Attachment U -- Public Comments from the ANA and HPNA

August 21, 2009
Carolyn M. Clancy, M.D.
Director
Agency for Healthcare Research and Quality
Submitted via email to:
[email protected]
Attention: AHRQ’s Desk Officer
cc:
Doris Lefkowitz
AHRQ Reports Clearance Officer
[email protected]

Re:

Agency for Healthcare Research and Quality Comment Request:
“Study of Factors Influencing Consumer Choices Among Health
Plans and Clinicians” (74 Fed. Reg. 36232, July 22, 2009)

Dear Dr. Clancy:
On behalf of the American Nurses Association, we appreciate the opportunity to provide
comments regarding the “Study of Factors Influencing Consumer Choices Among
Health Plans and Clinicians.” The ANA is the only full-service professional organization
representing the interests of the nation's 2.9 million registered nurses, through our state
and other constituent member nurses associations, and organizational affiliates.
The ANA commends AHRQ for undertaking this study “to determine factors that
influence consumers’ understanding and use of performance information to select
among health plans and clinicians.” We strongly support initiatives which enable
patients to make better choices in selecting health care providers and insurance plans,
and efforts to make available information more accessible and transparent. Improving
public access, choice, and available information are laudable goals and key elements of
true health care reform.
However, we urge AHRQ to correct a fundamental flaw in the study. While the
Notice of Proposed Collection uses the term clinician throughout – a term which
includes all types of health care providers – the survey itself is limited to questions
regarding a patient’s choice of doctor. For example, the “CAHPS III Reports Team
Experimental Research: Web-Pre-Exposure Survey for Consumer Choice Study Round
2” states that “A health care provider is a doctor, nurse practitioner, or physician’s
assistant.” Nevertheless, all the remaining questions focus entirely on the factors
affecting consumers’ choice of doctors. While the proposed project describes “clinician
choice experimental design,” the experiment itself is labeled “physician choice,” and the

August 21, 2009

American Nurses Association

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respondents use SelectMD to select only physicians. Respondents are helped to find “a
primary care doctor who is right for you,” rather than a primary care provider who is right
for them.
There are more than three million health care professionals in the United States
who are not doctors of medicine (MDs) or osteopathy (DOs). The 2.9 million
registered nurses in this country are by far the single largest group of health care
professionals. Primary care is provided by professionals other than MDs and DOs,
particularly advanced practice registered nurses (APRNs) such as nurse practitioners
(NPs) and certified nurse midwives (CNMs). Unfortunately, the significant contributions
of APRNs are not accurately reflected in many key surveys and data systems, because
these fail to separately identify or collect data specific to APRNs. When a study is
centered on patients’ choice of health care providers, and is funded by public tax
dollars, this omission is particularly problematic.
APRNs serve a critical role as primary care providers. Many APRNs serve as
primary care providers for their patients, and have significantly increased access to
primary care for the poor and uninsured, as well as those in underserved urban and
remote rural areas. At least 66% of NPs practice in primary care settings, with 20%
practicing in remote rural or frontier settings.1 Currently, some 600 million patient visits
are made to NPs each year. CNMs attend over 10% of all vaginal births in the United
States, in addition to their significant work in providing primary care for women
throughout the lifespan.
Many federal programs recognize NPs and CNMs as primary care providers. As
autonomous health care providers, APRNs may enroll as Medicare providers, and may
participate in the Physician Quality Reporting Initiative (PQRI) program. NPs and CNMs
play an increasingly important role in federally-funded community health centers. From
2000 to 2006, the combined number of NPs, CNMs, and physician assistants grew by
64%.2 NPs and CNMs are eligible for National Health Service Corps scholarships, for
addressing shortages in rural and underserved areas.
NPs and CNMs are critical to expanding access to primary care in a reformed
system. A recent seminal report on “Building a Primary Care Workforce for the 21st
Century” described the need for “at least an additional 15,585 primary care providers,
just over one third of whom are non-physician primary health care providers.”3 The
American Medical Association and the American College of Physicians have noted that
more NPs are needed to fill the gaps in primary care.4 Many NPs and CNMs are also

1

American Academy of Nurse Practitioners, Nurse Practitioner Facts. AANP Web site:
www.aanp.org/NR/rdonlyres/51C6BCOF-F1CO-4718-B42F-3DEDC6F5F635/O/AANPNPFacts.pdf.
2
National Association of Community Health Centers (NACHC), the Robert Graham Center and the
George Washington University School of Public Health and Health Services published “Access
st
Transformed: Building a Primary Care Workforce for the 21 Century,”
http://www.nachc.com/client/documents/ACCESS%20Transformed%20full%20report.PDF
3
Id.
4
Alliance for Health Reform (March 20, 2009). Pathways to Universal Coverage: Payment Reform
Strategies for Containing Costs. KaiserNetwork.Org: http://www.allhealth.org/briefing_detail.asp?bi=150.
American College of Physicians (2009), Nurse Practitioners in Primary Care: 12.

