How To Understand The Difference Between A Nurse Practitioner And A Physician

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Nurse Practitioners: Defining Our Role

in ACO’s and Other Quality-Based,

Cost-Effective Initiatives

Wendy L. Wright, MS, RN, APRN, FNP, FAANP, FAAN

Adult/Family Nurse Practitioner

Owner – Wright & Associates Family Healthcare @ Amherst, NH and @ Concord, NH

Owner – Partners in Healthcare Education, PLLC

Objectives

•

Upon completion of this session, the participant

will be able to:

–Discuss definition of ACO and other quality and cost based programs

–Identify implications of nurse practitioner exclusion from ACO’s

–Identify opportunities to work with payers to form/develop/alter ACOs and other models of care

Disclosures

•

Speaker Bureau: Novartis, GSK,

Sanofi-Pasteur, Merck, Takeda, Vivus

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What Are ACO’s: According to CMS

•

“Accountable Care Organizations (ACOs) are

groups of doctors, hospitals, and other health

care providers, who come together voluntarily to

give coordinated high quality care to their

Medicare patients”

•

Goal: Coordinated care which provides timely

and appropriate care without duplication of

services

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO accessed 08-01-2014

Background

•

Patient Protection & Affordable Care Act signed

March 30, 2010 (Affordable Care Act)

•

Section 3022 required Secretary to:

–Establish the Medicare Shared Savings Program

–Intended to encourage the development of ACO’s within Medicare

–Purpose of cost-savings and quality care delivery while avoiding duplication of services

http://www.aanp.org/images/documents/federal-legislation/Final%20RuleACO.pdf accessed 08-30-2014

Why Become Involved?

•

When an ACO provides high-quality care

and uses its healthcare dollars wisely, all

members of the ACO share in the savings

of the program

•

As such, many hospitals have begun to

form ACO’s together, even though they are

technically competing facilities

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Medicare

•

Have a number of different ACOs

–

Medicare Shared Savings Programs

–

Advanced Payment ACO Model

–

Pioneer ACO model

33 Quality Metrics

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/ Downloads/ACO-Shared-Savings-Program-Quality-Measures.pdf accessed 08-01-2014

Where Medicare/CMS

Goes….

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Many Organizations Have Formed ACOs

http://www.beckershospitalreview.com/hospital-physician-relationships/ 60-accountable-care-organizations-to-know.html accessed 08-30-2014

Issues Now At Hand

•

Sustainability: very expensive to form, organize

and run an ACO

•

Many organizations, who had originally

expressed desire and intent to form have begun

to back away

–? If ACO’s will begin to sunset….

Modify ACO

Language

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Accountable Care Organizations

• Nurse practitioners are authorized to be ACO professionals

• Patients who are assigned to this program cannot be counted as beneficiaries if they choose a nurse practitioner for their primary care provider

• It prevents NP patients from being assigned to a Medicare ACO, and the gleaning of any subsequent benefits that result from such participation

• Statutory change to reinstate assignment of patients of all ACO professionals i.e. nurse practitioners by adding (h) (1)(B) to Section1899 (c)

•

NP Barriers

http://www.aanp.org/images/documents/federal-legislation/issuebriefs/ Issue%20Brief%20-%20Recognize%20NP%20Practices.pdf accessed 08-30-2014

Accountable Care Organizations

•

Language excludes independently-owned nurse

practitioner practices

–In NH, this affects approximately 50,000 covered lives

–Approximately 2500 – 4000 Medicare recipients

•

Effectively eliminates the group of providers who

are providing millions of patient visits for

Medicare recipients

•

Language should allow NP’s to form ACO without

collaborative or supervisory association with MD

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This federal legislation excludes

all Nurse Practitioners in

independent practice!

American Association of Nurse

Practitioners

http://www.aanp.org/images/documents/federal-legislation/issuebriefs/ Issue%20Brief%20-%20Recognize%20NP%20Practices.pdf accessed 08-30-2014

What Have We Done in

New Hampshire?

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Anthem Patient Shared Savings

• Patient Centered Primary Care Program started January 2013

• There are financial incentives within this program:

–1. There is a per member per month fee paid to office based on the collective severity of illness of patients

–2. There is an incentive based on shared savings of cost which is calculated at the end of each year. This incentive is calculated by those practitioners working in a combined risk pool. The larger the risk pool the lower the risk become when there is a catastrophic risk

Sean Lyon APRN

•

Needs to be given credit for the foresight…..

•

He was at the table/on panel

•

Asked for NP’s to be grouped together for

aggregate data collection

•

And….it began what will hopefully be some

amazing information about NP’s and our

participation in ACO’s

We Are Evaluated….

•

Based upon our own scores but also our

medical panel

•

Medical panel in 2013:

–50% NP patients

•

Medical panel in 2014:

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January 2013

•

Prior to program, we received our score card

from Anthem

•

We used this scorecard to carefully dissect our

practice

•

Looked at what we were doing well and what we

needed to work on

•

This was the push we needed to ensure that we

were providing best care possible and meeting

reporting requirements

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Here Is What I Sent to Our Staff

Similarities:

A. Both offices STINK with pediatric preventive care. WE need to run:

• 1. 12 – 18 year olds and call them for PE’s.

