NP Practice Owners : Healthcare Law and Policy

NP Medical Home/Health Care Homes

Gretchen Moen — Thu, 08 Oct 2009 13:23:00 GMT

It has been a very busy fall for ECFC. In addition to general patient care and all the day-to-day administrative issues, we are faced with another task. The state of MN has mandated that all recipients of state-sponsored health insurance have access to and are members of a state-certified Health Care Home.

Eagan Child and Family Care is one of 15 recipients of a grant to attend the Institute or Family Centered Care Intensive Training session at the end of this month, in preparation for meeting the requirements to become a certified health care home. Our plan is to meet these requirements over the next 90 days. We are fortunate to have a DNP student who is helping us with this process as part of her doctoral project.

There are a number of agencies that offer some type of Medical Home or Health Care Home certification. Along with the State of MN, The National Committee for Quality Assurance (NCQA), The Joint Commission Accreditation on Ambulatory Care and Hospitals, Bureau of Primary Care/Health Resources and Service Administration, Medicare CMS Demonstration, and other state agencies. Some of these groups have fees associated with the process.

Criteria for certification for Health Care Home/Medical Home are slightly different, depending on which agency is involved, but there the basic requirements to measure performance are in these critical areas: patient access and communication, patient tracking and registry functions, care management, patient self-management, test tracking, referral tracking, performance reporting and improvement measures, electronic prescribing and advanced electronic communications. Within each of these areas there are components that are considered key and some that are highly recommended. Minnesota is developing a process to reimburse providers for care coordination services in an effort to defray the actual and potential costs of implementing and sustaining health care home services.

Care coordination, collaboration, patient centered care...these are the foundations of NP practice. I know the way we deliver our services is not going to change, more so the way we track and monitor the delivery of those services. I will keep you posted on our progress!

Another Membership Practice

Jill Rollet — Mon, 14 Sep 2009 15:35:00 GMT

We've noticed just a couple of practices across the country that are turning to a so-called membership plan to help curtail costs for patients. The model requires patients to pay a flat rate monthly or annually and then covers office visits, routine tests and the like.

All the coverage I've seen of this model is careful to emphasize that this is not an insurance plan. If it were deemed insurance, a whole host of regulations would apply.

Here's a nice local news clip of a physician-owned practice in Utah that has implemented the membership model. What do you think? Would this be beneficial for your patients and practice? Would you risk the insurance-regulation implications?

NP Practices Are Perfect for Healthcare Homes

Gretchen Moen — Tue, 07 Jul 2009 19:24:00 GMT

Summer is rolling along at ECFC. Thankfully, our June has been busier than May was. Within the next three weeks our state has mandated that all medical claims be filed electronically (July 15). The state has contracted with an organization to allow free access to their Web-based e-filing system. We are awaiting approval to go ahead and begin e-filing, but it seems like we are cutting it rather close.

In addition to e-filing, we have been looking at some Web-based electronic medical records and practice management systems. I will keep you posted. For those of you with little money to throw around, there are some free, corporate sponsored, EMR systems available which may be a way to get started.

I have been asked to represent my state nursing association on the Health Care Home Payment Methodology Steering Committee. Lots of words to say that we are charged with defining what constitutes coordination of care, which patients benefit from care coordination services and how cc services will be paid for.

The Health Care Home model is very hot in Minnesota. The thought is that by having a designated health care home for patients with chronic illness or at risk for chronic illness, health care providers can develop care models to include case management services within the primary care clinic and eventually lead to improved health and decreased medical costs. Care Coordination services are costly and have not been well defined in the past. It is believed that most primary care clinics provide some type of cc. Having a uniform definition of these services would help to guide primary care clinics in developing systems that would include all of the components of care coordination as defined in the Health Care Home mode. There are a number of agencies that have developed a process to "certify" clinics as Health Care Homes, most recognizable is NCQA.

It is exciting for me to see that the state is insisting that clinics provide health care services that are consistent with the NP model of care. Care coordination is fundamental to NP care. Developing plans of care for individual patient conditions, facilitating referral to specialty care or therapies, reviewing the treatment plan and making changes, as well as follow up phone calls or contact with patients between planned visits... hummm sounds like nursing to me.

I will keep you posted on our progress.

I am looking forward to July, with all its bells and whistles. On a final note about the budget - we were able to renegotiate our lease and got a modest rent reduction to assist with our 20% across the board cuts. Yay...slowly chipping away.

Calling All Pennsylvania NPs!

Joseph Marra — Thu, 20 Nov 2008 14:02:00 GMT

Pennsylvania NP regulations are up for legislative review. Letters are encouraged to be sent to the board of nursing by 12/8/08. I wrote one personally that you can read below, and I got several physicians, dentists, NPs, other colleagues, patients, and even representatives to send letters. Please show your support! If you are an NP from another state that is already independent, please write, showing that NP independence is really safe and affordable, and the quality of care provided is equal to our colleagues.

