Att U - Comments to FRN

Attachment U: Federal Register Public Comments

Comment #1:

Carol Walker,

Acting Reports Clearance Officer,

Centers for Disease Control and Prevention

Re: Proposed Data Collections Submitted for Public Comment and Recommendations National Ambulatory Medical Care Survey (NAMCS), (OMB No. 0920-0234 exp. 7/31/2012)--Revision--National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC).

Dear Ms. Walker:

The American Nurses Association (ANA) welcomes the opportunity to offer comments on this proposed revision of the National Ambulatory Medical Care Survey (NAMCS). The ANA is the only full-service professional organization representing the interests of the nation's 3.1 million registered nurses, the single largest group of health care professionals in the United States. We represent RNs in all roles and practice settings, through our state and constituent member nurses associations, and organizational affiliates. ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and advocating before Congress and regulatory agencies on health care issues affecting nurses and the public. Our members include Advanced Practice Registered Nurses (APRNs) such as Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Certified Nurse-Midwives (CNMs), and Certified Registered Nurse Anesthetists (CRNAs). ANA offers comments on this proposed revision as indicated below.

The proposed revision to the NAMCS would double the sample size of the survey over the next three years. It would be expected to improve the precision of statistical estimates derived from those data, and it would allow the robust calculation of some statewide estimates that currently are beyond the capability of the existing samples. The notice of this proposed revision cites the Public Health Service Act (42 U.S.C. §242k), which is described as authorizing NCHS to collect statistics on the utilization of health care provided by nonfederal office-based physicians in the United States. In fact, that particular section of the statute is actually more broad than described. The actual statutory language refers to health resources including physicians, dentists, nurses, and other health professionals. It directs the Secretary of Health and Human Services, through NCHS, to collect statistics on “. . . utilization of health care, including utilization of ambulatory health services by the specialties and types of practice of the health professionals providing such services . . . ” (emphasis added).

Consequently, the Public Health Service Act recognizes that health care is not just about physicians – and this needs to be reflected in the NAMCS. The ANA is concerned that the National Center for Health Statistics plans to devote significant additional funds for the short-term enhancement of a survey of just one segment of ambulatory care. Further, focusing only on that segment overlooks the growing importance of ambulatory care provided by health professionals other than physicians. It also overlooks the growing diversity of practice settings. Even physician services are increasingly delivered in other than traditional office-based settings. Moreover, there is increasing recognition of the growing importance of ambulatory care in diverse settings. For example, the Centers for Medicare and Medicaid Services plans to expand Graduate Medical Education funding in non-hospital settings, as described in the recent Medicare Physician Fee Schedule proposed rule.

While continuation of the existing survey is important, a better use of the funds implicit in the proposed revision would involve development of one or more surveys that more accurately capture and reflect the true picture of ambulatory care today. To gain truly accurate and useful data, it is imperative that any survey on ambulatory care include and reflect the significant and increasing diversity in providers and delivery settings as the U.S. health care system continues to evolve. The need for such survey designs is particularly acute in light of the pending changes due to the implementation of the Affordable Care Act with its emphasis on prevention and the development of multidisciplinary health care teams.

To accurately reflect the provision of ambulatory care, particularly health care visits that focus on primary care and prevention, surveys must include care provided by non-physician health care providers. New surveys should include the participation of many non-physician health care providers including advance practice registered nurses (APRNs). The new surveys should also collect statistics on the significant contributions of ambulatory care services provided in other settings – such as retail/minute clinics, student health centers, and student-based clinics, as well as family planning and reproductive health centers. Many healthy women of child-bearing age receive virtually all of their primary care in family planning and reproductive health centers. Working parents often are unable to pursue urgent care until after work or school hours, necessitating seeking health care during evening and weekend hours when very few primary care physicians are available.

With respect to APRNs, the NCHS should note that the Health Resources and Services Administration (HRSA) estimated there were 250,527 APRNs in the United States in its most recent Sample Survey in 2008. The APRN population includes Nurse Practitioners (NPs) who provide care along the wellness-illness continuum in a dynamic process in which direct primary and acute care is provided across settings. NPs are members of the health delivery system, practicing autonomously in areas as diverse as family practice, pediatrics, internal medicine, geriatrics, and women’s health care. NPs are prepared to diagnose and treat patients with undifferentiated symptoms as well as those with established diagnoses. Clinical Nurse Specialists (CNSs) are registered nurses who have graduate level nursing preparation at the master’s or doctoral level and are clinical experts in evidence-based nursing practice within a specialty area, treating and managing the health concerns of patients and populations. Certified Nurse-Midwives (CNMs) provide a full range of primary health care services to women throughout the lifespan, including gynecologic care, family planning services, preconception care, prenatal and postpartum care, childbirth, and care of the newborn. Certified Registered Nurse Anesthetists (CRNAs) are prepared to provide the full spectrum of patients’ anesthesia care and anesthesia-related care for individuals across the lifespan not only in hospitals but also in ambulatory surgical centers. CRNAs also provide some primary care and they greatly improve patient access in rural areas where physician shortages are particularly problematic.

