6. As of January 1, 1986, a nurse applying for initial certification shall have a master's degree with preparation in the specialty area in which expected to practice. 7. Payment of fees required by the Board. B. Notification of change of practice Change in practice status or settings shall be reported to the Board no later than 30 days after the change. C. Renewal of certification Shall be consistent with the current renewal system of the registered nurse as prescribed by the Board prior to the expiration date set forth in ORS 678.101 and shall be dependent upon: 1. Current license as a registered nurse in the State of Oregon. 2. Documentation of continued clinical competencies by professional performance review. 3. Documentation of a minimum of one hundred (100) clock hours of continuing education related to the specialty area to be submitted on or before 12:01 April 1, 1979 and every biennium thereafter. (See Administrative Rule 851-30-217): 4. Payment of fees required by the Board. D. Delinquent renewal A. Definition PROFESSIONAL PFRFORMANCE REVIEW Professional performance review is the process by which a physician or nurse practitioner, actively engaged in the practice of medicine/nursing in the same or related specialty area, evaluate the quality of patient care provided by individual nurse practitioner according to established standards of practice. B. Professional performance review team 1. Composition of Review Team: One physician and two nurse practitioners or three nurse practitioners. 2. Identification of Review Team: (a) Selection by the nurse practitioner. (b) Assistance from the Board of Nursing. C. Process for professional performance review team 1. Performance shall be evaluated in relation to: (a) Scope of practice as set forth in these Administrative Rules. (b) Standards of practice for safe and effective care in the specialty area accepted by the nursing profession. 2. Results of Professional Performance Review shall be reported on a form supplied by the Board. Negative evaluation shall have documentation attached. 3. Negative evaluations submitted shall be subject to process described in ORS 678.111 (2). THE ROLE OF THE NURSE PRACTITIONER IN AN EXPANDED SPECIALTY ROLE A. Definitions As used in these rules: 1. "Practice in an expanded specialty role" or specialty area means clinical practice based on specialized education which prepares a registered nurse to provide primary health care. 2. "Primary health care" means care which may be initiated by the client or provider in a variety of settings. The nurse practitioner is primarily responsible for the provision and management of a broad range of personal health services which may include: (a) Promotion and maintenance of health. (b) Prevention of illness and disability. (c) Management of health care during acute and chronic phases of illness. (d) Guidance and counseling of individuals and families. (e) Referral to physicians and other health care providers, and community resources when appropriate. B. Categories of specialty areas may include but are not limited to 6. Nurse Midwife. 7. Women's Health Care Nurse Practitioner. 8. School Health Nurse Practitioner. 9. College Health Nurse Practitioner. C. Scope of practice In addition to the services provided by the registered nurse, the nurse prac- D. Violations Nurse practitioners are subject to disciplinary actions as set forth in ORS STATEMENT OF EUGENE C. CORBETT, JR., M.D., CENTRAL VIRGINIA COMMUNITY HEALTH CENTER, NEW Canton, Va. The remarks which follow relate to the proposed legislation which would allow for the reimbursement of physician extender services under Medicare Part B (S. 708). I will contend that the proposed legislation is a step in the right direction and sets a good precedent for establishing alternative means for providing health care, particularly in rural areas. My discussion will focus on the reasons for the legislation as well as some specific aspects of nurse practitioner use. In addition, I include a suggestion for altering the legislation to provide reimbursement for physician extender services irrespective of the geographical location. I am a General Internist, city-born and raised, now living in rural Virginia and working within a Community Health Center. My interest in working in an area where there was a need for medical services brought me to the country in 1970. I was attracted to the country by my introduction to rural life and to the prospect of working within a rural Community Health Center. The Central Virginia Community Health Center was originally funded by O.E.O. in 1970. The Center currently receives grant support under Section 330 of the Public Health Service Act by the Bureau of Community Health Services, D.H.E.W. The Health Center provides a comprehensive range of health services and is the major medical provider for a three county, 1,200 square mile area. This area has a population of 25,000, approximately 60% of whom have used the Health Center facilities since its establishment six (6) years ago. The population is quite evenly disbursed over this area, the largest concentration of people being in a town of four hundred and fifty (450). About one-third of the population have incomes below the poverty level. Eleven and a half percent (11.5%) of the people in the area are sixty-fire (65) years of age or older and one-third are over the age of forty-four (44). No public transportation exists in the area and many families have no personal means of transportation, particularly to the distant urban Medical Centers. More than forty