Are some primary care providers more equal than others in CMS’ proposed rule for accountable care organizations (ACOs)? As the June 6 deadline for comment approaches, we need to take a closer look at just how the proposed rule might shape the future of primary care.
Here’s one big red flag: even though ACO participants can include many different types of health professionals, such as nurse practitioners and other advanced practice registered nurses (APRNs), only patients under the care of physicians will qualify these new organizations for shared savings. This omission diminishes the incentive for ACOs to include a diverse array of primary care practices.
Missing from this vision of health reform are a growing number of independent, nurse-led primary care practices who can make ACOs far more effective in serving millions of medically underserved Medicare patients, both urban and rural.
A Record Of Success For Nurse-Led Primary Care Practices
A recent study by Joanne Pohl and the Institute for Nursing Centers gives us a snapshot of the outcomes of patients receiving care from APRNs in nurse-led primary care practices and in collaborative or complementary practice arrangements. The data are compelling. Pohl used HEDIS measures (used to measure physician performance) from 15 of the largest nurse-managed health centers to evaluate quality outcomes for breast cancer screening, cervical cancer screening, diabetes care and hypertension.
Despite the provision of care to sometimes transient and most often disadvantaged populations, the mean outcomes for patients from these centers compared favorably, meeting or exceeding the 50th percentile HEDIS benchmarks, with greatest success well above the 50th percentile on hypertension management. Likewise, the measures compared favorably to federally qualified health centers in controlling hypertension and improving on the diabetic marker HbA1c below 7.
Spend some time in a nurse-led practice, and it’s easy to see why these positive outcomes occur. The National Nursing Centers Consortium, which represents over 250 nurse-managed health centers across the country, has 25 health centers located in Pennsylvania, serving close to 250,000 people.
These nurse-managed health clinics, defined in federal law, provide care to underserved and uninsured patients living in rural and urban locations, regardless of ability to pay. Patient satisfaction is high and so are healthier behaviors. Since 2004, annual report cards from Medicaid managed care organizations show that emergency department usage is 15 percent less than attained by physician providers serving a similar population; non-maternity hospital days are 35-40 percent less; and specialty costs and prescription costs are 25 percent less. These centers achieved preventive health care goals for 94 percent of children, including age-appropriate immunization and screening activities.
Many of these nurse-led sites model the best that health care can be: patient-centered, collaborative practice environments where multiple services are available. Patients at Philadelphia’s Family Practice & Counseling Network and Public Health Management Corporation have access to therapists during each primary care visit. These practices embrace the use of health information technology. Electronic health records at Life Long Care PLLC in New London, New Hampshire, include pop-ups to support care management; electronic prescribing; secure e-mail communication; and registries for congestive heart failure, diabetes, asthma and coronary artery disease. A web-based patient education project has already reduced hospital visits among that practice’s patients.
The Opportunity Ahead
Advanced practice registered nurses are providing the kind of primary care we know reduces health care costs over the long term. Nurses must be a major part of the solution to our country’s burgeoning crises of access and cost. Collectively, health care policymakers and professionals have an opportunity to dismantle the barriers that can prevent advanced practice registered nurses from practicing to the full extent of their education and training.
In addition to participating in rule making around ACOs, we need to support consistent use of provider-neutral language in all rules and regulations, and to encourage NCQA, URAC and the Joint Commission to continue efforts to broaden definitions of patient-centered medical homes to include nurse-led sites. This is our chance to move beyond traditionally siloed approaches to health care delivery.