Healthcare Finance: A Huge Barrier for Independent Nurse Practitioners in Outpatient Primary Care
The green states allow nurse practitioners to practice independently. You can now add New York to the list. One of the most powerful steps our American system could take to improve health and lower healthcare costs would be to foster development of chronic cardiometabolic condition clinics in these green states. There is a huge barrier to making this a reality that benefits all Americans—The current system of healthcare financing.
Optimal medical therapy (OMT) for patients with diabetes and heart artery takes time. It takes time to establish trusting relationships with patients and to help them understand their illness and how THEY can manage it. It takes time to review their many medications, lifestyle changes, labs, and measurements. Our current fee-for-service system does not pay primary care for time and success, it pays for office visit documentation. The primary care providers who make the most money under the current payment model race from room to room documenting the fact that they were face-to-face with the patient—hamster wheel medicine. There is no way to improve chronic condition management with brief visits like this.
Even in this system, primary care providers have very high overhead-around 60% or even higher. In large hospital systems, expensive procedures, admissions, specialty visits, emergency room visits, CT scans, MRIs, and other tests mitigate the impact of high primary care overhead. But here is the rub. Even though large hospital systems have this massive financial advantage, they get paid more per visit by Medicare and other payers. “… because hospital outpatient departments (HOPDs) often get paid at higher rates for the same service compared to physician offices, hospitals will buy up physician practices and then make money by receiving those higher rates….How much more money do HOPDs get compared with physician offices? In one example -- a Level 2 nerve injection -- if it is performed in a freestanding physician office, the doctor will be paid $256.28 under Medicare's Physician Fee Schedule (PFS), but if it is performed in an HOPD, which is paid under the Outpatient Prospective Payment System (OPPS), Medicare will pay $701.16” As a consequence, independent outpatient primary care practices are rare. Nurse practitioners have worked hard to achieve independence, but these financial barriers will dramatically limit the number who can set up their own practices in rural and underserved areas. Very few will be able to practice independently in these huge hospital systems.
The greatest opportunity to improve health and reduce costs lies in the outpatient independent primary care setting. While primary care has the biggest impact on improving health and reducing costs, these practices only generate 5% of American healthcare spending and that percentage is falling. Primary care providers direct 80% of care through their orders and referrals.
Heart disease is the number one killer of Americans. Primary care chronic cardiometabolic condition teams can reduce mortality by up to 90% while saving $21,900 per patient per year. We can make progress improving cardiovascular health and reducing costs right away. As it stands now, the payment model to support these teams exists only in accountable care organizations and Medicare Advantage plans. My colleagues and I would like to work with nurse practitioners and these organizations to bring the stakeholders together. All stakeholders should press hard for changing the payment model to support these teams in your state and community. Health will improve and overall costs will go down. whbester@gmail.com 423-782-0372