Healthcare: the Funding Practice Issues

Introduction

Nurse-managed centers (NMCs) have developed to form an important part of the healthcare system in the United States. Implementation of vital health policies has facilitated the transformation of community nursing into an independent healthcare profession that provides quality and cost-effective healthcare to underserved and underprivileged communities (Bruner, Davey, & Waite, 2011). The nurse-managed centers’ staffs are mainly from nursing schools’ faculties.

NMCs are currently funded through contracts for 5 year periods to provide support while other sources of funding are being developed alongside the establishment of third-party reimbursements (Buerhaus, 2010). Most NMC efforts have concentrated on the provision of standardized healthcare, sound financial management practices, and productive student-patient engagement practices. This paper seeks to point out the funding practice issues affecting NMCS; present an evidence-based argument to refute the issues and recommend policies that can be used to address the issues.

Issues

NMC’s are predominantly nonprofit and they offer healthcare services to patients who are not likely to receive care from mainstream healthcare providers. This population is often composed of individuals “from all ages who are not insured, the underinsured, or those living in poverty” (Codington & Sands, 2008, p. 1). People who cannot pay for their health needs are sometimes charged less or treated for free (Ebner, 2010). Due to the nature of their clients, most NMCs have continued to struggle financially. NMC’s located in poor communities “get their funds from Medicare and Medicaid reimbursements, government contracts and grants and private grants” (Turton, Nagle, & Torres, 2010, p. 55).

Some NMCs get monetary support from their parent organizations. Federal funding to NMC is limited because they are affiliated with nursing schools/institutions. Section “330 of the Public Health Service Act facilitates the provision of financial benefits to health facilities that are designated as federally qualified health centers” (FQHCs)- public or private nonprofit practices located in medically underserved communities or those that offer health services to vulnerable communities (Turton, Nagle, & Torres, 2010, p. 5). The financial benefits include the provision of higher Medicaid and Medicare reimbursements and malpractice insurance coverage (Schram, 2010).

NMCs meet most of the FQHCs’ criteria but they fail to fulfill the demand of being governed by a board that consists of at least 51% of the patients attending the center. The NMCs are operated by the board of their affiliated nursing schools and this disqualifies them from FQHC status. Thus, many NMCs are not able to receive financial support from the federal government and this puts a big burden on third-party reimbursements that are expected to cover much of the cost (Vonderheid, Pohl, Tanner, Newland, & Gans, 2009).

It’s important to note that most of the patients seeking health services from NMC are not insured. In addition, most managed care insurers also don’t reimburse centers where Nurse practitioners (NPs) acts as providers of primary care (Schram, 2010). The “federal government has formulated laws to prohibit Medicaid and Medicare managed insurers from discriminating NPs acting as primary care providers but the laws are not fully enforced” (Schram, 2010,p. 4). Another obstacle facing NMCs is the lack of a proper framework that can enable them to be recognized as medical homes. Medical homes provide a team-based approach that enables patients to depend on their primary care provider to coordinate all their care activities. The “medical home model enhances patient satisfaction outcomes, particularly for patients with chronic illnesses” (Schram, 2010, p. 4).

As much as the NP practices such as the NMCs are well suited for recognition as medical homes, the various physician groups have limited the sole provider status in medical homes to physicians only (Turton, Nagle, & Torres, 2010). Additionally, the National Committee for Quality Assurance (NCQA) fails to recognize NMC as medical home because it requires a medical home to be led by physicians (Schram, 2010). The “recognition of NMCs as medical homes is very important to ensure improved reimbursement and funding that is usually available for other primary care providers” (Turton, Nagle, & Torres, 2010, p. 4).

Personal position

NMCs role in the provision of primary healthcare in the United States is indisputable. It’s ironic that a model that ensures the provision of cost-effective quality healthcare is denied financial privileges through baseless arguments. The NMCs must be given the FQHC status even though they are overseen by boards of parent institutions. It’s also important that NPs are recognized as primary care providers by both physician bodies and the National Committee for Quality Assurance (NCQA) to enable the NMCs to acquire the status of the medical home. If this is done then the NMCs will be able to access more funding from managed care insurers and the federal government.

Arguments

The United States is suffering from a shortage of primary care physicians. The shortage is projected to hit between 35,000 and 44,000 by 2025 (Turton, Nagle, & Torres, 2010). On the other hand, the NP-managed centers have come up to play a critical role in the provision of quality primary healthcare to many Americans. The NMCs have earned a reputation for providing high-quality healthcare at affordable rates and are achieving high patient satisfaction rates (Schram, 2010). “Several decades of regulatory reform have enabled NPs to achieve prescribing privileges in all 50 states, making their scope of practice to be comparable to those of primary care physicians” (Buerhaus, 2010, p. 4).

Current statistics indicate that the nurse-managed centers “provide care to more than 2.5 million patients annually and have the capacity to care for more” (Bruner, Davey, & Waite, 2011, p. 2). The “NMC model of care emphasizes wellness promotion, prevention of diseases, and the management of chronic conditions such as asthma hypertension, and diabetes” (Schram, 2010, p.5). Some “provide dental, mental and behavioral health; reduction of environmental health risks; and general health education” (Schram, 2010,p. 4). The NMC’s provide care at a much-reduced cost compared to other healthcare models. A study carried out in Minnesota established that NMC’s saved between $50 and $55 per visit in comparison to other healthcare settings (Turton, Nagle, & Torres, 2010).

Policy recommendations

The federal government has formulated laws to ensure that health centers where NPs act as primary care providers are not discriminated against Medicaid and Medicare-managed insurers (Turton, Nagle, & Torres, 2010). These laws are however not fully enforced and thus NMCs continue to feel the effects of the discrimination. A policy should be formulated to ensure that the laws are followed to the latter. Secondly, another policy should be formulated to compel physician groups and the NCQA to recognize NPs as primary care providers. Implementation of such policies will enable the NMCs to access more funding, and acquire the much-needed medical home status for improved patient service, and satisfaction outcomes.

References

Bruner, P., Davey, M., & Waite, R. (2011). Culturally Sensitive Collaborative Care Models: Exploration of a Community-Based Health Center. Families, Systems, & Health , 29(3): 155-170.

Buerhaus, P. (2010). Have Nurse Practitioners Reached a Tipping Point? Interview of a Panel of NP Thought Leaders. Nursing Economics , 28(5): 346-349.

Codington, J., & Sands, L. (2008). Cost of Health Care and Quality Outcomes of Patients at Nurse-Managed Clinics. Nursing Economics , 28(2):74-83.

Ebner, A. (2010). What Nurses Need to Know about Health Care Reform. Nursing Economics , 28(3):191-194.

Schram, A. (2010). Medical home and the nurse practitioner: a policy analysis. J Nurse Pract , 6(2):132-139.

Turton, T., Nagle, D., & Torres, N. (2010). Policy & Politics: Nurse-Managed Health Centers, Key to a healthy future. AJN , 110(9):23-25.

Vonderheid, S., Pohl, J., Tanner, C., Newland, J., & Gans, D. (2009). CPT Coding Patterns at Nurse-Managed Health Centers: Data from a National Survey. Nursing Economics , 27(4):211-219.