Send your letters to Ann Steffanic, Board Administrator, Pennsylvania State Board Of Nursing, P.O. Box 2649, Harrisburg, PA 17105-2649.

Here's my letter:

November 16, 2008

Dear Ann,

My name is Joseph Marra Jr. and I am a CRNP that owns and operates the "Urgent Care Center" in central PA. I have been independent now since opening my practice February 14, 2006. I would like to take time to write in my perspective, just a few limitations that are imposed to CRNP's by the current regulations. First, many NP's have a limitation in prescriptive authority. Second is the limitation with collaboration with physicians. Third is the inability to prescribe home health and hospice due to certain language or interpretation within the regulations. Fourth is the limitation of admitting privileges into hospitals, just to name a few.

The current prescription authority limits us as well as our pt.'s. Many pt.'s must return every month even when they are stable within a disease process and medication regime, due to the inability to write for refills. This is not only an inconvenience for the pt. but increases healthcare dollars as well. Also several of my pt.s that have chronic pain from histories such as MVA, work r/t injuries, vertebral compression fractures etc. require monthly prescriptions for chronic pain medications, and we are limited to only 72 hours of medication administration. Many pt.'s come in as new pt.'s whose physician has retired or moved out of the area and had already been prescribed pain medications for years for chronic pain, and Adderall for ADHD, and I have to send them away due to my limitation. Another issue with prescription authority is the limitation with writing for suboxone. I work for Pyramid Healthcare, in addition to my own practice and have discussed with the DEA the rationale behind why we as CRNP's cannot write for a Schedule III drug? They responded; "The limitation is from the State Board of Nursing not us". I would be glad to go to the classes required for this extra education in prescriptive authority, but cannot with the current regulations. So many individuals would benefit from being on a maintenance dose of suboxone and ad to their community, as well as re-enter into the work force. This is such an under rated program, that it is disheartening to me. As a profession we compete for jobs and since we have limitations, we are often times looked over due to another individual with full prescriptive authority, even though we may be just as qualified and work for less money. Limiting our prescription ability simply limits access to quality care.

The second limitation that I would like to address would be the access to collaborating physicians. First of all I don't personally feel that this should be a requirement any longer. CRNP's have proven themselves time and time again, as safe and effective practitioners, with study after study. It has also worked in many other states, so why not in this state. Also it is difficult to obtain a physicians collaboration. They usually fear litigation on someone that they have never even seen. Also, if you must collaborate with the physician, and they tell you, you must address the situation a certain way that you don't feel safe or necessary, the pt., as well as the CRNP's license are at risk. Then there is the matter of paying the physician for their collaboration. This increases healthcare dollars as well. In my own family practice I have been not only trusted to make independent decisions but have been consulted by my physician peers for certain things. We as a profession know our strengths as well as our limitations. If the pt. needs something above what we were trained to do, we simply refer to the ER or a specialist, depending on the severity of the condition.

Third, I have had several pt.s that see me for family medicine due to the inability to get in with a PCP, from living in an underserved area. I offer the lowest prices in town, with a basic visit at only $40 per visit, and I use the $4 prescription plan at the local pharmacies as well as giving out free samples. But when NP's are limited to such things as home health, especially when pt.'s really require debilitating in home care, there is no where else to send them. I find it almost inhumane the way medicine is right now. I can provide the service to the pt., however am unable due to a regulation, and therefore a reimbursement issue. I of course don't turn these pt.'s away, but they get to a point where they can no longer make it to the office, and left with lack of proper care in the homes. Family members are left taking care of these pt.s that have a very high acuity. I implore you to take a serious look at our current regulations for our citizen's sake.

The fourth and last point that I will address in this letter, is that of the inability to admit to hospitals. When you think of total access to care, you must also think of continuity of care. When you have seen a pt. for years and know what meds. they have been taking for certain ailments and aware of the illnesses that have developed, but they have to be admitted under another practitioner, the quality of care is less in my opinion. Although hospitalists are worth their weight in gold, some family medicine practitioners continue to see their own pt.'s. My pt.'s continually express a dislike in this matter. I of course have no option but to reply; "My hands are tied". I understand that some hospitals allow for admitting privileges under other physicians. However, the pt. must be seen by that physician within a certain time frame. The decision made by the physician, may not be considered wrong, but not always the exact choice that HCP or pt. would choose.

In Summary, with limited access to primary care well documented, and less and less physicians going into this specialty, it stands to reason that someone must take over this responsibility. NP's are quite capable of taking care of this population. We are well trained, and several studies have shown that at the end of the study, NP's provide equal care to that of physicians and sometimes even better. I can forward you these studies if you would like. NP's make solid decisions and know their limitations as well. After practicing for over five years and being independent for almost three, I can tell you that this office functions quite efficiently with little to no complaints. In fact I will have some of my pt.'s send you their interpretation of the care that I, and my colleagues provide. I will offer my Urgent Care Center as a model if you would like. Take a day and actually come to my office, see how it runs, and ask the pt.'s what there perception of the quality of care is that they receive. I commend Governor Rendell, for his part in making changes that benefit this profession and ultimately our communities.