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American Nurses Association

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qualified to serve as “health care” or “medical” homes, and currently do so under state
models and private health plans.
Any study that seeks to determine factors that influence consumers’
understanding and use of performance information to select among clinicians
must include these critical primary care providers, not just physicians. The
survey’s respondent universe and sampling methods are carefully devised to ensure
diversity and broad representation among key demographic groups of consumers. The
experimental design needs to be equally accurate and inclusive with respect to a
diversity of providers. Asking respondents to identify only physicians is as faulty a
methodology as seeking participants with only particular ethnic backgrounds, or living in
only one area of the country.
We urge AHRQ to consistently use provider-neutral language, such as
“clinicians,” in describing the wide array of health care providers who deliver
valuable and important care to patients. The use of the term “physician” to practice
areas and contexts which involve all types of providers simply perpetuates the myth that
physicians are the only available care providers. This language is important to both
providers and patients, and needs to be inclusive to adjust to the realities of current
patient care.
Conclusion
With growing demands on the American healthcare system – including an aging
population, healthcare provider shortages, spiraling costs and more than 45 million
uninsured Americans, now is the time to ensure we are fully utilizing our existing
resources. The critical shortage of primary care providers is a significant barrier to our
ability to increase access to care and shift the focus toward primary and preventive
care. NPs and CNMs can certainly help fill the need for primary care services. This
study presents an opportunity to highlight the broad spectrum of providers that are well
prepared to create a stronger, more productive system. But first, they must be included
in the proposed project and recognized for their capabilities and value.
The American Nurses Association looks forward to working with the Agency for
Healthcare Research and Quality, to ensure and improve the quality of patient care. If
we can be of further assistance, or if you have any questions or comments, please feel
free to contact Lisa Summers, CNM, DrPH, Senior Policy Fellow, Nursing Practice and
Policy, at [email protected], or 301-628-5058.
Sincerely,

Mary Jean Schumann, MSN, MBA, RN, CPNP
Chief Programs Officer
American Nurses Association

August 12, 2009
Agency for Healthcare Research and Quality
John M. Eisenberg Building
540 Gaither Road
Rockville, MD 20850

Dear AHRQ’s Desk Officer,
The project proposed by the Agency for Healthcare Research and Quality (AHRQ) titled, “Study of
Factors Influencing Consumer Choices Among Health Plans and Clinicians” is a praiseworthy effort
in the path toward healthcare reform. The study’s intent to enable consumers to make better
choices in finding a health plan and provider, and to make the information that is available more
transparent and accessible, can only improve the current system.
However, one element of great concern in the study is that the only health providers included are
medical doctors. The Hospice and Palliative Nurses Association would like to take this opportunity
to remind the AHRQ there are more than three million healthcare professionals in the United
States – who are not doctors of medicine (MDs) or osteopathy (DOs) – who are critical
stakeholders in the movement to improve our nation’s healthcare. These professionals include
nurse practitioners, clinical nurse specialists, psychologists, certified nurse midwives, and
naturopathic physicians, among many others.
In fact many of these professions fill gaps in service and provide other benefits not offered by MDs
or DOs, including a higher degree of personalized care, specialty services, greater accessibility
and increased affordability. With growing demands on the American healthcare system – including
an aging population, healthcare provider shortages, spiraling costs and more than 45 million
uninsured Americans, now is the time to ensure we are fully utilizing our existing resources.
Most importantly, patients should be able to choose the type of provider that best suit their
individual healthcare and wellness needs, as having access to a range of healthcare options
ensures patients are able to receive the right care at the right time. What’s more, there is a direct
correlation between patient access to a wide range of healthcare providers and more efficient,
cost-effective healthcare.
This study presents an opportunity to highlight the broad spectrum of providers that are well
prepared to create a stronger, more productive system. But, they must first be included in the
proposed project and recognized for their capabilities and value.

Again, we commend you for your attention to researching patient choice, and hope you will
consider including these critical healthcare professionals who are not MDs or DOs.

Sincerely,

Meg Campbell, RN, PhD, FAAN
President, Hospice and Palliative Nurses Association
Member of the Coalition for Patients’ RightsTM