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1 Nurse Practitioners as Leaders in Primary Care: Current Challenges and Future Opportunities National Conference of State Legislatures Louisville, KY July 27, 2010 Tine Hansen-Turton, MGA, JD CEO, National Nursing Centers Consortium Executive Director, Convenient Care Association
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Nurse Practitioners as Leaders in

Primary Care: Current Challenges and

Future Opportunities

National Conference of State Legislatures

Louisville, KY

July 27, 2010

Tine Hansen-Turton, MGA, JD

CEO, National Nursing Centers Consortium

Executive Director, Convenient Care Association

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Today’s Presentation

A broad overview of the coverage and access

challenges facing our health care system.

Identify the limitations of health reform efforts.

Understand how nurse-managed health centers

(NMHCs) can strengthen reform efforts and increase

access to primary care services.

Discuss some of the challenges facing NMHCs.

Understand the role of retail-based convenient care

clinics in increasing primary care access.

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Crisis of Access

47 million Americans are uninsured, including 1 in every 8 children.

70% of Americans report they can’t get same-day appointments with their PCP.

29% of Medicare recipients (11.6 million people) have a hard time finding a PCP who accepts their insurance.

30% of Americans lack a regular source of primary care.

About half of all emergency room visits were non-emergent in nature or otherwise treatable in primary care settings.

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Health Care is in Crisis

Limited access to routine and preventive care.

Millions of consumers do not have an established physician relationship or health insurance.

Health care costs are rising at unsustainable rates.

Consumers are increasingly pressed for time and are demanding convenience.

These issues will worsen as the primary care physician shortage grows.

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What is Being Done to Help

First phase: health insurance

expansion

Since 2006, Massachusetts has

gone from having as many as

650,000 uninsured residents to

having 167,300 in 2008 (the lowest

rate of uninsured residents in the

nation).

Source: http://commonhealth.wbur.og/wbur-posts-and-stories/2008/12/states-uninsured-rate-is-down-to-26

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Does Coverage = Care?

Across Mass., wait to see doctors grows: Access to

care, insurance law cited for delays (Boston Globe, Sep.

22, 2008).

Numbers dwindle for primary care doctors: Medical

students in US choosing other specialties (AP, Sep. 10,

2008).

Workforce Study Confirms Shortage of Primary Care

Physicians (Mass. Med. Soc., Aug. 2007).

Experiences in Massachusetts

suggest not…

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Reform in Massachusetts

In August 2008, S. 2863 was passed (―An act to

promote cost containment transparency, and

efficiency in the delivery of quality health care‖).

Intended to address new issues raised by

increased access to health insurance

Focused on:

Health IT

Care Coordination

Pay-for-Performance

Increased utilization of non-physician providers

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Reform in Pennsylvania

Pennsylvania Governor Edward G. Rendell

signs first pieces of the “Prescription for

Pennsylvania” health care reform plan into

law at the University of Pennsylvania School

of Nursing, July 2007.

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A State Model for Including NPs in

Medical Home Initiatives

Chronic Care Initiative

In Pennsylvania, the Governor’s Office of Health Care

Reform, along with physicians, nurses, and insurers, has

successfully begun the implementation of the Chronic

Care Model and the Patient Centered Medical Home

across Pennsylvania.

By June 2009, more than 400 primary care practitioners

were involved in four learning collaboratives,

transforming care for more than 750,000 patients.

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Data from Southeastern Pennsylvania (2010)

Overall, the outcomes for nurse-led

and physician-led practices were

comparable.

Highlights

- Project Salud achieved best-in-region outcomes for controlling blood

pressure among diabetic patients

- Six nurse-managed health centers consistently scored better than the

aggregate on outcomes measures collected by the Commonwealth

- VNA Community Services’ pediatric clinic achieved best-in-region

outcomes for percentage of asthmatic patients with flu shots, percentage

of asthmatic patients on controller medications, and percentage of

parents provided with smoking cessation counseling

Source: Commonwealth of Pennsylvania, Governor’s Office of Health Care Reform. March 2010 (diabetes) and June 2010 (pediatric asthma).

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Where Do We Go From Here?

“Health reform legislation will dramatically Increase the number of Americans with health insurance. We need to make sure that we are using our existing primary care workforce – including nurse practitioners –to meet the new demand.”

- Ann S. Torregrossa, Director of the Pennsylvania

Governor’s Office of Health Care Reform

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NPs and NMHCs Can Help Meet the

Increased Demand for Care

Second phase – Health care provider expansion

Approximately 80,000 nurse practitioners now

provide primary care.

Nurse practitioners are by far the fastest growing

group of primary care professionals in the country

(compared to physicians, dentists, and physician

assistants).*

Approx. 70% of all NMHCs offer primary care.