Thank you for your consideration in this matter, and should you have any questions, please don't hesitate to contact me at the above number. I would be honored to answer any questions you or the board would have, in the possible revisions to our regulations.

Sincerely,

Joseph F. Marra CRNP

Administration vs. Practice

Joseph Marra — Thu, 09 Oct 2008 11:39:00 GMT

Owning your own business comes with many challenges. Including, managing the practice as well as seeing patients. Although I love seeing patients, I also enjoy spending time managing my own practice. This includes hiring, advertising, determining hours of operations, etc...

After practicing for several years now, I have come to really enjoy the administrative end of the practice. In fact, I hired a CRNP last month and am now in negotiations for another psychiatric CRNP to start within the next couple of weeks.(If anyone that is credentialed in Pennsylvania is interested........)

I would really like to move in to the administrative end of the business. This not only allows me to keep close tabs on the business, but allows for employment opportunities and population awareness. I feel strongly that the more of us that open our own practice and pave the way, the more acceptable, or could we say "standard NP practice" would become mainstay medicine.

I have seen a huge difference in reimbursement as far as insurance companies that will credential NPs since I first started. We are on the cutting edge of change in this country. Some of us must work for others for now, depending on their situation and state regulations, and others may find the opportunities available for self-employment. Some NPs may even be happy working for someone else.

However, we can all make a contribution to our profession by talking to legislators and lobbyists. If the time permits, do what you can to make a change. We are far from "total" independence at this point, therefore we must continue to face the obstacles and overcome them one at a time. We have obvious opposition who want us to fail. With so many seeing the benefits including cost effectiveness accompanied by care and compassion, a positive change is inevitable.

We are also faced with voting for a new President at this point. Who can benefit us the most with our profession? The debate is still out on that issue, in my book. It is unfortunate that so much is involved in voting for the next president. Consideration must be made in regard to the financial stability of our country and even the world. War is another hot topic. Do we continue in Iraq until the job is done or do we withdraw troops so that our young people do not have to face continued tours of duty and risk of life or limb? What of Afghanistan? Are we spreading ourselves to thin? What of the environment and even our addiction on fossil fuels?

So many major issues to consider at this point, may make our drive for independence and our place in this world seem small. Though these are some major topics on the political trail, health care is also very important. Health care is fortunately on the table, and reform may indicate a much needed revision with current health care, including NPs.

So maybe our drive is not so insignificant after all, you be the judge.

Patience and Persistence

Aaron Hartle — Mon, 22 Sep 2008 12:56:00 GMT

Owning an independent practice as a nurse practitioner can be very fulfilling. It can also be very stressful. Some NPs may be fortunate enough to open an independent clinic staffed with medical assistants, secretaries, billing personnel, a coding company, and so on to take care of the issues as they arise. However, many of us start as a one person show. This situation can present with many problems that require patience and persistence of the new independent NP.

Although I am generally near the top on my own priority list, I am generally near the bottom with important contacts I do business with. This has been a frustrating fact to deal with since day one. My patience was first tried as I tried to obtain a building license from the city to build my clinic. Over 2 months I was rejected twice because of parking issues. I didn't give up. I couldn't figure why they had a problem with the parking. I reviewed the plans and figures and finally found out that the city had a math error that figured one more parking spot than actually was needed based on square footage. I showed them the error and obtained the permit.

A few months after opening I decided it would be profitable to have a consulting physician so I could bill more insurance companies that would only pay me if I had one. I didn't know any in the area so I picked one and took him out to lunch. He said no. I still felt he was best for the position so I stopped by his practice every week to answer any concerns and to help him get to know me better. Six weeks later he signed on as my consulting physician.

With him on board, I could bill more insurances than I could have previously. However, I still wanted to contract with the largest insurance agency in Utah. This insurance agency refused to pay NPs in private practice. I joined a coalition of other NPs who had been writing and calling this insurance company to convince them to credential us. We professionally, but sternly, talked to them for months. Finally in July 2008 they agreed to credential NPs. This insurance alone will increase my patient population 30% to 40%.

There are several other issues from being an independent clinic owner that I have encountered. Some, like the examples given, I have been successful with. Others I have not been so successful with. I've had to be patient, but have persisted. As you run into various government, state, insurance or other regulations, stand up and fight. Be professional and courteous, and realize that change takes time, but don't give up.

Finally, don't just stand on the sidelines and think that other NPs or other associations will do the work for you. We need to elevate the practice of nursing. The only way we can do that is if we all stand up together for our profession.