Inside the Beltway is a member-only benefit developed by NAPNAP’s Health Policy Team to keep members up to date on key policy issues at the federal level.
The NP Preceptor Shortage
Contributed by Health Policy Committee member Jennifer F. Flippo, DNP, CPNP-PC, PMHS, CNE
Shortages of advanced practice providers in both rural and urban areas is a concern across the U.S. because it presents a barrier to or delay in care for many patients. Part of the shortage problem is due to the lack of available education and training settings for nurse practitioner (NP) students, as well as a dearth of experienced providers to precept NP students. In NP education, precepted clinical experience is a requirement. When precepted clinical placements are not available, students face delayed course progression and stalled graduation. For the public, this means some NPs are delayed in entering the workforce and taking care of patients.
Why is there a shortage of NP preceptors?
NP student enrollment is increasing despite challenges for clinical placement and lack of preceptors. According to the American Association of Colleges of Nursing, more than 36,000 new NPs completed their programs in 2021-2022. Many NP programs place the burden of locating and engaging preceptors on the student. If the student is not familiar with the practice area, finding someone locally to train with for ~360 hours in a semester can be difficult.
For experienced NPs, being asked to precept a student can pose some challenges as well. If a practice compensates its NPs through productivity benchmarks where billing is based on the clinical care performed, efficiency in providing care and charting becomes a priority for NPs. Affording uncompensated time to teach while working may not be feasible for every provider or practice site. Some practice sites have rules that limit experienced NPs to only precepting students from specific NP programs. Additionally, potential preceptors may have less teaching experience or training than NP programs require.
How can NPs be incentivized to precept NP students?
Literature reviews have shown that that nurses are willing to share their knowledge and to give back to their profession. Whereas NPs may feel they have an obligation to volunteer their time, it can come at a financial cost. In a 2015 article in the Journal for Nurse Practitioners, Dr. Judith Webb and team noted that many preceptors would prefer remuneration in the form of a stipend.
One solution is tax credits. Six states give tax credits for NP preceptors, with the amount of the credit and number of students permitted per year varying by state. For example, Hawaii allows $1,000 per student and up to $5,000 per year in tax credits. Because these tax credits are limited to state income tax, expansion of the concept is limited to the other 35 states that impose state income tax.
Congress has yet to pass legislation to address the nurse practitioner preceptor shortage; however, the “Providing Real-world Education and Clinical Experience by Precepting Tomorrow’s Nurses Act” (S 1627) has been introduced in the Senate to compensate NPs for undergraduate and graduate nurse precepting. A federal tax break is a more viable solution to more equitably compensate preceptors across the country.
To encourage NPs to share advanced practice knowledge with future members of the profession, financial compensation can demonstrate respect for preceptors’ time and expertise.
Funding Cliff Faces Congress in New Year
After passing a two-tier plan in November to extend current government funding into the new year, Congress adjourned for the holidays without moving any closer to a final agreement on fiscal year 2024 appropriations for nursing education and workforce programs or for the rest of the federal government. When lawmakers return to Washington in January they will have eight legislative days to pass four of the 12 annual spending bills before programs under the Agriculture-FDA, Military Construction-VA, Energy and Water, and Transportation-Housing measures will run out of money Jan. 19. Two weeks later the funding for programs under the remaining eight spending bills including those in the Labor-HHS-Education bill will also expire Feb. 2. Congress has yet to complete any of the bills providing funding for the fiscal year that started Oct. 1 and Speaker Mike Johnson has vowed that the House won’t pass another stopgap extension, calling instead for a full-year continuation of funding under spending caps that would resources for domestic programs by more than $73 billion.
There has been no movement on funding for nursing programs since Republican leaders pulled their Labor-HHS-Education spending bill (H.R. 5894) from the House floor, lacking the votes to pass it. The House bill would cut $19.4 million from Title VIII nursing workforce programs, eliminating funding for the Nursing Workforce Diversity Program. Senate Democrats have yet to bring their Labor-HHS bill (S. 2624) to the floor after appropriators proposed a $2 million increase in the Title VIII programs.
Health Legislation Progresses In House and Senate
Committees in both chambers of Congress advanced legislation in December that could develop into a wide-ranging health policy package in the new year. On Dec. 11 the House voted 320 to 71 to pass the “Lower Costs, More Transparency Act” (H.R. 5378), a package of provisions from three committees to require greater price transparency from health providers, alter reporting rules for pharmacy benefit managers in small group health plans, and allow Medicare beneficiaries to pay the same for drugs in off-campus hospital outpatient departments as in clinical offices. A day later, the House cleared the “Support for Patients and Communities Reauthorization Act” (H.R. 4531) on a 386 to 37 vote, providing a five-year extension for drug prevention and treatment programs and mental health initiatives first enacted in 2018 under the bipartisan SUPPORT for Patients and Communities Act, most of which expired Sept. 30. The Senate Health, Education, Labor, and Pensions Committee also cleared its version of the reauthorization bill (S. 3393) Dec. 12.
