How will Health care reform affect me as nurse practitioner?

monicanurse · Mar 24, 2010

I would hate to think Im spending all this money on NP school to be making what Im making now as an RN in the near future. Yet, I did not get into NP school for the money but more for the role it allows me to play. I guess in a weird way, it might attract people that truly are doing it for the right reasons instead of just money. Food for thought? ( this is assuming the overall reimbursement for services will go down and salaries will decrease as well)

mammac5 · Mar 24, 2010

The donut hole is a joke -- no matter who created it or allowed it to happen. My mother (a part-time RN) is on Medicare now and my father (also on Medicare) has a secondary plan available to them that would cover lots of their meds...but not that darned donut hole! Since Mom is on Humira injections, she was advised by Humira reps NOT to take the secondary. Turns out if she doesn't have that coverage whatsoever, the drug manufacturer will put her on their patient assistance program.

There's so much nuttiness in the who system, I don't know where they're going to start unraveling the whole mess!

Trauma Columnist · Mar 26, 2010

As I've said before, I work nephrology with ESRD and our numbers of pts are increasing. We took a 21% CUT in reimbursement this year. Our pts have the doughnut hole that they must all live with.

All I foresee is my wages will stagnate while my personal expenses continue to expand. Second job here I come!

Jstand · Mar 28, 2010

Unless the medicare fix gets passed anytime soon, expect salaries for all health care workers to decrease.
Even then, the bill is unsustainable, despite what congress says. Eventually they will cave and drop reimbursement because of political pressure. In this bill they have made no important steps to curb costs and have created things that will actually increase costs for the federal gov't.

From what I understand, the medicare fix is not going to be passed. Providers are budgeting for it to lapse in October as currently scheduled. It is also my understanding that this would be a cut of up to 21%. What that sounds like to me is that if you reimburse at 80% of current costs, you are approximately at the current reimbursment rate for nurse practitioners. If they are allowed to practice independently at those rates, you have a very sustainable position. This would also allow nurse practitioners to increase their incomes when practicing independently. That is a VERY important step towards curbing costs. Furthermore, most providers who have a more largely commercial payor mix are expecting to see their reimbursment rates drop as a result of this bill because commercial insurers are going to negotiate lower rates. Yet another important step in cost controls. What that means for providers is that they have to lower their cost structures. Probably less advertising and some cheaper space along with lowering administrative burden will be the best way to do this. When pressure from the lower reimbursment rates comes, it will require them to look very closely at discretionary spending. This is something that providers have not done in the past at all. Welcome to the competitive market and the future of healthcare

Jstand · Mar 28, 2010

While I completely agree that we will need many more NPs in primary care (as well as doctors, RNs etc), I fail to see how this bill does anything to shift the paradigm from a "sick" approach to a "prevention approach." It made literally no new steps in this direction, it just gave 30 million more access.
In terms of salary increases, I doubt it. As it stands now the medical model is not lead by market forces, but rather by the whims of the politicians as they set medicare rates (and insurance follows suit). As NPs get more independence, they too will feel the yolk of the gov't and the control of their salaries.
Don't believe me? Well, there is a tremendous demand for primary care physicians yet their salaries continue to plummet despite working longer hours and having more hastles to deal with along the way. Expect the same trend to continue for them and also for NPs.

What you are failing to see is that there will be market forces at work as this plan gets implemented. There is a requirement to obtain coverage and what I believe we are going to see is young people opting for a high deductible plan with an HSA because it is far cheaper than buying a traditional plan. Once people get an HSA that allows them to keep the money that they don't spend, they definitely become smarter consumers. They no longer want expensive brand name drugs if a cheaper generic will work. They also see how much some of these drugs cost and they will begin to demand cheaper alternatives. When a large number of consumers start to demand something, the market usually complies and offers it to them. The same will be true with primary care services. What you fail to see is that there is room to increase the salary of a nurse practitioner who practices independently and still offer the services for much cheaper than they are currently offerred. You frame your entire argument in the backdrop of the current system. Things aren't going to be the same as they always have been.

There also is a broad wellness program provision in the new bill. It may largely depend on how this is implemented as to wether there is a difference in approach, but the point is, there is an opportunity for it to happen.

cruisin_woodward · Mar 28, 2010

I only hear about it positively affecting PRIMARY CARE. What about acute care positions etc. I am worried my job will be in jeopardy. Isn't it cheaper to use a resident then an ACNP?

prairienp · Mar 28, 2010

I only hear about it positively affecting PRIMARY CARE. What about acute care positions etc. I am worried my job will be in jeopardy. Isn't it cheaper to use a resident then an ACNP?