* Statement of A. Bruce Steinwald, Health Care Director, U.S. Government Accountability Office, Testimony Before

the Committee on Health, Education, Labor and Pensions, U.S. Senate, 2008.

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Innovations that Work

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Nurse-Managed Health Clinics

& Convenient Care Clinics

Nurse-Led Care can help expand the capacity of the primary care system

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Now is the Time to Invest in NMHCs

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The federal government has created a Massachusetts-style health reform plan.

Health insurance reform will strain our existing primary care network

Governors are looking to emerging health care models and non-physician providers to increase access to quality health care and reduce expensive, unnecessary emergency room usage without increasing burdens on state budgets.

Lawmakers (and the President) are ready to invest in health workforce development and primary care in a way that they have not in the recent past.

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NMHCs: An Overview

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Nurse-Managed Health Center

Background

Increased awareness and prominence over past 30-40 years:

Increasing emphasis on care in communities and health disparities/vulnerable populations.

Development of the advanced practice nursing role.

Bring the best of nursing to the community.

Need for faculty and student practice sites.

Need for faculty and student research sites.

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What is a Nurse-Managed Health

Center (NMHC)?

An accessible service site that delivers family and community oriented primary/wellness care.

The majority of care is provided by nurses—a team of Nurse Practitioners and Nurse Midwives (Advanced Practice Nurses) and other health professionals.

Direct access to APN care.

Dominant theme: nurses control their own practice and provide the patient/client care.

Other models:

School-Based Centers

Wellness centers

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NMHCs Generally

Currently over 250

nurse-managed

health centers

operate throughout

the United States,

serving diverse

communities in

urban, rural, and

suburban locations.

Source: NNCC Member Survey, 2008

Patients Served by NNCC Members, 2008

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NMHCs Are Community-Based

Locations: public housing developments, churches, schools, community centers, and homeless or domestic violence shelters

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NMHCs and Workforce Development

Year 1: 26 NMHCs

1,491 total students

Median 42/center

Year 2: 25 NMHCs

1,467 total students

Median 45/center

Year 3: 2- NMHCs

1,435 total Students

Median: 55/center

Source: Institute for Nursing Centers (INC)

0100

200300

400

500600

700

To

tal N

o.

Nurs

ing -

BS

NN

urs

ing -

Maste

rsP

harm

acy

Medic

al

Public H

ealth

Oth

er

Year 1 Year 2 Year 3

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Geographical Location

38% 28% 24% 10%

30% 22% 26% 22%

29% 37% 17% 17%

Year 1

Year 2

Year 3

Midwest South Northeast West

Source: Institute for Nursing Centers (INC) three year study of academic NMHCs

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Rural vs. Urban Location

10.0% 10.0% 24.0% 56.0%

7.4% 18.5% 11.1% 63.0%

12.5% 12.5% 16.7% 58.3%

Year 1

Year 2

Year 3

Rural Small Town or City Small Urban Urban

Source: Institute for Nursing Centers (INC) three year study of academic NMHCs

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Services Provided

Primary Care

Mental/Behavioral Health

Family Planning

Prenatal Services

Disease Prevention

Health Promotion

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Most Common NMHC Diagnoses

Hypertension

Depression

Diabetes

Child Health Exam

Hyperlipidemia

Adult Health Maintenance Exam

Obesity

URI

Asthma

Normal pregnancy

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NMHCs Offer a Diverse Staff of

Health Professionals

Health care providers:

Nurse Practitioners – 20%

Advanced Practice Nurses –23%

RNs – 9%

Therapists and social workers – 6.5%

Outreach workers – 4%

Collaborating physicians – .5%

Administrative Staff – 12%

Health educators, students and others – 25%

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NMHCs Serve Clients

Across All Age Groups

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NMHC Payer-Mix

37%

8%7%

2%

46%

Medicaid

Medicare

Privat e/ commercial

uninsured

ot her

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NMHCs and Cost

The average primary

care encounter cost for

NMHCs is 10% less

other types of providers.

The average personnel

cost for NMHCs is 11%

less than the personnel

costs for other types of

providers.

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NMHCs in Primary Care

Centers report: High patient satisfaction

ER use 15% less than aggregate

Non-maternity hospital days 35-40% less

Specialty care cost 25% less than aggregate

Prescription cost 25% less than aggregate

NMHCs see their members an average of 1.8 times more than other providers

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Challenges to NMHCs

Patchwork of reimbursement in the U.S. and addressing the uninsured.

NMHCs are challenged to be financially sustainable in a very complex health care system that doesn’t consistently recognize nursing for reimbursement purposes.

NP policy issues (scope of practice, reimbursement regulations) vary state by state.

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Challenges in Managed Care

A national survey conducted by the National Nursing Centers Consortium in Summer 2009 found that nearly half (48%) of all major managed care organizations in the U.S. do not credential nurse practitioners as primary care providers.

