Appendix C.  Original Index Calculations

This appendix contains a table that documents the detailed calculations used to compute the practice environment indices for the three professions for each of the 50 States plus the District of Columbia. It includes the following subsections:

• NPs
• PAs
• CNMs

The original practice environment index developed by Sekscenski et al for 1992 was based on a number of specific criteria and point allocations reflecting the then current practice environment for the profession. The specific criteria and point allocations used in creating the index are presented below.

Legal Status (Maximum = 20)

License or Title Recognition = 6.

Practice Defined by the Board of Nursing = 7.

No Supervision by Physician = 7.

Reimbursement (Maximum = 40)

Mandated Payment = 20. [This was understood to mean any required payment to Nurse Practitioners by Medicare, Medicaid, Workers Compensation, or private payer.]

Services Covered = 0 – 10. [Particularly favorable environments were awarded 10 points, while somewhat favorable environments were awarded 5 points]

Medicaid % Pay = 0 – 10. [This was computed by multiplying the percent of physician reimbursement rate x 10. Thus NP reimbursement at 80 percent of physician rate received a score of 8.]

Prescriptive Authority (Maximum = 40)

Full Authority = 40. [This was defined as prescriptive authority for Schedule II-V controlled substances and legend drugs.]

Partial Authority = 10 – 30. [Schedule III-V and legend drugs was valued at 30 points. Schedule IV-V and legend drugs was valued at 20 points. Legend drugs only was awarded 10 points.]

No Authority = 0.

The details of the point allocations for each of the fifty States and the District of Columbia can be found below.

PAs

The original practice environment index developed by Sekscenski et al for 1992 was based on a number of specific criteria and point allocations reflecting the then present practice environment for the profession. The criteria and point allocations used in creating the index are presented below. The detailed point allocations for the 50 States can be found below.

Legal Status (Maximum = 20)

License or Title Recognition = 5.

Professional Practice Regulations = 5.

Practice Under Indirect Physician Supervision = 0 – 10. [On-site supervision = 0; Distance limitations in the regulations = 5; and Indirect supervision with electronic communication = 10.]

Reimbursement (Maximum = 40)

Mandated Payment = 30. [This was assumed to mean any required payment by Medicare, Workers Compensations, Medicaid or third party payer.]

Payment for Services Under Indirect Supervision = 10. [This was determined to be the Medicaid percent times ten.]

Prescriptive Authority (Maximum = 40)

Any authority to Write Prescriptions = 20.

Limited Authority to Order Medications in Inpatient Settings = 0 – 10. This was a subjective category scored according to the variation across the states in the privilege to write scripts in hospitals. If orders for medication must be signed by a physician before execution, for instance, fewer point were awarded. If PAs could write orders for immediate implementation with post review of records, 10 points were awarded.]

Absence of Specific Restrictions = 0 – 10. [This was scored by a review of all restrictions on prescriptive authority. A point was discounted from the full value of 10 for each restriction found.]

Table C-2 Professional Practice Index Scoring Criteria Original Scoring System for PAs for 2000

CNMs

The scores on the Sekscenski CNM professional practice index indicate a trend toward greater autonomy in State practice environments for CNMs across the fifty States and the District of Columbia between 1992 and 2000. The scores indicate the trend towards greater professionalization, socialization, and standardization of the CNM profession over the last decade. These trends are discussed more fully at the end of this chapter.

Legal Status (Maximum = 20)

License or Tile Recognition = 10.

Regulation by Board of Nursing Alone = 10. [These points were allocated only if the Board of Nursing had sole regulatory authority. If another agency or board had any influence on some aspect of professional practice, such as prescriptive privilege, no points were awarded.]

Reimbursement (Maximum = 40)

Mandated Payment = 20. [This was interpreted to mean that reimbursement is required by Medicare, Medicaid, Workers Compensation, or third party payers.]

Services Covered = 0 – 20. [This was a subjective award with 20 points given to very favorable payment environments, 10 points awarded for somewhat favorable environments, and fewer points given as determined by the reimbursement environment in a particular State. Incorporated in this category was Medicaid percentage payment times ten (as found in the CNM scale).]

Prescriptive Authority (Maximum = 40)

Full Authority = 40. [This was defined as prescriptive authority for Schedule II-V controlled substances and legend drugs. Schedule III-V and legend drugs was valued at 30 points. Schedule IV-V and legend drugs was valued at 20 points, while legend drugs only was awarded 10 points.]

The detailed point allocations for CNMs for the 50 States are presented below.Table C-3 Professional Practice Index Scoring Criteria Original Scoring System for CNMs for 2000