Depends on whose perspective. The hospital has found the residents less costly, as our tax dollars covers the expense (salary/+ expenses). Now if our tax dollars are not used for resident salaries you may find acute care NPs very marketable.

Jstand · Mar 28, 2010

I only hear about it positively affecting PRIMARY CARE. What about acute care positions etc. I am worried my job will be in jeopardy. Isn't it cheaper to use a resident then an ACNP?

I have often thought that a DNP is much better of being a generalist than specializing. I know that there are lots of NPs that do specialize but it seems to me that it is a field that lends itself better to primary care fields and that you are much more marketable if you do not specialize.

core0 · Mar 28, 2010

I only hear about it positively affecting PRIMARY CARE. What about acute care positions etc. I am worried my job will be in jeopardy. Isn't it cheaper to use a resident then an ACNP?

Whether a resident is cheaper depends completely on the payor mix. Residents are paid and have additional money that comes with the resident. The money for the salaries is called DME (direct medical education money) and IME (indirect medical education) money pays for the costs of the residency. Above and beyond the cost of the resident is the cost of running the program (time away from the bedside for adminstrativa by the physicians) the secretaries office space etc. Also included is the fact that the practice is less efficient with residents. In exchange for this, the physicians cannot charge for the work done by the residents (but can charge for work done by the physicians).

Where this matters is when there is a high level of un/underinsured. If you are not getting any reimbursement then it is cheaper to use residents since there is no reimbursement either way. The closer that the reimbursement gets to costs then the more sense it makes to use NPPs. For example I'll use surgery. A colectomy by Medicare would reimburse around $2000 for the surgery and care for the next 90 days. In a resident setting thats all the practice gets. The surgeon is then responsible for supervising the resident care after this. Also it will take longer to do the colectomy so the surgeon could only do 3 per day instead of four for example. On the other hand residents can be forced to work longer (up to 80 hours) but they have non work related distraction such as training.

In a private practice setting in addition to the surgeons fee, the practice could collect a first assist fee if the PA (or appropriately trained NP) assisted. This is 14.5% of the surgeons fee for medicare for example. In the case above it adds an additional $290 per case. In addition since the PA or NP can act with relatively more autonomy (depending on the training vs. the current level of training of the resident) the physician can be doing other thing such as new patient consults while the PA or NP is rounding on the patient or seeing the patient in followup. Over time this adds up.

The short answer is that for most private practices with a decent payor mix it will be more cost effective to use an experienced NP or PA. With most community safety net settings it will be more cost effective to use residents. The question with health care reform is will the insurance resemble Medicaid (ie horrible reimbursements) or private payors.

The other thing to remember is that the number of residents is fixed in the US. Its not like a hospital can choose to hire more residents than it has. If a hospital wants to add residents to say surgery it has to take them from somewhere else such as family practice (and get approval to move the slots).

There has been a move to more concentrated practices and 24/7 coverage. With an increase in the number of insured there will be an increased use of hospital services. Given the fixed number of specialists, the number that exist will have to be more efficient. One way to do that is to use NPPs. This assumes of course that increased primary care does not decrease overall disease burden. The cynic in me thinks this unlikely at least in the short term.

David Carpenter, PA-C

Wildschmidt · Mar 30, 2010

There's a good summary of the bill on the AANP website: http://www.aanp.org/NR/rdonlyres/D0BC1356-E320-420E-B9C2-D98E266DF280/3898/finalhcrsummary.pdf It's still long and complicated, but only 13 pages instead of 2000!

As an FNP student, I'm hopeful about this bill, since it does seem like much of the money is targeted to primary care and underserved places. Some highlights that I picked out:

More loan repayment program, via states, national and service corps

Medicaid rates get bumped up to Medicare rates for primary care

Increase in Medicare federal funding for primary care

Health plans have to spend at least 85% of their $ on health care costs

There's other provisions that we'll have to wait and see how they play out, such as the comparative effectiveness research that might control costs. They're also starting a pilot program reimbursing for Medicare "episodes" of service rather than each procedure. And yes, there's definitely some benefits for insurance corps and pharmaceuticals (like extended time before generic meds can be introduced.)

Overall, I think the biggest difference will be that many more patients will have coverage, and the coverage will be more similar across the board. This should eliminate some of the confusion and incentives that exist now. (Like patients without coverage going for a "free" ER visit that they'll never pay for instead of preventive services.) This is all focused towards primary care so I don't know what the impact will be for the ACNPs out there.

It's not perfect, and it will definitely change incentives, but it seems better than the s$#%show we have now!