Many of the MCOs not credentialing NPs are Medicare and Medicaid plans.

These policies limit patients’ flexibility to choose NPs for their primary providers, limiting access to care.

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Challenges with Medical Home Demonstrations

Nurse practitioners cannot currently participate in some CMS-directed ―medical home‖ initiatives.

In the fall of 2008, 13 Senators wrote a letter to the Secretary of Health and Human Services requesting that nurse practitioners be included in the demonstration projects.

NCQA’s Patient-Centered Medical Home certification product line can only be used to accredit physician-led practices.

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Support HIT Initiatives for NPs

The American Recovery and Reinvestment Act of 2009 authorizes the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals who are successful in becoming ―meaningful users‖ of electronic health record (EHR) technology.

The meaningful users definition must be broad enough to include NPs who often do not qualify for EHR incentives.

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What Patients Say About NMHCs ―And it gives you more continuity of care. Because

you have your specific provider that sees you on a regular basis, they’re quite familiar with your health care needs.‖

―And they will follow-up and call you. That is like getting the doctor to come out in the middle of the night.‖

―It is good because it is a neighborhood clinic and the neighborhood side of it means that it is accessible to people‖

―If the clinic was not here it would be a real disaster, you can believe that.‖

Source: Quotes taken from NMHC patient focus groups in the state of Michigan.

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Recommendations Invest in new models of care – like nurse-managed health

centers – Congress needs to appropriate the $50 million it authorized for the clinics in the Health care reform legislation

Include nurse-managed health clinics and NPs as primary care providers in demonstration projects and quality collaboratives

Encourage insurance companies to credential NPs as primary care providers – Aetna just changed its national policy

Encourage a practice environment that allows NPs and advanced practice nurses to perform all of the functions permitted under state scope of practice regulations and beyond

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Support Innovation in NP-Led Care

Convenient Care Clinics

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Retail-Based Convenient Care Clinics

Accessibility The majority are run by nurse practitioners.

Located in high-traffic retail outlets.

Extended weekday and weekend hours.

No appointments necessary.

Visits take 15-20 minutes.

Affordability Transparent pricing; prices are clearly posted .

Services cost between $40 and $75.

CCCs accept many insurance plans.

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Top Treatments at CCCs

Source: 2008 Market Strategies International report

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Positive Primary Care Impact

Third-party data from RAND Health and other sources support the value of convenient care: Equal to or better than primary care physician practices,

urgent care centers, and emergency departments in terms of quality and cost.1

Accessible within a 10-minute drive for 1/3 of Americans.2

Reaching segment of the U.S. population that currently goes without care (up to 60% of clinic patients do not have a regular source of primary care).3

1. Mehrotra A., Hangsheng L., et al. Comparing Costs and Quality of Care at Retail Clinics With That of Other Medical Settings for 3 Common

Illnesses. Annals of Internal Medicine 151 (2009): 321-328.

2. Rudavsky R., Pollack C.E., & Mehrotra A.. The Geographic Distribution, Ownership, Prices, and Scope of Practice at Retail Clinics. Annals

of Internal Medicine 151 (2009): 315-320.

3. Mehrotra A., Wang M.C., et al. Retail Clinics, Primary Care Physicians, and Emergency Departments: A Comparison of Patients’ Visits.

Health Affairs 27(5) (2008): 1272-1282.

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High Clinical Quality

Clinics adhere to CCA

Quality and Safety

Standards, and are

either certified or

accredited by a third

party.

Clinics use electronic

health records and

evidence-based

practice guidelines to

achieve consistently

excellent outcomes.

Woodburn J., Smith K.L., & Kelson G.D. Quality of Care in the Retail Health Care Setting Using National Clinical Guidelines for Acute

Pharyngitis. American Journal of Medical Quality 22 (2007): 457-462.

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Patients Want Change

The Deloitte Center for Health Solutions concludes that consumers are taking a more active role in their health care, and are willing to seek out and use innovative approaches to care.

―[T]o consumers, health plans and employers [the clinics] offer an important care alternative with a strong value proposition.‖

- Deloitte Center for Health Solutions. Retail clinics: Update and Implications (2009).

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New Focus on Consumers

“The essential element

behind disruptive

innovation is customers

who demand products

and services that provide

more value and are more

affordable than the

current ones.”

Lee, P.V. Making Space For Disruption: Putting Patients At The Center of Health Care, Health Affairs 27, no. 5 (2008):

1345-1348.

“We need to see

disruption as a

virtue. Continuing

to allow the

perpetuation of the

status quo will not

improve

Americans’ health

status.”

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For More Information

Tine Hansen-Turton, MGA, JD

215-731-7140 (phone)

[email protected]

National Nursing Centers Consortium

www.nncc.us

Convenient Care Association

www.ccaclinics.org


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