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Center for Medicare and Medicaid Innovation

Request for Information on Advanced Primary Care Model Concepts

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Request for Information (RFI)

SUMMARY: The Centers for Medicare & Medicaid Services (CMS) is seeking input on initiatives to test innovations in advanced primary care, particularly mechanisms to encourage more comprehensive primary care delivery; to improve the care of patients with complex needs; to facilitate robust connections to the medical neighborhood and community-based services; and to move payment from encounter-based towards value-driven, population-based care.

DATES: To be assured consideration, comments must be received by March 16, 2015.

ADDRESSES: Comments should be submitted electronically to: APC@cms.hhs.gov. FOR FURTHER INFORMATION, CONTACT: APC@cms.hhs.gov with “RFI” in the subject line.

BACKGROUND: Section 1115A of the Social Security Act, as added by section 3021 of the Affordable Care Act, authorizes the Secretary of Health and Human Services to test innovative models of payment and service delivery that have the potential to reduce program expenditures while preserving or enhancing the quality of care for Medicare, Medicaid and CHIP

beneficiaries.

CMS is issuing this Request for Information (RFI) to obtain input on the design of the next generation of advanced primary care model(s). Advanced primary care is based on principles of the Patient Centered Medical Home and builds on the care delivery models employed in other CMS model tests, including the Comprehensive Primary Care initiative (click hyperlink for more information). Next generation model(s) for advanced primary care would seek to improve further the delivery of patient-centered care and population health and would align with the Secretary’s goal to increase the use of alternative payment models. General topics of interest include:

1. Increased comprehensiveness of, and patient continuity with, primary care (i.e., care provided with greater depth and breadth and through longitudinal relationships between patients and primary care providers),

2. Care of patients with complex needs,

3. Closer connections between primary care and other clinical care (“the medical neighborhood”) and community-based services,

4. Moving from encounter-based payment or encounter-based payment with care management fees towards population-based payments (PBPs) to support the infrastructure needed for advanced primary care, create incentives for

innovation in care delivery, and promote accountability for costs and quality of

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care, including consideration of appropriate mechanisms to assign beneficiaries to unique practices,

5. Mechanisms to support small primary care practices in the transformation to advanced primary care,

6. Advanced primary care within accountable care organizations (ACOs), 7. Multi-payer participation,

8. Performance measurement that is meaningful to beneficiaries and clinicians, 9. Matching documentation requirements to the goals of advanced primary care

while protecting CMS program integrity, and

10. Use of health information technology (HIT), including electronic health records, data analytics, and population health tools, to support advanced primary care.

CMS seeks broad input from consumers and consumer organizations, health care providers, associations, purchasers and health plans, Medicaid agencies and other state offices, quality review organizations, social service providers, HIT vendors, and other stakeholders. Commenters are encouraged to provide the name of their organization and a contact person, mailing address, email address, and phone number in the following field; however, this information is not required as a condition of CMS’s full consideration of your comment.

CMS may publicly post the comments received, or a summary thereof, so commenters should not share proprietary information. The information and questions in this RFI reflect ideas that CMS is considering, but it takes no position on whether any of the options discussed here or that may be raised by commenters in response to this RFI would be feasible or permissible.

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Organization: National Nursing Centers Consortium Contact: Tine Hansen-Turton, CEO

Mailing address: Centre Square West, 1500 Market St, LM - Mailroom, Philadelphia, PA 19102

Email: tine@nncc.us Phone: 215-731-7140

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SECTION I: INFORMATION REGARDING

ADVANCED PRIMARY CARE MODEL CONCEPTS

The next generation of advanced primary care model(s) could test moving payment for primary care services from encounter-based, or encounter-based with care management fees (as is being tested in the Comprehensive Primary Care Initiative), towards population-based (payment based on a practice’s population of beneficiaries). Population-based payments (PBPs) could cover two components:

(1) Severity-adjusted, non-visit based care management services, and

(2) A portion or all of the expected, severity-adjusted fee-for-service (FFS) payment for a basket of services provided in primary care (“rolled-up FFS”)

With PBPs, services billed by primary care practices that are not included in the basket would continue to be paid via FFS. Practices that receive only a portion of expected FFS payment for the basket through “rolled-up FFS” would continue to receive traditional FFS payment for billed services in the basket, but at a rate reduced by the amount of the “rolled-up” portion (e.g., if a practice elects to receive 50% of expected FFS for the basket in “rolled-up FFS,” then traditional FFS payment for billed services in the basket would be reduced by 50%). Practices could also be accountable for clinical quality metrics, patient satisfaction, and the total cost of care.