We would be happy to provide data on the proportion of ambulatory care which is provided by APRNs – and other non-physician practitioners -- but unfortunately the NCHS has created a Catch-22. These data are not available because that information is not being collected in the NAMCS. Similarly, the other NCHS survey that touches on ambulatory utilization, the National Hospital Ambulatory Medical Care Survey (NHAMCS) captures only a small slice of non-physician utilization in hospital outpatient departments but only some of the care provided by health professionals in OPD's. If the CDC fails to include a broad array of ambulatory care settings, and non-physician health care providers such as APRNs, then the proposed revised NAMCS alone might provide a more precise but less accurate picture of ambulatory care in this country. The ANA urges the CDC to correct this oversight, and expand data collection to include all types of ambulatory care settings and non-physician health care providers.

We appreciate the opportunity to comment on this important rule. If we can be of further assistance, or if you have any questions or comments, please feel free to contact either Peter McMenamin, Ph.D., Senior Policy Fellow, Department of Nursing Practice and Policy at [email protected] or 301-628-5073 or Eileen Carlson, RN, JD, Associate Director, ANA Government Affairs at [email protected] or 301-628-5093.

Sincerely,

Mary Jean Schumann, MSN, MBA, RN, CPNP

Chief Programs Officer

American Nurses Association

Comment #2:

I’d like a copy of the proposed NAMCS instrument and data collection plans.  Thank you.

Jan Moore, MA, MBA, MSM

Research Project Manager

University of Kansas

1122 W Campus Rd, Rm 517

785-864-3788 (ofc)

786-864-7799 (fax)

[email protected]

Comment #3:

THIS COLLECTION CERTAINLY DOES NOT NEED TO BE DONE EVERY YEAR. EVERY 5 YEARS OR EVERY TEN YEARS IS MORE THAN ENOUGH. MORE IS A STUPID WASTE OF TAX DOLLARS IN AN OVERTAXED NATION. THERE IS A COMPLETE FAILURE OF THIS AGENCY FAILING TO DO ANYTHING WITH THE INFORMATION THEY GATHER. NO ACTION RESULTS, SO WHAT GOOD IS COLLECTING THE INFORMATION TO LIE IN A DRAWER. AND HOW MANY OTHER AGENCIES ARE COLLECTING THE VERY SAME INFORMATION. HAVE YOU CHECKED BECUAE THERE ARE AGENCIES OTHER THAN THIS ONE COLLECTING THE VERY SAME INFORMATION SO THE TAXPAYERS ARE PAYING FOR TWO OR MORE NON PRODUCTIVE AGENCIES. I THINK IT IS TIME TO CANCEL THIS SURVEY. IT IS EXPENSIVE. YOU DO NOTHING WITH IT. THE TAXPAYERS ARE TAPPED OUT. ALSO HOW DID YOU SELECT PARTICIPANTS. I HAVE NEVER MET ANYONE WHO HAS BEEN IN THIS ALLEGED SURVEY. I BELIEVE IT IS PROBABLY A NON EXISTENT SURVEY. OR DO YOU SURVEY ONLY SELECTED INSIDERS IN WASHINGTON DC. CANCEL THE WORK. FIRE THE EMPLOYEES.

JEAN PUBLIC 8 WINTERBERRY COURT WHITEHOUSE STATION NJ 08889

Comment #4:

Dear Sir/Madame,

 

I am responding to the NCHS request for comments on the proposed data collection for the NAMCS and NHIS. Neither survey contains questions which allow researchers to examine the impact of limited English proficiency (LEP). This is a crucial gap, given that over 55.7 million American speak a primary language other than English at home, and 24.4 million are LEP. I would propose adding the following questions (derived from the US Census), to ensure that these data are collected and available to researchers and policymakers:

 

Reproduction of the Questions on

Language From Census 2000

Source: U.S. Census Bureau, Census 2000 questionnaire.

11a. Does this person speak a language other than

English at home?

Yes

No Skip to 12

11b. What is this language?

(For example: Korean, Italian, Spanish, Vietnamese)

11c. How well does this person speak English?

Very well

Well

Not well

Not at all

 

Any response to 11c other than “very well” classifies the respondent as limited in English proficiency (LEP), in which case a medical interpreter or bilingual provider is needed for the encounter.

 

Please let me know if I can be of further assistance with this request (I've actually published extensively on language barriers in healthcare).

 

Thank you for considering my request.

 

Best Wishes,

Glenn Flores, MD, FAAP
Professor of Pediatrics & Public Health
Director, Division of General Pediatrics
Judith and Charles Ginsburg Chair in Pediatrics
UT Southwestern Medical Center
Children's Medical Center of Dallas
(214) 648-2424
Fax: (214) 648-3220