percent (40%) of homes in the area have no flush toilets and more than thirty percent (30%) have no running water. The infant mortality rate is above the national average. In addition, because of the lack of jobs and industry in the area and the declining viability of small farms, young adults tend to leave the area during their productive years leaving many families composed of young children and older aged individuals. (Demographic data source: 1970 U.S. Census) The number of rural solo practitioners in the area continues to dwindle. At the present time there are three solo practice physicians in the area of whom only one (1) practices full time. Only one (1) of these physicians is less than sixty-five (65) years of age. The only other medical facilities within reach are those found in the distant cities forty to seventy (40-70) miles from New Canton. The Health Center staff includes six (6) full-time physicians and seven (7) full-time nurse practitioners. They work in teams, composed of a physician and nurse practitioner, which are generally responsible for specific geographical sub-sections of the service area. The comprehensive range of services provided includes acute and chronic disease care, preventive health services, family planning services and home health services under the supervision of the team physician and nurse practitioner. Health services are provided at five (5) locations. The main center includes facilities for laboratory, x-ray, pharmaceutical, dental and other support services and is centrally located in the three-county area. The four (4) satellite clinics are located within a twenty (20) mile radius of the main Health Center. Satellites are staffed three (3) days a week by nurse practitioners and one (1) day a week by the team physician. Services have been provided at these satellites since 1972 by nurse practitioners. The care so provided is reviewed by the team physician although he is not physically present at the time these services are delivered by the nurse practitioner. Each satellite has protocols for the treatment of a variety of common adult and pediatric illnesses and for health maintenance procedures performed for children and adults. All visits are recorded using a problem oriented medical record. In addition, the Center has an on-going quality assurance effort and appropriate pharmaceutical administration and procedures. Both phone and radio contact are available between the satellite facilities and the main center for consultation between the physician and the nurse practitioner. I should mention that as the years have gone by since 1970, staff turnover among the physicians and nurse practitioners has tended to stabilize so that there is a considerable amount of familiarity and confidence among the professional staff. EFFECT OF THE PROPOSED LEGISLATION The Health Center relies on the comprehensive grant funding from D.H.E.W. for the bulk of its revenue. The Public Health Service Funding Regulations rightly rquire that Community Health Centers, like ours, make every effort to obtain third-party reimbursements for the services we provide. The Health Center currently has its non-reimbursed costs covered by our D.H.E.W. grant, but those funds are steadily shrinking in the face of rising costs and cannot reasonably be relied upon forever. Our Center's inability to obtain reimbursement for medical services provided by nurse practitioners at satellite clinics under Medicare and Medicaid (except EPSDT) place the viability of those facilities in question. This legislation would allow us to bill Medicare for an additional $17,000$25,000 annually for mid-level practitioner satellite visits. While this amount alone would not insure the continuation of these services, it would help fill a serious financial gap. Such reimbursement would be most welcome and quite frankly is past due. We also hope passage of this legislation will set a precedent soon to be followed to allow for Medicaid reimbursement, and hopefully other health insurance sources. Paying patients already are billed for and pay for nurse practitioner services, including non-directly supervised care. WHY THE PROPOSED LEGISLATION MAKES SENSE There are three major reasons why S. 708 makes sense: (1) It would recognize and encourage the provision of care in the community which might otherwise be provided in the hospital. (2) It would allow the physician to spend more time with the more complex and serious illnesses while allowing him to delegate more responsibility to the nurse practitioner for less complex forms of care. (3) It would allow for the reimbursement of a needed medical service and would lessen the emphasis on the physician as the provider of care. For a variety of reasons rural residents are not necessarily hospitalized at the same rate and for the same sorts of illnesses as urban residents. Many rural patients do not wish to go to a distant city for care. In addition, many illnesses for which a patient would be hospitalized in the city can be cared for as well and more conveniently at home if there is proper medical attention and follow up capability. This kind of practice became familiar only as a result of my experience in the country-it was not something I was taught in medical school. Medicare will reimburse for the care of most illnesses if patients are hospitalized. It is unfortunate that such care is not as easily paid for when brought out into the community. With the assistance of a nurse practitioner and perhaps a home health aide, a physician in the country can provide for the