SECTION II: QUESTIONS

1. Please comment on the above description of PBPs in terms of (a) the impact on the delivery of advanced primary care and (b) primary care practices’ readiness to take on such

arrangements.

2. What portion of expected FFS payments for the basket of services would practices be interested in receiving via “rolled-up” FFS?

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The National Nursing Centers Consortium (NNCC) is a 501(c)3 nonprofit member organization of community-based nurse-managed health clinics (sometimes called nurse-managed health centers or NMHCs). NMHCs provide a full range of health services, including primary care, health promotion, and disease prevention, to several million low-income, often underinsured and uninsured, patients across the United States. The NNCC works closely with other nursing groups, such as the American Academy of Nursing, who have also submitted responses to this RFI, and writes separately to highlight the experiences of the more than 500 small, nurse-led community-based health centers delivering care in underserved

communities--whether in schools, in public housing, in birthing centers, or at community clinics. These nurse-led community health centers improve access to high-quality health and social services and simultaneously train a community-health oriented workforce for the next generation—yet too often they are overlooked in favor of large, hospital-based systems when cost-saving strategies are

contemplated.

The NNCC’s comments focus mainly on the role of advanced practice nurses

(APNs), particularly nurse practitioners, as they currently lead, organize, and deliver primary care as individual providers, as the leaders of primary care teams, and at the organizational and executive level in primary care. As such, nurse practitioners and other APNs, like nurse midwives and clinical nurse specialists, will play a

significant role in adopting Population Based Payment (PBP) models throughout the United States. The importance of APNs will only continue to increase within

existing hospital and health system teams, in retail clinics, and, especially, in community-based nurse-managed health centers.

(a) The NNCC is generally in support of the transition in primary care away from fee for service (FFS), encounter-based payment-centered models and towards a

value-based, patient-centered model. The current FFS, encounter-driven system drives volume, and ignores the contributions of other key team members who are not reimbursable. For nurse-managed health centers, where interdisciplinary health teams are the standard of care, members of the team critical to patient outcomes, like care coordinators, outreach workers, social workers, and RNs, are not

reimbursed. However, these new models must account for care delivered by nurse practitioners and at nurse-managed health centers that have Clinical (not Medical) Directors in order for the millions of individuals that receive health care in these settings to benefit from these models. It is imperative that, when introducing

innovative payment models, CMS ensures that innovators in care delivery, such as nurse-managed health centers, can afford to participate.

Assuming the payment mechanism for the delivery of PBPs is done through health insurers, CMS must mandate that all health insurance plans credential and contract with nurse practitioners as primary care providers and nurse-managed health clinics as delivery sites. Current studies show that 25% of all Medicaid/Medicare private health insurers do not contract or credential nurse-managed health centers or nurse practitioners, which means they cannot serve the population in their plans, even if that population wants to get services in a nurse-managed health center.

(b) The issue of readiness rests in large part on the size and financial footing of the practices. The reality is that small independent practices, or any practices that do not have significant operational reserves, such as nurse-managed health centers, are not likely to have the option of deferring their expenses until a future "settle up" period when they learn whether they are winners/losers of the at-risk payments; therefore, it is likely that only a small percentage of the rate can be put into the "rolled up" portion. It is likely that a graduated approach--starting with a modest 10% and increasing as experience and confidence in the financial modeling and ability to control costs is gained—would be prudent for such practices. There is near universal agreement that the current FFS is untenable, and therefore, there is a readiness for moving in this direction, but with caution - and to date CMS has not demonstrated an interest or support for smaller clinics, like nurse-managed health centers and nurse-led federally qualified health centers. To date, nurse-managed health center proposals to CMS under the CMMI grants have not been considered because of their lack of ability to scale in the communities due to their small size and independence from hospital systems. Thus, health centers dedicated to serving low-income communities with high rates of complex chronic conditions have been excluded from the conversation on cost-savings despite intrinsic alignment with the goals of CMS.

