May 10, 2025

Ladies and Gentlemen of the DOJ Antitrust Division:

My name is Dr. Lynn Rapsilber, APRN and I am the CEO of NNPEN, a national network of Nurse Practitioners (NPs) who are owners of, and employees within, nurse-led clinical practices.  These NPs are included within MACRA’s QPP definition of “eligible clinician” and CPC+’s definition of “practitioner”.

As a general statement, NNPEN believes that replacing a legislative/prescriptive definition of scope of practice with one that defers to the education and training of the designated practitioner’s license is a good thing.  Is it the educational preparation or the license that counts?

My comments relate to the effect of recent Executive Orders but also more broadly to how CMS, guided by healthy healthcare competition policy, can take the lead with other payers in the construction of infrastructure that facilitates the quickest uptake of, and access to, advanced practitioners into the Medicare provider network—increasing competitors and competition. 

Expecting that AANP and many other friends of NPs will also be responding, NNPEN restricts our comments to preparing NPs to be informed risk-takers in Value Based Payment risk programs that can sustain small, nimble group practices.

NP Scope of Practice [SOP] success is a pyrrhic victory and will not reduce harmful barriers to healthy competition without NP access to Value-Based Payment arrangements that we know can reliably reward the NP outcomes that flow from the Nursing Process.  Recent executive orders give this conversation—i.e., NP risk-taking skills required to succeed in Value Based Payment programs --new and significant urgency. 

Here are our comments detailing opportunities for the DOJ, partnering with CMS, to level the SOP playing field short and long term and create provider choices that the American consumer deserves:

#1—Preserve/extend the low cost and high quality benefits of the Nursing Process

• Uncontroverted literature of >100 peer-reviewed studies finds that NPs produce quality and cost outcomes as good or better than those of physician PCPs. Why? because of the integrated view of the patient that is the backbone of the Nursing Process. This patient-facing hard-wired Nursing Process also explains why nurses are consistently viewed as the most trusted profession, and the group most trusted to “fix” health care.
• Yet the Nursing Process is desecrated by the dominant medical model pressure to “see”25-30 patients per day, squeezing patient office visits into 15 -minute segments
• NP-owned practices are typically small and community based—by design.  They struggle to find SBA lenders that appreciate their creditworthiness. To preserve the benefits of nurse-led care, NP practices need many more sustainable independent practice options, that give consumers access to healthcare and preserve the benefits of the Nursing Process in all fifty States.  Recent Executive Orders do not do that;  CMMI has stood up only one model, the REACH ACO, as “NP friendly” because it recognizes the physician and NP PCP ‘s network eligibility and payment options as equivalent, while CMMI’s dominant Medicare Shared Savings ACO model does not.
• Even Original Medicare, which does not reflect the anti-NP bias of private insurers that’s been built into managed Medicare, punishes the NP PCP by paying NPs only 85% of the physician fee schedule for the same work, and adds insult to injury by perpetuating an “Incident to” billing policy  that recognizes the billing provider [deemed to be the physician in most institutional settings], not the treating provider who would be paid only 85% of the physician’s charges].  MedPac’s recommendation to abandon incident- to billing has not prevailed.
• Given these VBP program limitations, the SBA needs much more encouragement to create a robust lender safety net for NP practices who form the healthcare safety net in underserved communities.

#2—Full Practice Authority (aka Independent Scope of Practice) will generate a much-needed NP primary care outcomes database that supports pricing based on competition

• As long as the NP is not the independent Primary Care Provider, no performance data is being separately attributed to the NP--- syphoning NP value off to benefit the billing physician and allowing payers to resist exploration of VBP with NPs for “lack of credible data”. CMS terminating the practice of incident- to billing would support collection of the longitudinal data that is essential to measuring and documenting the NP’s (and all other PCPs’) management of population health risk

• ·         The metaphor when Medicare sneezes everyone gets a cold is trite but true here. Think of this as the encore to our government’s funding technology development in early years by supplying the expensive hardware.

 

#3--Without NPs delivering primary care access across the nation, CMS will fail to meet its Quadruple Aim Goals

• We are losing primary care physicians at an unprecedented rate across the U.S., especially in rural areas where the needs are extremely high and opioid addiction/deaths are skyrocketing.  Many doctors are moving to "concierge" care models which leave out the poorest/sickest in the U.S.
• NPs are the fastest growing health care professional group by a lot. The American Association of Nurse Practitioners’ website reports there are 385,000 NPs in America in 2024. According to the Bureau of Labor Statistics, overall employment of physicians and surgeons is projected to grow 4 percent from 2023 to 2033 with 23,600 openings annually. https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm

Empowered by the current administration’s libertarian leanings, and reinforced [but never enforced] by ACA Section 2706 prohibiting insurer discrimination on the basis of license, DOJ and CMS have the power and gravitas with a top- of -license SOP vision to overcome the staunch payer resistance and physician stonewalling that still confounds SOP progress in more than half of our 50 states.  The marketplace and the workforce are ready for SOP change that is refreshingly bipartisan.  The time is now! 

We applaud President Trump for his recognition that advanced practice providers, specifically Nurse Practitioners that can practice independently, are the market disruptors his administration needs to break down the barriers to healthy primary care access. 

On behalf of our independent NP practice membership and an America filled with consumers without access to primary care, NNPEN thanks you for our opportunity to comment on barriers to healthy competition in health care today.

Sincerely,

/s/ Dr. Lynn Rapsilber, APRN