AANP President Sophia Thomas Speaks on Health Disparities and Nurse Practitioners’ Roles in the Pandemic

The nation’s nurse practitioners are in the thick of things when it comes to caring for our most vulnerable residents in the middle of the COVID-19 pandemic, including when it comes to attempting to navigate inequities in the payment and delivery system. One who has a national perspective on the situation is Sophia Thomas, DNP, FNP, PNP, FAANP president of the Washington, D.C.-based American Association of Nurse Practitioners (AANP), the largest association representing nurse practitioners (NPs) of all specialties. The AANP represents more than 100,000 NPs nationwide. Thomas, a nurse practitioner who practices at the Daughters of Charity Health System in the Kenner area of New Orleans, spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland regarding some of the more pressing issues in the midst of the COVID-19 pandemic. Below are excerpts from that interview.

I know that you are deeply concerned about some of the health disparities that are becoming more apparent in the midst of the COVID-19 pandemic. What are your high-level thoughts in that area?

I’ve been practicing in Louisiana for nearly 25 years, and most of my practice has been in rural health clinics and community health centers, so I’ve seen the disparate impact on communities of color. Fortunately, the patients I see do have access to care, as they’re coming into the clinic where I practice. But nearly 80 percent of rural America is designated as a medically underserved health shortage area.

So we’re really seeing that now with regard to COVID-19 deaths. 30 percent of Louisiana is African-American, yet 60 percent of the deaths are of African-Americans. So COVID-19 has really highlighted these health disparities. They aren’t anything new; they’ve been around for a long time. But I want to shine a light on it for policy leaders and lawmakers.

And many are relying on the Medicaid program, but there are challenges in that regard, correct?

That’s right. Initially, Louisiana did not expand the ACA, but our new governor, John Bel Edwards, did expand Medicaid, which has been very helpful. But as far as reimbursement, Medicaid has been the lowest payer, so there’s been little incentive for providers to care for those patients. And there are so many comorbidities and the social determinants of health that come with those patients, at a time when providers are being graded on those measures. For diabetes, for example, you have to show that you’re getting hemoglobin a1c under control, but there’s only so much you can do in a 15-minute visit. So you can do nutritional education, but there’s little reimbursement for that. And if there aren’t any local community health centers to care for the uninsured and they have to go a long way to access care, that will be a problem.

What can be done to improve the situation?

One important thing that we can do is to allow nurse practitioners to practice at the top of their licenses. In 22 states, DC, the VA, and the Indian Health Service, nurses have full practice authority, but in the other 28 states, NPs are required to enter into a collaborative services agreement with a physician, and in many places, the NP is required to pay a monthly fee for the monthly collaborative practice agreement, ranging from $500 a month to one-third of all billings. And when a nurse practitioner is attempting to open up a practice in a challenging area, you have to keep your fees down at a reasonable level. You may end up bartering. I know a nurse practitioner who gets eggs for payment. And so it could be cost-prohibitive.

As many have noted, the levels of deaths in communities of color are so high in some cases because of existing comorbidities in community residents, including chronic illnesses. Can you speak to that element? are so high?

Yes, in Louisiana, we have high numbers of heart, lung, renal disease, etc., and then they catch this disease, and they’re going to have worse clinical outcomes. Asthma, true. And you couple that with a lack of understanding of true infection control, based on word on the street. Or their going to a funeral for a family member who died of COVID, and more family members catch it. So there’s a lack of understanding, coupled with comorbid conditions; as well as fear of going into hospitals. So some people are staying home and delaying care when they otherwise would be going to the hospital.

Another disparity is around the lack of specialized physicians in many hospitals in smaller towns and rural areas, as well as the lack of facility preparation for massive influxes of patients requiring intensive care, right?

Yes; I can speak out of personal experience there. My mother lives in Tallulah, a small Louisiana town. There is a critical-access hospital there. If they had a true COVID case there, the closest major hospital is about an hour away. They couldn’t handle a true COVID case. And my mother had an asthma attack and an allergic reaction a few months ago, and they did a terrific job for her. But they would not be able to handle a true COVID case there; they would have to transport the patient to a major city. And you have hospitals in the same city not even doing the same thing. In northeast Louisiana, again, there’s one hospital treating patients only based on evidence, not based on anecdotal information. There’s one hospital that is choosing not to apply certain treatments to the disease; meanwhile, there’s another hospital about five miles away using everything in their arsenal, and that facility is having tremendously better outcomes. So hospitals are using different protocols. So it’s been pretty haphazard. Certainly, in my own personal view, I’d rather go to hospital number two.

What should hospital and health system leaders be thinking about right now?

Obviously, the short-term objective is improving the COVID-19 outcomes for all patients. But in the long term, we need to take a serious look at how to improve the overall health of our citizens. And I’m not talking about some token program. I’m talking about taking a hard look at improving the overall health of our country. We have to take a look at doing things differently. At the same time, we have to look at where our healthcare assets are, including staffing. Are we going to be prepared to manage all of this? So this is a time to look at our current state, and look to the future in terms of modernizing our healthcare laws. I’m pleased that the President has gotten rid of a lot of the regulatory red tape to streamline things, and I hope that continues, because too much red tape gets in the way. Certainly, all providers need to be practicing to the top of their training and education. For me as a nurse practitioners, I’d like all nurse practitioners to be able to practice to the top of their education and training.

And for me, it’s important that we not forget the root causes of the disparities impacting the death rate. And when I went to school 25, 26 years ago and learned about the populations most at risk for diabetes, heart disease, etc., it was African-American and Hispanic communities; and that data hasn’t changed in 25 years. We need to take out all the stops, in order to achieve the best outcomes possible.