Nurse practitioners should be eligible to serve as “medical homes” for primary care
By Eileen Shannon Carlson, JD, RN
Congress is working to develop a comprehensive bill to address Medicare and Medicaid policies this year. Part of this bill will include a program to address coordination of care. This concept, called a “medical home,” has been the focus of lobbying efforts by nurse practitioners (NPs). What is this, and why is it such a priority?
Primary care providers (PCPs) who serve as “medical homes” receive additional payments for providing ongoing care and coordination of care, particularly for complex patients. The concept was developed in the 1960s by the American Academy of Pediatrics to increase coordination of health care for children with special needs.
Several states have enacted laws creating programs for children, and many are considering expanding them to adult patients. Terms such as “patient-centered home,” “health care home,” and “primary care home” have also been used. State rules vary on whether NPs can qualify.
Medical homes are designed to improve the quality of patient care, while reducing costs. With greater coordination of care, PCPs may prevent complications for their patients—particularly those with chronic conditions—and decrease the need for specialists. Yet primary care services are widely recognized to be both time-intensive and undervalued. This contributes to a widespread shortage of PCPs, particularly among physicians.
Many NPs provide primary care—particularly Family Nurse Practitioners, Adult Nurse Practitioners, and Pediatric Nurse Practitioners. Their nursing education and experience contribute to their holistic approach. NPs often excel in this role, as recognized by patients and other healthcare providers. As providers of high quality, safe, coordinated care, NPs meet the National Committee for Quality Assurance standards for a medical home. In rural and underserved areas, NPs may be the only PCPs available. Regrettably, “primary care” and “medical home” have sometimes been defined in terms of physicians only, at both the state and federal levels.
In the Medicare Improvement and Extension Act of 2006 (Public Law 109-432), Congress created the Medicare Medical Home Demonstration Project, the first federal program for medical homes. This law limits a medical home to a “board-certified physician,” thus excluding NPs and other healthcare providers. While the initial project is limited to three years and eight states, there is serious concern that its exclusion of NPs from eligibility as medical homes could become the standard for Medicare—and consequently the entire healthcare industry. Especially in areas of the country where the only PCPs available are NPs, this could be extremely damaging to patients.
Fortunately, the Medicare Payment Advisory Commission (MedPAC), which makes recommendations to Congress on Medicare policy, has recognized the valuable contribution that NPs make to primary care. As we reported in the March 31st, 2008, Capitol Update, an ANA online newsletter, MedPAC has explicitly recommended including NPs in both an expanded Medicare medical home project and fee adjustments for primary care. MedPAC’s proposal would allow NPs and other PCPs to serve as medical homes if they meet all of the following criteria:
• furnish primary care, including coordinated preventive care, health maintenance, and acute care
• use health information technology for active clinical decision support (including, but not limited to, electronic health records)
• conduct care management
• maintain 24-hour patient communication and rapid access
• keep up-to-date records of patients’ advance directives
• have a formal quality improvement program
• have a written understanding with patients, designating the provider as their medical home, and encouraging patients to inform the medical home of “relevant service use.”
All PCPs would also have to meet minimum quality improvement standards. MedPAC commissioner Jennie Chen Hansen, MSN, RN, would prefer calling these “healthcare homes,” and noted that NPs are not the only advanced practice registered nurses (APRNs) who provide primary care.
The ANA and other organizations representing APRNs have been working with members of the Senate Finance and House Ways and Means Committees to ensure that any legislation they develop on medical homes includes NPs. Collaboratively, nurses can work to ensure that patients have the broadest access to the best qualified providers.
To read the latest information on this issue, please go to www.capitolupdate.org or visit www.nursingworld.org.
Eileen Shannon Carlson is Associate Director of ANA’s Government Affairs.