a workforce that addresses the needs of society, or do we value more producing a 00:28:11.100 --> 00:28:18.030 position:50% align:middle NP or APRN workforce that fulfils professional interests? 00:28:18.030 --> 00:28:21.080 position:50% align:middle So, it's a question around values. 00:28:21.080 --> 00:28:23.110 position:50% align:middle It's also a question about balance. 00:28:23.110 --> 00:28:29.020 position:50% align:middle It's not to say that we should not be educating specialty care NPs or others, 00:28:29.020 --> 00:28:30.345 position:50% align:middle that's not what I'm saying. 00:28:30.345 --> 00:28:36.545 position:50% align:middle But we do need to look at the balance, are we producing enough who will be able to be 00:28:36.545 --> 00:28:46.005 position:50% align:middle in working productively and effectively in multiple community settings, non-acute care settings? 00:28:46.005 --> 00:28:57.565 position:50% align:middle So also, I think that we may be really at a point where we need to hold nursing education programs accountable. 00:28:57.565 --> 00:29:06.950 position:50% align:middle There is a lot of money that has come into the health workforce community over the past couple of years, 00:29:06.950 --> 00:29:13.450 position:50% align:middle thanks to COVID, and some of the bills that have been passed by Congress. 00:29:13.450 --> 00:29:17.410 position:50% align:middle And it's a huge amount of money. 00:29:17.410 --> 00:29:25.583 position:50% align:middle We need to hold not just nursing but all of our workforce accountable to producing nurses 00:29:25.583 --> 00:29:32.435 position:50% align:middle that will be able to respond to primary care needs, geriatric care needs, our growing population, 00:29:32.435 --> 00:29:37.350 position:50% align:middle behavioral and mental health, the challenges of maternal health care, 00:29:37.350 --> 00:29:41.501 position:50% align:middle how to better address social determinants and health equity. 00:29:41.501 --> 00:29:50.311 position:50% align:middle If our workforce is not prepared for this, and we already saw evidence from the 2018 survey that 00:29:50.311 --> 00:29:57.931 position:50% align:middle NPs feel they don't have that preparation, why should we fund our education programs? 00:29:57.931 --> 00:30:03.253 position:50% align:middle So, I think this is a serious challenge, and I want to be firm about them. 00:30:03.253 --> 00:30:12.224 position:50% align:middle Now, if we're going to take on the challenge of narrowing the gaps between the demand 00:30:12.224 --> 00:30:20.884 position:50% align:middle for healthcare and what nursing is producing, it'd be a lot more effective if our education practice 00:30:20.884 --> 00:30:29.104 position:50% align:middle research and policy approaches integrate what we know about social determinants and achieving health equity. 00:30:29.104 --> 00:30:32.153 position:50% align:middle I think that is happening, you see a lot of good signs of that, 00:30:32.153 --> 00:30:36.563 position:50% align:middle so I think we're moving along in the right direction there. 00:30:36.563 --> 00:30:42.473 position:50% align:middle If you haven't seen the report, there's lots of information on how that can be achieved 00:30:42.473 --> 00:30:47.443 position:50% align:middle in our education settings, and lots of recommendations for practice and research 00:30:47.443 --> 00:30:49.223 position:50% align:middle and leadership as well. 00:30:49.223 --> 00:30:57.883 position:50% align:middle Now, the last challenge, before I conclude, is what I want to talk about is sort of the wise use 00:30:57.883 --> 00:31:03.996 position:50% align:middle of our comparative advantage, What I was talking about earlier. 00:31:03.996 --> 00:31:12.986 position:50% align:middle Now, we have this shift away from fee for service payment towards value-based payment. 00:31:12.986 --> 00:31:22.426 position:50% align:middle This shift has been endorsed by both Republican and Democratic presidents over the past 10 years, 00:31:22.426 --> 00:31:29.166 position:50% align:middle and it has been enjoyed bipartisan support in Congress as well. 00:31:29.166 --> 00:31:37.134 position:50% align:middle And the movement is slow but steady and going to be picking up pace. 00:31:37.134 --> 00:31:47.374 position:50% align:middle And this is going to be increasingly affecting where NPs work in hospitals, non-hospital settings, 00:31:47.374 --> 00:31:51.074 position:50% align:middle and in private practice as well. 00:31:51.074 --> 00:31:58.487 position:50% align:middle And what this all means is that if you are a provider or an organization, and you are producing 00:31:58.487 --> 00:32:05.774 position:50% align:middle high-value care, really good outcomes at lower costs, you'll receive higher reimbursements. 