A statute is a law enacted by a state legislature or Congress. Laws are found in state and federal codes. For example, Maryland statutes are found in the Maryland Code Annotated, and federal statutes are found in the US Code Annotated (U.S.C.A.).

Citizens have input into the enactment of statutes by electing representatives who they think will vote as they would wish and by lobbying those representatives for passage of bills about specific issues.

For example, in many states, NPs’ prescriptive authority is found in a statute. In those states, the legislatures have considered the issue of NP prescribing and have approved.

A regulation is law written by a state or federal agency in accordance with a statute. Agencies are a part of the executive branch of government. A regulation cannot directly contradict a statute but may expand upon a statute, supplying details not
included in the statute. The divided responsibility—between the legislature to enact statutes and the executive branch agencies to write regulations—is part of the balance of power constructed by the US Constitution.

Citizens have input into regulations in that regulations, prior to being adopted, usually are published for public review, with an opportunity for public comment. Agencies may or may not accept the comments. Further, citizens who are unhappy with a current regulation could enlist their legislators to enact laws that would require agencies to change the regulations. For example, if state regulations addressing nursing homes do not address NP practice in nursing homes, a state NP organization will want to: (1) ask the director of the appropriate state agency for a change of regulation to include NPs as providers in nursing homes; (2) ask legislators to request a regulation change, and, if necessary; (3) ask legislators for a statute that would require the agency head to change regulations to allow NPs to practice in nursing homes.

Policies are rules, made by companies or government agencies, that do not have the force of law but that dictate day-to-day decisions. Citizens have input on policies only insofar as they can convince whoever has authority for the policy to change it. Citizens may also lobby legislators for a law that requires companies or government agencies to change policy. For example, a hospital may have a policy to give admitting privileges to physicians only. Local NPs who want admitting privileges will want to persuade the appropriate hospital decision maker, through facts, figures, and a presentation of projected benefits to the hospital, of the need to change policy and allow NPs to admit patients.

Simply put, managed care is a system where the insurer is not only the payer, but also the provider of health care. Prior to managed care, insurance companies paid bills submitted by providers. The insurer had no control over the quality or quantity of care being given. The insurer had no responsibility to the patient other than to pay the bills. Under managed care, the insurer is responsible for the care given. The insurer keeps close tabs on the services provided. The insurer monitors how the healthcare services are utilized and sometimes denies, in advance or retrospectively, payment for services. Under fully developed managed care, insurers agree with purchasers to give care—whatever care is needed—for a fixed monthly or yearly fee, and clinicians agree with insurers to give whatever care is needed for a fixed monthly fee. The clinician shares with the insurer the financial risk that a patient will need more care than a payment covers.

Insurers are not only concerned with cost, but also they now monitor the quality of care given by providers and practices.

The healthcare industry has recently come under scrutiny regarding quality of care from the people who purchase the most services—employers who buy health care for employees—and from consumer-oriented groups such as the National Committee for Quality Assurance (NCQA), which accredits health plans and monitors and reports on quality of care. Employers are beginning to base decisions about which health plan services to offer employees based upon quality data gathered as reported by the NCQA. Employers monitor the NCQA data, NCQA monitors health plans, health plans monitor practices, and practices monitor individual providers.

State and national legislators, wanting to ensure that citizens’ best interests are not overshadowed by the goals of employers and insurers to make money, are introducing bills to improve quality and to make sure that citizens get the care they want or need. For example, some state legislatures have passed bills requiring that health plans allow postpartum mothers to stay overnight in the hospital for 24 hours after delivery. Health plans had been requiring mothers to go home after delivery. Citizen groups felt that good care required that postpartum mothers have at least a one-night hospital stay. Thus, legislatures have been delving into healthcare decisions formerly made only by clinicians, and lately made by insurers and clinicians.

NPs’ place in the managed care landscape will depend upon the stage of managed care in the region. In the early stages of managed care, most patients are covered by traditional insurers, and MCOs try to encourage employers who purchase health plans to enroll employees by offering premiums that cost less than those of traditional insurers. In the middle stages of development of managed care, more patients are enrolled, and MCOs try to control costs by decreasing hospital visits, length of stay in hospitals, emergency department visits, and by bargaining with medical practices for reduced rates on visits. In the advanced states of managed care, most patients are enrolled in managed care, and medical practices have agreed to share the risks. In other words, medical practices agree to take care of patients for a fixed amount of money per year. If care costs more than the set fee, providers will lose money. If care costs less than the set fees, providers will make a profit. In the later stages of development, much attention is paid to providing care that will prevent hospitalization and other high costs in the future, and to providing the nuts and bolts of care most cost effectively. It is at these later stages that NPs are most likely to fulfill the needs of MCOs.

The position of NPs is well described by a favorite quote of the late Congressman Sonny Bono, “We have good soap to sell, but we have to go out and sell it.” NPs are likely candidates for the position of PCPs, responsible for their own panels of patients. Consider the endorsement of NP practices given by Dr. Stephanie Seremetis, director of the Women’s Health Program at Mount Sinai Medical Center, “Probably in the future the best use will be nurse practitioners in independent practice, using a physician as a backup for complex conditions and for system analysis.”² Or consider the endorsement by Joseph A. Califano, Jr.:

The views expressed by Dr. Seremetis and Mr. Califano concern the general welfare. What about the welfare of the NP? Consider the view of Joseph Tommasino, a physician assistant writing about both physician assistants and NPs:

Salary aside, NPs, who are practice owners, have the opportunity to design a flow of care that makes sense from the point of view of the NP owner. It is not cast in stone that care must be given through the office visit. The office visit mode of healthcare delivery came about because of a physician-driven effort to tie reimbursement to physician services. Under capitated managed care, any model of care delivery that keeps patients satisfied and meets quality standards is a good model. That could mean increased use of community health nurses, home visits, and school-based health care. Groups of NPs with open and creative minds could design effective models that get out of the box established by fee-for-service medicine. Currently, however, in most states, NPs are giving primary care but are doing so under the auspices of a physician. The present situation is a function of: (1) past history; (2) the present law; and (3) public perceptions of physicians as givers of medical care.