It is likely that the percentage will vary based on the type of practice and its ability to withstand variations in payment without risking practice financial integrity. Allowing a phased implementation, such as starting at 10% and moving upwards over time while practices ensure they have the ability to manage in a PBP system would be advisable although larger practices may be able to move more quickly and

aggressively to take advantage of the new system. Again, the NNCC encourages CMS to consider small practices like NMHCs as it introduces PBP and other payment innovations.

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3. What services should be included in the basket (e.g., all primary care Evaluation and Management (E&M) services; primary care E&M services based on certain diagnoses; primary care E&M services plus certain procedures; all services in primary care)? Please provide a rationale for the recommendation.

4. To what extent are primary care practices willing to be accountable for total cost of care?

5. Through what mechanism should practices be accountable for total cost of care (e.g., savings paid or losses collected annually; withhold a portion of PBPs and pay/collect the difference between the withhold and saving/losses; modify (increase/decrease) future PBP amounts based on savings/losses; bonus/penalty)?

6. What key challenges do primary care practices face in assuming financial accountability?

a. What supports or mechanisms could assist practices in overcoming those challenges (e.g., limitations on total practice financial benefit or risk during reconciliation; exclusion of specified high cost beneficiaries during reconciliation; allowing pooling of risk among practices)?

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All primary care E&M services should be included, including the newer care coordination service code, as well as all procedures for which primary care providers are privileged within their primary care practice. The nurse-managed health center model has been very successful because of its team-based approach, where nurses, nurse practitioners, social workers, psychologists, community

outreach workers, students, etc. provide comprehensive primary health care services, integrated with behavioral health services and also in-home-based services. However, despite having shown outcomes that reflect significant cost savings, these services have never been reimbursed. Additionally, as innovative care delivery increasingly demands new technologies to improve access to care, support for telehealth and tele-monitoring must also be reimbursable. Therefore, it is essential that in-home and telehealth care services as well as the behavioral health services of medical/BH (psychiatrists and psychiatric APRNs) and behavioral health counselors (LCSWs, LSWs, psychologists, etc.) be covered. Again, for innovative payment models to achieve their goals with respect to quality care delivery, CMS must prevent insurers from unnecessarily restricting reimbursement for these services by erecting barriers with respect to the type of provider. A key driver to controlling cost is keeping the patient within the primary care system to the greatest extent possible. As soon as the patient needs to leave the primary care system, the risk of duplication of services, fragmentation, and increased costs of specialty care begin to rise.

NNCC looks at "total cost of care" in multiple ways. First, a true total cost of care means every healthcare dollar spent on the patient, in any setting--and alternatively more graduated approaches such as all outpatient care or even just all care

provided within the primary care setting. Again, the tolerance and appetite for risk will be based in part on the size, financial strength, and infrastructure of the primary care practice. In large integrated systems, the primary care practices are likely to be able to consider accountability for total cost of care. Large nurse-managed health centers may be willing to be accountable for the total cost of care up to but not including inpatient care. Size and type of organization is likely to be a key driver. However, like most community-based health centers, whether

nurse-managed, federally qualified or independent community practices, the size and inability to scale will limit their ability to be accountable for total cost of care. Thus, CMS should take these factors into consideration and perhaps create alternative CMMI demonstrations to evaluate a different way for those practices, which generally have excellent patient outcomes, but on a smaller scale, to participate.

Any mechanism has to allow for the investment in primary care to be recognized for its impact on total cost of care, even if the primary care practice is not "at risk" for the total cost of care. For small community-based nurse-managed health centers and other smaller community-based practices, e.g. federally qualified health

centers, bonus payments will be the only way they can sustain their existence given the low margins in primary care.

The costs in primary care are fixed, with perhaps 70 percent of the costs directly tied to the people who deliver the care or support care delivery. Direct care costs are not variable, therefore variations in payment, or the risk of significant loss of payment, is not easily tolerated. This is compounded by a health care system in which there is no single payor with a single set of rules for risk/accountability, but instead multiple payers. Across the United States, some payers still refuse to reimburse for care delivered by nurse practitioners and many nurse-managed health centers are paid less than physician practices due to the CMS 85 percent reimbursement rate for nurse practitioners. Assuming financial accountability when most nurse-managed health centers cannot survive without supplemental funding, e.g. from foundations, could be devastating to their existence.