care of a mildly unstable diabetic or the patient with mild heart failure distant urban medical complex. It seems ironic that if a patient were hosat least as well as it might be cared for if the patient were sent off to a pitalized, the Medicare reimbursement would include the cost of non-physician and physician services. This legislation makes sense because it recognizes and financially supports such care being provided in the community. The desirability and often the necessity of in-community care for the patient needs to be recognized. As a practicing rural internist I could relate to you many instances in which I sent a patient with such an illness home after having arranged a care plan and follow up with the assistance of my nurse practitioner and a home health worker. I know from my training and experience in the city, that had the same patient been seen in an urban setting, they would more likely have been hospitalized for the acute phase of that illness. For the rural physician to be able to provide in-community care with as much assurance of the benefit to the patient, he needs help. The nurse practitioner is invaluable in delivering such care. In our attempts to bring this care out to rural patients, we are limited by our inability to obtain financial reimbursement for these services even though the cost would be much higher if the patient were hospitalized. Failure to recognize and act on this fact is a failure to correct an easily identifiable factor in any cost-containment effort. Secondly, through the use of nurse practitioners the physician has more time to spend with patients so that a higher quality of service can be provided. The saga of the rural solo physician providing acute care but having little time for much else is well known. Much of the reasons for my own venture into the country was the recognition that my skills in providing more comprehensive care could be realized when the rural setting included an appropriate and well-equipped facility and the assistance of other health professionals including the nurse practitioner. I want to point out that doctors and nurses have always worked well together in the hospital and in this setting provide a more comprehensive care effort for a patient than if the physician had to work alone. In the ambulatory setting as well-especially in the country-the physician can use assistance in the provision of quality services which necessarily includes other than acute care. (Preventive health care, chronic disease management, family planning, etc.) With the assistance of a competent nurse or other physician extender such a type of practice becomes possible. The third reason why this legislation makes sense is because it would enable us to focus more on the type of care provided than on the type of practitioner providing that care. What seems important here is that care is given which is competent and appropriate to the health or disease state of the patient. It is less important who provides the care. Traditionally we seem to have focused more on who provides care and on paying doctor bills rather than looking at what care is provided and paying the patient bill. What I am saying is that as long as the patient with a urinary tract infection or hypertension is treated appropriately, such a service should be equally reimbursable regardless of whether a doctor or a nurse practitioner actually performed the service. As long as the practitioner is competent and observes appropriate standards of care, it is not necessary for them to be under the same roof as a physician. It has never been required, nor is it necessary, that the hospital physician remain within shouting distance of the caring nurse. Similarly it is also not necessary for the rural physician to remain within shouting distance of the physician extender. THE QUESTION OF QUALITY Considerations regarding quality of the care provided include those that relate to the individual competence of the practitioner and those that relate to the care provided by that individual. Traditionally, the competence of the individual in medical practice has been based upon the completion of an accredited program followed by a State and/or National licensure or a board certification. I see no reason why the same stipulations applied to the physician extender would not guarantee a similar degree of competence of the physician extender as it does the physician. Although there may be questions about how well such stipulations guarantee the competence of the individual practitioner, this consideration applies to physicians as well. It would be appropriate for purposes of this legislation to require that the practitioner have completed an appropriate training program and received licensure and/or certification. I don't believe it is necessary to apply a different standard to the physician extender than is already applied to physicians. Regarding the quality of the actual care provided to the patient, measures should be taken to assure that the services are of appropriate quality. In our own setting this effort is a continuous process which takes place between the team physician and the nurse practitioner. The physicians generally review all of the clinic notes of the nurse practitioners and meet with them at specific intervals to review problems and other care aspects. Quality assurance efforts include periodic chart reviews for the care of various medical conditions by both physicians and nurse practitioners. In addition, when physicians and nurse practitioners work together over a period of time, par |