• 2. 3-11 year olds and do the same B. Branded Medications

• Both offices are using more than standard of BRANDED nasal steroids and BRANDED SSRI’s – (this should not be needed as they are all generic); will encourage providers to consider generics

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Here is What I Sent to Our Staff

C. Differences:

Concord Weaknesses:

1a. Med adherence/statins/ACE 2a. Branded Stimulants

3a. Diabetic eye examinations 4a. SNRI – branded

5a. ER visits – 4 avoidable! Amherst Weaknesses:

1a. Med adherence: statin/ACE 2a. Branded sleep agents

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We Used This As Our Starting Point!

•

Here is what we have done so far:

–Run reports of all children and looked at last well-visit

•Called in for well-child visits

–Created care planning initiative

–Partnered with Simmons Graduate Nurse Practitioner Students to look at our diabetes metrics

–Partnered with a Doctoral NP Student to work on medication adherence initiative

When We Started This….

•

We realized that the scorecard provided to us

from Anthem was wrong

–For instance, we were told that there were numerous children and adolescents who had not had WCC within previous year

–In fact, Anthem had paid us checks on the majority of these kids for WCC.

•We submitted days, children’s names and check numbers to Anthem who recognized a glitch

•Only pediatricians were being counted as being appropriate providers

We Are Doing This for

All Four Thousand

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Care Planning

Pre-visit Preparation

•

Improving clinician visit and improving

patient outcomes

•

Our model of care:

–

Longer visits with comprehensive care

•What This Means: we attempt to address all preventive and acute needs at every visit, every time

Pre-visit Preparation

• Two days before visit: check out sheet is completed by staff member working with particular provider

–Focus is on HEDIS/Quality measurements

–Address: •Mammograms •Bone density •Colonoscopy •Immunizations •Diabetes measurements –A1C –Foot examination –Microalbumin –Eye examination

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Check-out/Care Planning Sheet

Here is what has happened…

• Began implementing early 2013

–Billables have increased significantly

–More vaccines are being given

–More A1C, microalbumin testing is being done

–More preventive visits/procedures are being booked

• Mammograms/colonoscopies – procedures that were overdue are being booked

–Staff books these at check-out

–Serves two purposes:

•Gets accomplished

•Provides excellent malpractice defense

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Here is what has happened…

•

Specifics:

–Amherst:

•Two of the past 5 months have been the highest billable months in the history of our practice

•No new staff has been added (providers) •Number of patient visits is NOT higher

•Means that more vaccines, A1C’s, microalbumins are being done

–Concord:

•Highest five months of billables in three year history of practice •Still with one provider

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Ultimately, Most Important Goal…

•

Good patient care

•

Improved outcomes

•

Happy customers

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Simmons College

Partnership:

Graduate NP Program

Project…

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Ran report of all individuals with Diabetes

enrolled as patients within both sites

•

Provided report to graduate NP students

•

Four graduate NP students and faculty

instructor came on site and reviewed each

patient individually for a number of quality

metrics

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Project started June 1, 2013…

•

Diabetes Metrics

–

A1C < 7.0%

–

LDL < 100

–

Microalbumin within 1 year

–

Diabetic retinal examination with in 1 year

–

Foot examination within 1 year

–

Percent of individuals adherent with

medication > 80% of days

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Results of Project: Completed August 2013

•

Diabetes Metrics

–

A1C < 7.0%:

83.95% (whose A1C should be <

7.0%)

–

LDL < 100:

62.34%

–

Microalbumin within 1 year:

80.72%

–

Diabetic retinal examination with in 1 year:

63.85%

–

Foot examination within 1 year:

73.49%

–

Percent of individuals adherent with

medication > 80%:

83.14%

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What Do We Do From Here….

•

We have set reminders in individual charts of all at

risk individuals

–i.e patient overdue for eye examination

–i.e. patient overdue for microalbumin

•

We have sent messages to MA inbox to have MA

•

Take time at outset to build templates

–We have 1 clinician and 1 MA responsible for templates

–Schedule quarterly long staff meeting, MA and NP work on building and modifying templates to meet needs of providers

• Must put time in up-front to create useable templates

Optimizing Clinician Visits

•

Offer prescription refills during visits

•

Serves two purposes

–Attest to ERX requirements for CMS/medicare patients

–Cuts down on calls into office which increases staffing demands

•

Discuss medication adherence at these

visits

Utilize Reminders

•

Here are three examples of our reminder system

to enhance patient care and improve outcomes

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Utilize Reminders

•

Diabetes: Recommended Hepatitis

Series for all individuals with diabetes <

60 years of age

Utilize Reminders

•

Hepatitis C screening

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Amherst Office

Office vs. Panel

Anthem Paid Out…

•

3.6 million dollars in 2014 for this project

–NP practices earned:

•$125,000

•$80,000

•$50,000

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Thank You!

I would be happy to entertain any

comments or questions you may have

Contact Information:

www.wrightfhc.com

[email protected]

www.4healtheducation.com