By Rice Leach, M.D.
Public Health nurses have been an integral part of the health team for decades especially in patient homes and schools and in public health emergencies. They acted on behalf of the health officer and were an extension of physicians’ offices. They still do that work but their role expanded considerably in 1988 when the Kentucky General Assembly amended the Kentucky Revised Statutes to enable local health departments to be reimbursed by Medicaid for preventive health services provided by directly by registered nurses and used Medicare rates for services provided by advanced nurse practitioners. Those changes occurred because many Medicaid eligible women and children and uninsured people had trouble finding preventive, screening, communicable disease and chronic disease services. The lack of access was also a compliance issue because the United States had created a Medicaid entitlement for beneficiaries that Kentucky was not always able to meet.
The General Assembly transferred some state general funds from the Department for Public Health budget to the Medicaid budget to take advantage of the federal match and authorized the Cabinet for Human Services to establish a delivery system with appropriate standards of care, training for registered nurses, quality control, and signed standing orders and oversight by a qualified local physician. The Kentucky Department for Public Health arranged appropriate training for registered nurses and nurse practitioners in prenatal care, well child care, sexually transmitted diseases, tuberculosis, breast and cervical cancer screening, childhood immunizations, family planning and other preventive services. Registered nurses follow specific and detailed protocols approved by the state and a local physician and teams from the Kentucky Department for Public Health use chart review and on-site consultation for quality assurance. Also each health department has arrangements with its local medical care community for further assessment and treatment of positive findings like abnormal laboratory findings, possible tuberculosis and for labor and delivery for pregnant women.
This law enabled both local health department registered nurses and nurse practitioners to be independent practitioners because the new rules did not require a physician to be in attendance to bill Medicaid. Health Department revenue increased substantially, the ranks of registered nurses expanded, school nurse presence in public schools expanded, over one million patients were able to get preventive services close to home and the state met its obligation under the Medicaid entitlement. Beyond those direct patient benefits, this law enabled Kentucky public health departments to demonstrate that nurses and nurse practitioners can act independently and collaboratively, including dispensing from an approved drug formulary, when a proper system is in place. Finally, it gave Lexington’s only public health physician a workforce capable of managing the clinical side of public health. This added capacity is even more significant in the majority of the state’s health departments where there is no physician on staff.
So why does this matter to Kentucky’s docs? From the author’s perspective it matters because it demonstrates how a small change in the rules of practice can expand capacity, demonstrate good patient care, impact poor health incomes and do so at lower cost. In addition it is an example of how a system developed in Kentucky by Kentucky health professionals can be considered as the state seeks options for seeing more patients with limited resources. Every physician practicing in Kentucky has a health department capable of providing some or all of the services described above. The challenge is to find ways for the health departments to help the docs and for the docs to help the health departments. It worked years ago with tuberculosis and polio, it is working now for certain services and it will work in the future if boards of health, physicians, and health departments take time to develop systems that work where they live.
By Rice Leach, M.D.