The measures join several other health policy proposals that could be attached to a fiscal 2024 spending agreement in January or February, including provisions of the “Bipartisan Primary Care and Health Workforce Act” (S. 2840) that includes $1.2 billion in grants to community colleges and state universities to increase the number of students enrolled in accredited, two-year registered nursing programs, $28.5 million for the Nurse Faculty Loan Program, a $15 million faculty salary demonstration program, and increased funding for NURSE Corps scholarship. The Senate Finance Committee also advanced its draft “Better Mental Health Care, Lower-Cost Drugs, and Extenders Act” including provisions to partially mitigate s scheduled cuts in 2024 Medicare Part B payments to providers and to partially extend an alternative pay model bonus beyond 2023, as well as averting cuts in Medicaid disproportionate share payments to safety-net hospitals through fiscal 2026.
Fee Schedule Boosts 2024 Medicare Payments to NPs
Nurse practitioners will see an average 2 percent increase in 2024 Medicare payments for services under the Part B fee-for-service fee schedule, according to final regulations released by the Centers for Medicare and Medicaid Services (CMS) last month. The final fee schedule rule reduces overall payments by 3.4 percent cut, but the cuts were offset to some primary care providers. The rule also includes a wide range of policy changes including expanding the ability of NPs to assign patients to Medicare accountable care organizations without seeing a physician.
The agency also finalizes proposals to pay for caregiver training services provided by nurse practitioners, clinical nurse specialists, certified nurse-midwives, physician assistants, and other professionals as long as they train caregivers to support patients with certain diseases or illnesses carry out a treatment plan. The rule also adopts a set of new health equity codes and payments for Community Health Integration, Social Determinants of Health (SDOH) risk assessments and Principal Illness Navigation services will help account for resources used when clinicians involve community health workers, care navigators, and peer support specialists in furnishing medically necessary care.
Other provisions of the final rule include an array of behavioral health policies including broadening the types of mental health providers who can be reimbursed by Medicare, including addiction counselors under the definition of mental health counselors, and boosting payment for psychotherapy during crisis care. It also extends current flexibilities to allow periodic assessments for opioid use disorder patients to be furnished via audio-only telehealth through the end of 2024 and extends payment for telehealth services furnished in rural health clinics and federally qualified health centers through 2024, delaying the in-person requirements for mental health visits furnished by those facilities.
In Other News
Feds Propose Rules to Curb Methane Gas Emissions
The Environmental Protection Agency (EPA) unveiled sweeping new regulations Dec. 2 targeting methane emissions from the oil and gas sector, a significant milestone for President Joe Biden’s strategy for curbing the pollution driving up global temperatures. The rule’s rollout was timed to coincide with the 28th United Nations Climate Change Conference in Dubai, where the U.S. has sought to play a leading role in global efforts to reduce emissions of the powerful planet-heating gas. But the biggest test for the new standards will come in the legal arena at home, where conservatives on the Supreme Court have slapped down regulations the justices viewed as White House overreach.
The EPA estimated that the rule would prevent an estimated 36 million tons of methane emissions through 2035. That’s equivalent to 810 million metric tons of carbon dioxide, or about the same as all greenhouse gas emitted from the nation’s fleet of coal-fired power plants in 2020, the agency said. The rule strengthens existing standards for new pollution sources and for the first time will require producers to upgrade equipment and actively search for leaks at hundreds of thousands of wells and other oil and gas infrastructure. In a major change from current practice, companies would no longer be allowed to depend on calculated estimates to report how much methane leaks from their sites. Instead, they will have to use sensors and other equipment to take measurements.
Menthol Tobacco Ban Tabled Until 2024
The Biden administration confirmed Dec. 6 that the Food and Drug Administration’s anticipated ban on menthol cigarettes and flavored cigars will be pushed back into next year after an updated federal regulatory agenda reflected a delay until at least March for the ban, which had earlier been scheduled to be finalized in August. The White House declined to comment but regulatory officials have scheduled meetings in January with law enforcement officials and convenience store representatives about the potential impacts of a ban.
NAPNAP has joined public health and children’s advocates in pushing for the menthol ban, which the FDA has been working on a menthol ban since at least 2011 when its tobacco advisory committee concluded that menthol cigarettes disproportionately harm Black Americans. Nine years later, public health groups, including the African American Tobacco Leadership Council and the Action on Smoking and Health, sued the FDA for failing to take action on menthol cigarettes. In 2021, the agency said it was planning a ban, and the agency proposed the rule in April 2022.
McCarthy Retirement Headlines Capitol Hill Turnover
Barely two months after being removed as Speaker of the House, California Republican Rep. Kevin McCarthy announced Dec. 6 that he would not seek reelection to his congressional seat and would retire from Congress at the end of the month. His departure will further narrow the fractious Republican majority in the House and adds to a growing list of legislators no longer interested in serving in Congress.
The turnover is likely to have a significant impact on health policy legislation in the 118th Congress. At least 35 members of the House won’t be returning, including 16 who are retiring and 15 who are seeking other elected offices, while at least seven senators will be leaving. In addition to McCarthy, his designated Speaker Pro Tempore, Rep. Patrick McHenry of North Carolina, won’t seek reelection after shepherding the House through its transition to Speaker Mike Johnson. At least 18 seats on the House’s top five committees – Appropriations, Ways and Means, Energy and Commerce, Financial Services, and Rules – will be open. Appropriations Committee Chair Kay Granger of Texas is leaving, while two of the Energy and Commerce Committee’s longtime health policy leaders – Republican Michael Burgess of Texas and Democrat Anna Eshoo of California – will be stepping down. In addition to Burgess, the Republican Doctors Caucus will lose Ohio Rep. Brad Wenstrup