00:32:05.774 --> 00:32:12.407 position:50% align:middle But if you're producing just okay, average outcomes, or below average outcomes, and your costs are high, 00:32:12.407 --> 00:32:14.271 position:50% align:middle you'll get less money. 00:32:14.271 --> 00:32:21.105 position:50% align:middle So, there is an incentive for organizations to employ individuals and practitioners 00:32:21.105 --> 00:32:23.539 position:50% align:middle who can contribute high value. 00:32:23.539 --> 00:32:30.798 position:50% align:middle This is going to help stabilize their reimbursement and their economic health. 00:32:30.798 --> 00:32:38.808 position:50% align:middle Now, already sort of established that nurse practitioners have a comparative economic advantage 00:32:38.808 --> 00:32:44.532 position:50% align:middle over many primary care physicians, because their outcomes are high, their costs are low. 00:32:44.532 --> 00:32:54.558 position:50% align:middle Going forward into this decade, it will be critical for NPs and any other APRN to avoid 00:32:54.558 --> 00:32:59.758 position:50% align:middle anything that lowers their outcomes or increases their cost, 00:32:59.758 --> 00:33:03.619 position:50% align:middle because that will harm their comparative advantage. 00:33:03.619 --> 00:33:12.439 position:50% align:middle Now, I want to be careful on this slide because I understand that this could be a little touchy. 00:33:12.439 --> 00:33:21.479 position:50% align:middle But what I run into oftentimes are nurse practitioners who insist that no matter what, 00:33:21.479 --> 00:33:24.649 position:50% align:middle they want to be paid at the same rate as physicians. 00:33:24.649 --> 00:33:29.849 position:50% align:middle Now, I'm not saying this is all NPs or even a majority. 00:33:29.849 --> 00:33:39.383 position:50% align:middle But I get a little concerned about that because it seems that when I ask about what's going on in their 00:33:39.383 --> 00:33:44.413 position:50% align:middle local marketplace, what is the state of value-based payment, they are unaware, 00:33:44.413 --> 00:33:53.633 position:50% align:middle and they have not done enough research to know if insisting on being paid at the same rate is viable. 00:33:53.633 --> 00:34:02.246 position:50% align:middle Because what you do, if you insist to be at the same payment rate as a physician, you've just given up 00:34:02.246 --> 00:34:03.632 position:50% align:middle your comparative advantage. 00:34:03.632 --> 00:34:06.156 position:50% align:middle You've upped your cost to the organization. 00:34:06.156 --> 00:34:14.840 position:50% align:middle And so, now, don't get me wrong, equal pay for equal work, that's what I aspire, 00:34:14.840 --> 00:34:17.160 position:50% align:middle and I think that should be where we are at. 00:34:17.160 --> 00:34:24.199 position:50% align:middle But it could be that not in all situations, in all marketplaces is that a viable option 00:34:24.199 --> 00:34:26.047 position:50% align:middle for some NPs. 00:34:26.047 --> 00:34:27.658 position:50% align:middle So, just be careful. 00:34:27.658 --> 00:34:28.779 position:50% align:middle Be thoughtful. 00:34:28.779 --> 00:34:34.681 position:50% align:middle Get information about what is the state of the marketplace, where is value-based payment at, 00:34:34.681 --> 00:34:40.004 position:50% align:middle how is it being received, how are organizations looking at this, 00:34:40.004 --> 00:34:48.601 position:50% align:middle because you don't want to inadvertently give up your advantage by raising your costs. 00:34:48.601 --> 00:34:54.324 position:50% align:middle Because if you do, an organization may say, "Well, the two are pretty much the same, 00:34:54.324 --> 00:34:57.163 position:50% align:middle I'll hire the physician over the NP." 00:34:57.163 --> 00:35:03.439 position:50% align:middle And if that happens, you're not employed, you're not in the organization where your value can 00:35:03.439 --> 00:35:09.330 position:50% align:middle be observed, and you can up your earnings over time, and you can use, sort of, if you will, 00:35:09.330 --> 00:35:13.807 position:50% align:middle carry the cause of how nurse practitioners increase value. 