CMS must understand that a high proportion of people are still uninsured. Despite aggressive insurance enrollment efforts, at least 30 percent of care in

nurse-managed health centers is still delivered to uninsured patients and completely uncompensated. Nurse-managed health centers are the ones taking care of the uninsured and keeping people out of the hospitals—without recognition or

consideration from CMS. Should all nurse-managed health centers close their doors tomorrow, thousands of patients would be using the emergency room for primary health care.

Finally, size and infrastructure impact the ability of primary care practices to assume financial accountability. Primary care practices need not only clinical programmatic strength, but also the financial and IT/HIT infrastructure to follow all patients at all times, both clinically and from a claims/cost perspective.

All of these strategies should be considered and would work with CMS on alternative CMMI demonstrations to evaluate strategies to address these challenges that are specific to smaller practices.

Based on the proposed PBPs, NNCC would recommend a fixed global capitation for primary care, adjusted for acuity, and inclusive of specialist consults, pharmacology, and lab services, and allowing for significant shared savings based on total cost of patients. This most closely aligns with the ability of primary care to focus on its impact on the total

well-being of the patient through addressing the medical, behavioral, and social aspects of care in the context of the patient, their family, their home, and their community.

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7. The move from FFS to PBPs could allow a revision of current medical documentation requirements. What elements of documentation could be revised to be consistent with PBP and not affect patient care negatively?

8. Practices caring for patients with complex needs–either the practice’s full population or a subpopulation of its patients–could receive additional incentives and resources to deliver enhanced services to these patients, including better integration with social and community-based services, behavioral health, and other health care providers and facilities. What are the best methodologies to identify patients with complex needs (e.g., a claims-based comorbidity measurement (Hierarchical Condition Category scores, age, specific conditions, and/or JEN frailty calculation); a claims-based utilization measurement; attribution of a population of local beneficiaries without primary care utilization; and/or practice identification through a risk assessment tool and/or clinical intuition)? Please be specific in your responses and provide examples if possible.

a. Is there a minimum number of patients with complex needs required for a practice to develop the necessary infrastructure and services to offer these patients?

b. Should the payment structure discussed in questions 1-7 above differ for these patients? If so, how?

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NNCC suggests that documentation include documentation of the social

determinants of health, and that the documentation requirements tied to time and medical complexity be revised to consider non-face-to-face time and

social/educational complexity as well as medical complexity.

Many tools are available that take into account well-known impact factors such as age and disease-specific acuity. However, incentives that support care for patients with complex needs rarely include or account for behavioral health factors, health seeking behaviors, addictions and lifestyle, and social determinants (education, income, and employment in particular), as well as the impact of adverse effects such as trauma. This has led many nurse-managed health center practices to come up with their own dashboards to identify risk factors for their patients.

Nurse-managed health centers (as described above) know that it takes a team of people, with maximum flexibility in terms of who provides the care, in what setting, and over what time period. Typically, more than 50 percent of patients receiving care from nurse-managed health centers have chronic illnesses and/or behavioral health issues. Thus, the average primary care panel size in nurse-managed health centers is 1000 given the medical complexity of their patient roster. The NNCC believes 150-200 patients with complex needs would be a good estimate of the minimum number of patients required to develop the necessary

infrastructure.

Again, to encourage primary care practices to move in this direction, establishing a global primary care capitation payment for this sub-group would encourage innovation and minimize financial risk to the practice as they shift to a PBP methodology. And again, as this global capitation payment is developed, it must take into consideration that a nurse practitioner can be the lead of the team. This has been one of the major barriers to date in any CMS demonstration - and why NNCC and our nurse-managed health centers remain so cautious about supporting new payment mechanisms. Unfortunately, CMS has not demonstrated its support for the nurse-managed health center model, nor nurse practitioners as the primary care provider or team leader.

