Policy Issues for Certified Registered Nurse Anesthetists for 2017 and Beyond. What s Happening in DC

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1 Policy Issues for Certified Registered Nurse Anesthetists for 2017 and Beyond What s Happening in DC

2 Conflict of Interest Statement I have no financial relationships with any commercial interest related to the content of this activity. I will not discuss off-label use during this presentation

3 What we will cover 115 th Congress and a Trump Administration Repeal and Repair Veterans Health Administration Full Practice Authority Other AANA legislative activity What you can do as an advocate CRNA-PAC Questions and open discussion

4 Donald Trump 45 th President of the United States

5 2016 Election Recap GOP has simultaneous control of the White House, the Senate, and the House of Representatives. 3 rd time in history; First time since 1928, when Herbert Hoover Republicans now hold an all-time high of 68 out of 99 state legislative chambers. Republicans control both chambers in 32 states, including 17 with veto-proof majorities. Those 32 states cover 61 percent of the U.S. population.

6 Secretary of Health and Human Services Nominee: House Budget Committee Chairman Tom Price, M.D. (R-GA) Background: Orthopedic surgeon whose wife is an Anesthesiologist Served on the House Committee on Ways and Means, as Chairman of the Republican Study Committee, and currently as Chair of the House Budget Committee. Worked in private practice for 20 years as an orthopedic surgeon. Served as Medical Director of the Orthopedic Clinic at Grady Memorial Hospital in Atlanta. Leading member of the House Republican Doctors Caucus Policy Positions: Supports the repeal of the Affordable Care Act (ACA). Opposes full practice authority for CRNAs in the VHA Long time opponent of CRNA issues Supports eliminating much of the federal government s role in healthcare,

7 Administrator of the Centers for Medicare and Medicaid Services (CMS) Seema Verma, CEO, SVC Strategic Health Policy Solutions Background: Is President, CEO, and founder of SVC, Inc., a national health policy consulting company. Has a close relationship with Vice President-Elect Mike Pence due to her past work in Indiana s healthcare system. Policy Positions: Helped to implement health policies favored by Republicans, such as: Supports Health Savings Accounts healthy lifestyle requirements for beneficiaries Is considered the architect of the Healthy Indiana Plan (HIP), the nation s first consumerdirected Medicaid program. Developed many of the recent Medicaid reform programs, including waivers for Iowa, Ohio, and Kentucky, and helping to design Tennessee s coverage expansion proposal.

8 Secretary of Veterans Affairs Dr. David Shulkin, MD 1 st Non-Veteran to be nominated in recent memory Background: Immediate past Undersecretary for Health at the Department of Veterans Affairs. served as the President and Chief Executive Officer of Beth Israel Medical Center Served as President of Morristown Medical and the Atlantic Health System Accountable Care Organization. Policy positions Opposes CRNA full practice authority Supportive of more privatization of the VHA

9 North Dakota Congressional Delegation Senator John Hoeven (R)- Signed opt-out as ND Governor; Mil Con Approps Subcommittee Senator Heidi Heitkamp (D)- Supportive behind the scenes Congressman Kevin Cramer (R)- VHA FPA Co-sponsor

10 VHA Full Practice Authority Background What it means Current Status What have we done What s next

11 What is full practice authority What is full practice authority Improves Veterans Access to timely, high quality care Removes unnecessarily burdensome supervisory or regulatory requirements that available evidence shows do not improve outcomes but do increase costs and limit access Allows VHA facilities to utilize existing staff in most efficient manner possible to meet the demands of our Veterans

12 Background 6 years ago VHA began down this road independently Spurred by access issues, IOM report and DOD policy 4 years ago early iteration of document recognizing APRNS as licensed Independent Practitioners (LIP) LEAKED to ASA AANA and ASA began efforts Proposal became very contentious VHA leadership decided to elevate to an official regulation Initially was going to be released as an Interim final rule. Dr. Shulkin pushed for comment and rule making 2 previous physician Undersecretary s for Health Supported CRNA full practice

13 Status of the Proposal Final rule adopted January 13, 2017 excluding CRNAs Uncommon 30 day comment period CRNA access, recruitment and retention

14 Rationale for Exclusion From VHAs final rule: The safety of CRNA services has long been recognized by the VHA and underscored by peer-reviewed scientific studies, including a major study published in Health Affairs which found that anesthesia care by CRNAs was equally safe with or without physician supervision. VA agrees with these comments, but has chosen not to include CRNAs in this final rule due to VA's lack of access problems in the area of anesthesiology.