00:35:13.807 --> 00:35:19.170 position:50% align:middle So, think about it is what I'm saying, we need to think about it and learn more 00:35:19.170 --> 00:35:24.080 position:50% align:middle about value-based payment, because it's here to stay and it will be developing 00:35:24.080 --> 00:35:26.990 position:50% align:middle more so over this decade. 00:35:26.990 --> 00:35:37.754 position:50% align:middle So, let me wrap up and just say that we have a number of strengths that are blowing at the backs 00:35:37.754 --> 00:35:41.123 position:50% align:middle of our APRN workforce. 00:35:41.123 --> 00:35:43.333 position:50% align:middle We talked a little bit about them. 00:35:43.333 --> 00:35:48.523 position:50% align:middle Don't forget about them, find ways to leverage them. 00:35:48.523 --> 00:35:57.763 position:50% align:middle Moving forward, we have work to do to increase the racial diversity of our APRN workforce. 00:35:57.763 --> 00:36:06.181 position:50% align:middle We have some gaps in our educational preparation that need to be addressed by our education systems. 00:36:06.181 --> 00:36:13.801 position:50% align:middle We have new opportunities and new challenges to address access to care for rural populations and other 00:36:13.801 --> 00:36:20.531 position:50% align:middle vulnerable populations, particularly dual eligibles in rural counties. 00:36:20.531 --> 00:36:29.761 position:50% align:middle We think or at least I think that we are at a point where we may need to just pause and rethink and 00:36:29.761 --> 00:36:37.950 position:50% align:middle restrategize about how can we go about removing these barriers to practice among payers, 00:36:37.950 --> 00:36:40.890 position:50% align:middle among our organizations and among states. 00:36:40.890 --> 00:36:47.264 position:50% align:middle Will we have to go through another decade of slow change or is there something that we can do 00:36:47.264 --> 00:36:49.050 position:50% align:middle to speed up this change? 00:36:49.050 --> 00:36:57.460 position:50% align:middle Given all the demands that are coming down on society, arising from primary care, geriatrics, 00:36:57.460 --> 00:37:04.392 position:50% align:middle mental and behavioral health, women's health, etc, we need to quickly get that workforce effective and 00:37:04.392 --> 00:37:08.972 position:50% align:middle distributed and able to address those societal needs. 00:37:08.972 --> 00:37:16.072 position:50% align:middle And in all of this, realizing that we're moving forward into a different payment environment, 00:37:16.072 --> 00:37:24.762 position:50% align:middle one that is quite attractive, and will favor those NPs who have a 00:37:24.762 --> 00:37:30.222 position:50% align:middle comparative advantage, that is, their outcomes are as good or better than physicians, 00:37:30.222 --> 00:37:31.957 position:50% align:middle and their costs are lower. 00:37:31.957 --> 00:37:42.047 position:50% align:middle This can be exploited for the benefit of the workforce and also to the benefit of the populations 00:37:42.047 --> 00:37:44.667 position:50% align:middle that nurse practitioners serve. 00:37:44.667 --> 00:37:50.377 position:50% align:middle So, I'm going to stop there, and I'll pause, I know we're going to have some discussion here. 00:37:50.377 --> 00:37:53.995 position:50% align:middle But I just wanted to be sure that you saw this... 00:37:53.995 --> 00:38:00.806 position:50% align:middle I've included some references to the fourth strength that I mentioned earlier about terms of this 00:38:00.806 --> 00:38:06.680 position:50% align:middle broader base of evidence above, not just about quality of care but other areas. 00:38:06.680 --> 00:38:08.816 position:50% align:middle And so, here are the references. 00:38:08.816 --> 00:38:14.893 position:50% align:middle So, I thought I would give those to you, because I think these are points that could be made 00:38:14.893 --> 00:38:22.987 position:50% align:middle when you're talking with Republicans or with Democrats, with policymakers, members of governor staffs, 00:38:22.987 --> 00:38:25.592 position:50% align:middle or the private sector and the public. 00:38:25.592 --> 00:38:31.671 position:50% align:middle So, let me say thank you very much, and I look forward to having a little 00:38:31.671 --> 00:38:33.170 position:50% align:middle discussion with you. 00:38:33.170 --> 00:38:36.157 position:50% align:middle And, again, thanks very much.