NPs and ACOs

[shannonFNP, BSN, MSN, RN]

I found this article from http://onlinenursepractitionerprograms.com/blog/ about implications for APRNs re: Accountable Care Organizations. What are your thoughts?

With all the recent discussion on the Affordable Care Act (ACA) being heard before the Supreme Court, I wanted to discuss one of the programs that was borne from the ACA. The Centers for Medicare & Medicaid(CMS) define Accountable Care Organizations (ACOs) as "... groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors."

Wow, this sounds great so far, and seems to be congruent with nurse practitioner-partnered care, what could be wrong with this model? Read on.

The "ACO Professional" is defined, "...as a physician (as defined in section 1861®(1) of the Act) or a practitioner described in section 1842(b)(18)©(i) the Act (that is, a physician assistant, nurse practitioner or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act))."

Wow, a win-win all around - a new model of care that is coordinated to reduce waste and duplication, utilizes nurse practitioners and is part of federal legislation. What's the catch?

It is embedded here in the Federal Register:

Thus, although the statute defines the term ''ACO professional'' to include both physicians and non-physician practitioners, such as advance practice nurses, physician assistants, and nurse practitioners, for purposes of beneficiary assignment to an ACO, the statute requires that we consider only beneficiaries' utilization of primary care services provided by ACO professionals who are physicians. The method of assigning beneficiaries therefore must take into account the beneficiaries' utilization of primary care services rendered by physicians. Therefore, for purposes of the Shared Savings Program, the inclusion of practitioners described in section 1842(b)(18)©(i) of the Act, such as PAs and NPs in the statutory definition of the term ''ACO professional'' is a factor in determining the entities that are eligible for participation in the program (for example, ''ACO professionals in group practice arrangements'' in section 1899(b)(1)(A) of the Act). However, assignment of beneficiaries to ACOs is to be determined only on the basis of primary care services provided by ACO professionals who are physicians.

Did you catch that? Yes, that's right, while NPs are included as "ACO Professionals," if a Medicare patient utilizes a nurse practitioner as their provider, they are not eligible to participate in the ACO unless the beneficiary is assigned to a physician. If that seems non-sensical to you, that's because it is.

So what can NP practices do who want to participate in this money saving model of care (where half of the savings are reaped by the practice)? Unfortunately, the public comment period has closed on this issue. Right now, if an NP-owned practice wanted to participate in a similar type of shared savings model, they would have had to apply for a grant under the CMS Innovation Program and hope to get a similar award for what an ACO would bring. That deadline was due in January and the actual awards should be announced any day.

This is where NPs get shut out of the system. Yes, NPs may participate in an ACO, will improve care, reduce costs and duplication, but the only party benefitting is the physician or hospital-owned ACO. Doesn't seem fair, does it? We must let our representatives know how backwards this is.

[bsnanat2]

NP's and nurses in general are historically weak and politically naive. While I am not a political person myself, I do see the need and benefit of lobbyist and PAC's on professional issues. Until there is a more comprehensive true APRN organization nationally, this will continue to happen and get worse. The nursing regulations in most states are a hobbled together mess of multiple legislations. A strong central organization could create a standard (better than the consensus model) that could then be lobbied on the federal and state levels. PA's don't have near the problem with their practice as NP's do because they are strong and centrally organized. It is unbelievable to me that the only real organizations for NP's are the ones trying to sell us the tests. That is their business, not growing the profession. Yes, I know they are different but the point remains. If nurses were organized and had some political sense, by sheer numbers we could get whatever we wanted. The sad fact is that most nurses do not belong to any professional organization and the professional organizations that exist do a very poor job in representing nurses.

[shannonFNP, BSN, MSN, RN]

Agreed. I'm actually working on this issue for a course in my Politics class for my MSN-NP. Part of the assignment requires sending letters to legislatures. Unfortunately, I think it may be too late for my contribution, but we'll see what the response is. If it wasn't for apathy, we'd have several million nurses involved in political issues. That would clearly overwhelm the ballots. The AMA has been quite successful in politics, and our voice in numbers has the potential to be about 20 times larger than theirs. Not that it's Nursing vs. AMA; Just that there's no reason we can't be just as successful in policy change.

[TX RN]

I think this was decided when Patient Centered Medical Homes (PCMH) were defined as physician led only.

Legislation for ACO's had to follow what the "standard" was/is at the time, given that medical homes are at the heart of reigning in costs.

I see this as a glass half full issue. I think NP's will still benefit from the additional revenues that are generated from medical homes and implementation of ACO's. More spending at the primary care level will mean more opportunities for NP's.