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c. What would the estimated costs be on a per-patient-per month basis to develop the necessary infrastructure and provide ongoing advanced primary care to these patients? Please provide justification to support these estimates.

d. What performance metrics are most appropriate and meaningful to assess the quality of care for these patients?

9. What data do practices need from payers to perform well and manage population health in a model that includes PBPs, financial accountability, and specified requirements for primary care delivery? Please be specific in describing helpful feedback or utilization reports in terms of timing, content (e.g., patient characteristics, services used, providers of services), and format.

10. What transformative changes to HIT – including electronic health records and other tools – would allow primary care practices to use data for quality measurement and quality

improvement, effectively manage the volume and priority of clinical data, coordinate care across the medical neighborhood, engage patients, and manage population health through team-based care (e.g., transitioning from an encounter-based to a patient-based framework for organizing data; using interoperable electronic care plans; having robust care

management tools)?

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NNCC encourages CMS to look at the reimbursement rate for federally qualified health centers. The wrap around rate takes numerous wrap around services and providers into consideration. For a Medicaid patient with serious chronic illness, it costs the average nurse-managed health center about $180 per encounter in real costs, including the infrastructure costs. Thus, a per-patient-per-month rate, should take into account the actual cost of the encounter and come up with a reasonable amount of times this patient should be seen and come up with a per-patient-per month cost. Furthermore, the cost may vary by type and age of patient. A frail elderly patient will have higher costs when accounting for care

coordination, home-visiting, etc.

The NNCC recommends the following performance metrics: (1) Ability to remain at home and living independently;

(2) Absence of in-patient stays for ambulatory care sensitive diagnoses or chronic illness exacerbations;

(3) Overall well-being as defined by patient -GAF, SF-15;

(4) Continuity of care with practice team (not necessarily with one PCP); and

(5) Evidence that the family and patient have had significant input and involvement in care planning, treatment, and goal setting.

The NNCC believes the following types of data would assist practices: (1) Accurate attribution of patients--critical with timely notification;

(2) Notification/flagging when primary care attributed patients "hit" the health care system in terms of ER use or admission to hospital, behavioral health in patient treatment, or SNF; and

(3) Timely and ongoing communication from payers/plans on any contact with the patient by the plan's care coordinators or managers.

Across the country, innovations in the development of tools and apps that

significantly enhance our capabilities in population management and care of chronic and complex patients are being developed, and at a rapid pace. We are building a body of "best practices” in dashboards, care coordination, transition management, care planning between disciplines, planned care dashboards, portal access and sharing, and self-management goal setting via apps.

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a. In what ways, if any, could CMS encourage advanced primary care practices to implement innovative HIT tools (e.g., facilitate collaboration between HIT vendors and practices)?

11. The development of advanced primary care practices within ACOs could potentially yield synergistic improvements in cost and quality outcomes. What resources (financial and/or technical assistance) do ACOs currently provide to primary care practices/providers to enable care delivery redesign, and are they sufficient to deliver advanced primary care as described in this RFI?

a. Should primary care practices within ACOs receive PBPs?

b. What should be the relationship, if any, between ACOs and primary care practices receiving PBPs?

12. What potential program integrity issues for CMS are associated with the payment and care delivery concepts discussed in this RFI?

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Rather than a focus on public domain ownership and standard interfaces, the development continues to be on proprietary HIT systems and their clients. All of these best practices and apps need to move as much as possible into the public domain where they can be integrated within EMRs regardless of the vendor type and across settings.

Currently, there are no ACOs that work with nurse-managed health centers and very few that work with other safety-net providers like federally qualified providers. The absence of these important health care delivery mechanisms is a flaw in the ACO model design. The NNCC encourages CMS to further explore the ACO model and identify ways to support ACOs that contract with or include nurse-managed health centers and FQHCs in their network.

There is no reason to categorically exclude primary care practices from population based payments, but the practice (and the ACO) need to be able to demonstrate their competency and readiness to manage the clinical, data, financial, and technology implications.

Again, they should be encouraged to work together.

CMS is always concerned, understandably, with ensuring the dollars are invested wisely and patients are well treated--neither subjected to overuse, nor to underuse, or inappropriate services. However, program integrity should also include the analysis of whether all providers get to participate in the new models. The NNCC remains concerned that nurse-managed health centers and nurse practitioners will be excluded from being full participants in these new models unless CMS makes a deliberate attempt to include them.

