Should nurse practitioners be part of the Open Payments Program?

CMS released data detailing $6.49 billion in financial transactions involving over 600,000 physicians and 1,000 teaching hospitals as part of the new Open Payments system, yet notably absent from the data release was any information relating to increasingly prominent players in the United States health care system: nurse practitioners and physicians assistants (see CMS lets the light in on $6.49B in 2014 Open Payments, July 1, 2015). A ProPublica analysis determined that nurse practitioners and similar providers wrote over 10 percent of all Medicare Part D prescriptions in 2013. However, drug manufacturers are not required to report financial relationships with nurse practitioners or physicians assistants as they are required to do for physician relationships. Some have argued that this lack of reporting may cover up questionable financial relationships and encourage illegal kickbacks to providers who are becoming increasingly prevalent as a result of health reform efforts. However, some states have stepped in to close the gap and have enacted state payment reporting requirements for nurse practitioners and similar providers.

Payment reporting requirements

In response to concerns over the prevalence of financial relationships between physicians and drug and medical device manufacturers, the Physician Payment Sunshine Act, (42 U.S.C. Sec. 1320a-7h) was passed as section 6002 of the Patient Protection and Affordable Care Act (P.L. 111-148) (ACA). The Sunshine Act requires drug and medical device manufacturers who participate in federal health programs to report any payments or items of value that they make to doctors or teaching hospitals to CMS. The agency collects the information and compiles it into a national, publicly available database, known as the  Open Payments Program. The Open Payments Program does not require manufacturers to report financial dealings with nurse practitioners or physicians assistants.

Kickbacks

Heather Alfonso, an Advanced Practice Registered Nurse (APRN) in Connecticut, pleaded guilty to receiving kickbacks as part of prescriptions she wrote to Medicare beneficiaries. Alfonso was employed by a pain treatment center and wrote controlled substance prescriptions for clients of the clinic. According to Part D prescription data compiled by ProPublica, Alfonso was a prolific prescription writer, reportedly one of the nation’s top prescribers of powerful controlled substances. Alfonso prescribed one cancer pain drug more than any other prescriber in the state. However, interviews with her patients revealed that most did not even have cancer, and were instead taking the drugs for chronic pain.  The manufacturer of the drug paid Alfonso speaker fees in the amount of $1,000 per event for over 70 dinner programs. The investigation also revealed that many of the dinner programs were attended only by Alfonso and a drug company sales representative. Even when others were present at the dinner, she often failed to give presentations about the drug. Alfonso admitted in court that the $83,000 paid to her by the drug manufacturer influenced her to prescribe the drug.

Increased role of nurse practitioners

It has been suggested that the ACA, with its focus on primary and preventive care, will require increased utilization of nurse practitioners. According to an article in the Online Journal of Issues in Nursing, “Implementation of the ACA presents an unprecedented opportunity for APRNs (nurse practitioners, certified nurse midwives, and clinical nurse specialists) to take a leadership role in offering primary care and strengthening preventive services.” Additionally, a number of states have passed legislation allowing nurse practitioners to practice independently from physicians. According to the American Association of Nurse Practitioners, 22 states have passed such legislation, including Connecticut, the state in which Alfonso practiced.

Some have argued that by exempting APRNs like Alfonso from the payment reporting requirements, the Open Payments Program is leaving out an increasingly important segment of health care providers who may be susceptible to receiving questionable financial payments. As jointly reported by ProPublica and NPR, Allan Coukell, Senior Director for Health Programs at the Pew Charitable Trust stated, “To the extent that a lot of prescribing now is done by health professionals who aren’t physicians, and a lot of marketing is directed at them, they ideally should also be part of the disclosure.”

State reporting requirements

However, some states are stepping in to close the reporting loophole and have taken steps toward requiring the reporting of payments made to APRNs to state databases. Connecticut, the state in which Alfonso practiced, recently passed a law requiring reporting; it became effective on July 1, 2015. It still remains a question as to whether other states will follow suit or whether the Open Payments Program will be expanded to include an additional class of prescription-writing providers.