15 Faulty logic Arbitrary decision pushed by 1 individual Extremely weak justification: Access to cardiovascular and colonoscopy services related to lack of anesthesia care specifically cited in VHAs own Independent Assessment Outside anesthesia contracts Diverting Patients Chronis Pain Management Services Overall access issues

16 AANA Activity in Support of Full Practice Lobbying/legislative Grassroots Grasstops Coalitions PR Social media Engaging Veterans and the public

17 Worked to introduce multiple bills supporting full practice authority HR 1247 S 2279/HR 4134

18 Multiple Dear Colleagues Bi-partisan, bi-cameral, official comments submitted to the VHA Multiple support letters from members of Congress

19 American Society of Anesthesiologists HR Department of Veterans Affairs Expiring Authorities Act of 2016 Appropriations- Report language S. 297 HR 2267

20 Grassroots Ask your Senator to Contact the Administration in Support of Proposed Rule (October 3-Present): 1,530 Contact your Senators in Support of CRNA Full Practice Authority (September 8, 2016): 3,972 Contact your Representative to remove Anti-CRNA language from Veterans Extenders (September 2016): 6,572 Contact your Legislators in Support of CRNA Full Practice Authority in the VA (June 22, 2016): 4,881 Total : 16,955

21 RK1

22 Slide 21 RK1 Could you give me the totals for this site. Ralph Kohl 11/7/2016

23 Digital Media Campaign

24 Social Media

25 Official Comments Over 30,000 comment letters submitted supporting CRNA practice specifically!!!

26 Well positioned to continue the fight Independent arbiters have all come to the same conclusion, that full practice authority including CRNAs is the right policy at the right time for our Veterans. Current supporters includes Over 95 members of Congress Support VHAs own final rule recognizes CRNAs are qualified to work with Vets independently Commission on Care Department of Veterans Affairs $60 million Independent Assessment AARP American Hospital Association Federal Trade Commission Iraq and Afghanistan Veterans of America Military Officers Association of America AmVets Reserve Officers Association Naval Enlisted Reserve Association Air Force Sergeant Association

27 Continuing the Fight Recent action: Freedom of Information Act request from AANA Filed December 20, 2016 Letter from Representative Sam Graves requesting CRNA specific information from inside the agency Bi-Partisan letter expressing serious concerns with VHAs rationale in excluding CRNAs IG/GAO Report

28 Continued efforts to improve Veterans Access to care Continues!!! Building Connections to the Trump VA team Introduction of CRNA full practice legislation in the House and Senate CRNAs are good business and part of the solution!!!!

29 Other Critical issues Protecting and advancing our interests in repeal and replace efforts Provider Non-Discrimination Title VIII Nursing Workforce programs Chronic pain management Rural Anesthesiology

30 Pro Repeal and Replace Three-Pronged Approach to Repeal and Replace Obamacare 1. REPEAL AND REPLACE DISASTROUS OBAMACARE 2. PROVIDE ESSENTIAL REGULATORY RELIEF 3. REFORM HEALTHCARE THROUGH ADDITIONAL LEGISLATION

31 American Health Care Act Introduced under reconciliation rules to repeal and replace key parts of the Affordable Care Act The AHCA would have repealed the parts of the Affordable Care Act within the scope of the federal budget, including provisions contained within the Internal Revenue Code such as the individual and employer mandates and various taxes, and also modifications to the federal Medicaid program.

32 Increase the number of uninsured by 24 million by 2026 Decrease the budget deficit by $337 billion

33 What Happened??? Increased division among House Republicans over the replacement Largest opposition came from members of the House Freedom Caucus Concessions lost moderates Legislation was DOA in the Senate Push back from both sides of the ideological spectrum No support from Democrats Legislation was withdrawn on March 24, 2017

34 Future of Repeal and Replace Speaker Ryan has vowed to continue negotiations on repeal and replace. What is the path forward Bi-partisan? CRNAs role!!! Trump administration Regulatory efforts to stabilize or destabilize ACA? Future negotiations? Working with Democrats? Broad agenda Taxes Infrastructure

35 CRNAs in Repeal and Replace Protect Provider Non-Discrimination Ensure full recognition and utilization of CRNAs Highlight value that CRNAs bring to meaningful reform. Access, Quality Cost Three legs of reform stool

36 America s aging population needs excellent care and CRNAs and other APRNs are a major part of the solution AANA is working in both the House & Senate along with our Nursing Community partners to secure $244 million for Title 8 nurse workforce development in FY 2017 Labor-HHS appropriations Nurse Anesthesia educational programs collectively receive about $3 million each year through the Title 8 Nurse Workforce Development Program, funded through Labor-HHS Education Appropriations legislation.