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a. How can these issues be prevented or addressed?

b. What data elements should CMS collect to detect any fraud, waste or abuse issues? Please be specific in your responses and provide examples if possible.

13. For stakeholders involved with primary care for Medicaid beneficiaries, please provide comments on any of the concepts discussed in this RFI and any unique considerations to be taken into account for the Medicaid population.

SPECIAL NOTE TO RESPONDENTS: Whenever possible, respondents are asked to draw their responses from objective, empirical, and actionable evidence and to cite this evidence within their responses.

THIS IS A REQUEST FOR INFORMATION (RFI) ONLY. This RFI is issued solely for information and planning purposes; it does not constitute a Request for Proposal, applications, proposal abstracts, or quotations. This RFI does not commit the Government to contract for any supplies or services or make a grant award. Further, CMS is not seeking proposals through this RFI and will not accept unsolicited proposals. Responders are advised that the U.S. Government will not pay for any information or administrative costs incurred in response to this RFI; all costs associated with responding to this RFI will be solely at the interested party’s expense. Not responding to this RFI does not preclude participation in any future procurement, if conducted. It is the responsibility of the potential responders to monitor this RFI announcement for additional information pertaining to this request.

Please note that CMS will not respond to questions about the policy issues raised in this RFI. CMS may or may not choose to contact individual responders. Such communications would only serve to further clarify written responses. Contractor support personnel may be used to review RFI responses.

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CMS needs to be deliberate about including nurse-managed health centers. As defined by Section 254c-1a of the Public Health Service Act, NMHCs are “nurse-practice arrangements, managed by advanced

practice nurses (APNs), that provide primary care or wellness services to underserved or vulnerable populations and are associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency.” If CMS is not proactive about including nurse practitioners as primary care providers and potential team leaders in this model, nurse-managed health centers will continue to remain on the periphery of change, despite strong patient outcomes and innovative models of care.

We trust that CMS will determine these measures. However, we would suggest that whatever elements are used, that CMS share this data with practices. Such data could include under/over and non-utilization of care, by type and in what amounts, in what settings and by what types of providers. As we move forward in this area, understanding the differences between practices (solo, nurse managed health centers, FQHCs, academic, etc.), types of providers, and the range of services provided in a practice and its impact on cost and outcomes will be very valuable.

Everything that has been addressed in the prior comments applies to the Medicaid population. The Medicaid population has substantial challenges, even as compared to the Medicare population, given the linguistic barriers, prevalence of racial/ethnic disparities, and the range of age groups found in the Medicaid population.

Therefore, programs and services like home visitors for high risk families, intensive group support (Centering) during pregnancy, trauma informed care, case based distance learning for providers in managing high complexity issues like HIV, Hep C, chronic pain, and opioid addiction within primary care (Project ECHO model) would all be important to consider.

Finally, the NNCC asks CMS to remember the enormous efforts that

nurse-managed health centers and other primary care practices are making to educate and train the next generation of primary care providers and their team members to a high performance, patient-centered, interdisciplinary model of care. Primary care is the obvious setting to learn and practice population based

management, team based care, integrated behavioral and primary care, and expert use of technology. Nurse practitioners, who are becoming the backbone of primary care in the United States, need clinical placements and training opportunities in the community health and interdisciplinary settings to meet the needs of primary care. Students of the health professions need to learn and practice in environments that reflect our highest goals, and this training has an impact on the cost and efficiency of the primary care practice. To date, this is not recognized in reimbursement strategies, therefore leaving training sites to shoulder the cost of this training in addition to the high costs described above of delivering care to high-need, underserved populations.

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Responses to this notice are not offers and cannot be accepted by the Government to form a binding contract or issue a grant. Information obtained as a result of this RFI may be used by the Government for program planning on a non-attribution basis. Respondents should not include any information that might be considered proprietary or confidential. This RFI should not be construed as a commitment or authorization to incur cost for which payment would be required or sought. All submissions become Government property and will not be returned. CMS may publically post the comments received, or a summary thereof.

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