Att Q - FRN comments

Attachment Q: 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 shortterm 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 anesthesiarelated 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 nonphysician 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