37 Title VIII in Congress House Nursing Dave Joyce (R-OH) and Tulsi Gabbard (D-HI) introduced H.R To amend title VIII of the Public Health Service Act to extend advanced education nursing grants 18 Bi-partisan co-sponsors House Nursing Caucus Co-Chairs Suzanne Bonimici (D-OR) and Rodney Davis (R-IL) Circulating a bi-partisan letter requesting adequate funding

38 President Trump s Proposed Budget $403 million dollar cut to health professions and nursing training programs (as cited in the budget) does not provide specific details with respect to Title VII or Title VIII, but does note, - lack evidence that they significantly improve the Nation s health workforce. The Budget continues to fund health workforce activities that provide scholarships and loan repayments in exchange for service in areas of the United States where there is a shortage of health professionals.

39 CRNAs role in Chronic Pain Several proposals and initiatives focused on opioid abuse CRNAs are an untapped resource in the battle against opioids Educate members of Congress, their staffs and the administration about CRNAs role in chronic pain

40 CRNAs are Critical to Rural Health Rural hospitals are struggling Critical Access hospitals are closing in droves In the vast majority of rural counties, CRNAs are the sole anesthesia professionals CRNAs ensure rural access to surgical, labor and delivery, and pain management

41 Reintroduction of Medicare Access to Rural Anesthesiology Act of 2015 Lynn Jenkins (R-KS) Amends title XVIII (Medicare) of the Social Security Act to allow Anesthesiologists to participate in the Medicare Part A reasonable cost pass through program. Additional costs to the system without improving access or outcomes

42 CARE ACT HR 4553 Critical Access and Rural Equity Act of 2016 Representative Greg Harper(R-MS) and Dave Loebsack (D-IA) Broader package aimed at supporting Rural and Critical access hospitals (C) Standby and on-call costs for certified registered nurse anesthetist services, regardless of the number of surgical procedures requiring anesthesia services and regardless of the number of full-time equivalent physicians.

43 House of Representatives Majority Leadership Speaker of the House Paul Ryan (R-WI) Majority Leader Kevin McCarthy (R-CA) Majority Whip Steve Scalise (R-LA) Minority Minority Leader Nancy Pelosi (D-CA) Steny Hoyer (D-MD) James Clyburn (D-SC)

44 Key House Committees Chairman And Ranking members of Key Committees Ways and Means Chairman Kevin Brady (R-TX) Ranking member Richard Neal (D-MA) Energy and Commerce Gregg Walden (R-OR) Frank Pallone (D-NJ) Veterans Affairs Dr. Phil Roe (R-TN) Tim Walz (D-MN)

45 Key Senate Committees Senate Finance- Chairman Sen. Orrin Hatch (R-Utah) Ranking member Sen. Ron Wyden (R-Ore.) Health Education Labor and Pensions (HELP)- Lamar Alexander (R-Tenn.) Ranking member Patty Murray (D-WA) Veterans Affairs- Chairman Sen. Johnny Isakson (R-GA) Ranking member Senator Jon Tester (D-MT)

46 Uncertainty Makes Advocacy Even More Critical Continue your journey as a lifetime advocate and advocacy leader Contribute to PAC regularly Be a member Give to the Foundation

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49 93% + Success in our giving 9 th largest health care PAC in DC $1.6 million Largest nursing PAC ASA has the LARGEST PAC in DC $5.1 million

50 At the table or on the menu?!?!?!

51 AANA Foundation

52 Thank you and questions

53 AANA Federal Government Affairs Team Ralph Kohl, Senior Director Federal Gov t Affairs Catharine Harris, Associate Director Political Affairs JP Mason, Associate Director of Federal Government Affairs Romy Gelb-Zimmer, Associate Director Federal Regulatory and Payment Policy Randi Gold, Associate Director Federal Regulatory and Payment Policy Matt Thackston, Assistant Director of Federal Government Affairs Octavia Thompson, Administrative Assistant