The Renaissance of Primary Care: Primary Care Is Too Important

The health reform legislation has created some very real urgency around the current primary-care crisis in this country. By 2014, potentially 32 million more people will become insured, and insurers will be required to eliminate cost-sharing (no-copayments) for preventive health services. Creative “bundling” payments, in which delivery systems get paid a lump sum for an entire episode of care, will shift the risks for healthcare costs and all complications away from the payers and onto the delivery systems. As a strategy to incentivize systems to deliver higher-quality care and bend the healthcare inflationary curve, bundling payments dramatically shifts the current power relationships between payers and systems of care. It holds delivery systems financially accountable for the care they deliver; those delivery systems with fewer errors, complications, and re-hospitalizations are paid more. Nurse practitioners (NPs), whose role grew out of a national primary-care shortage in the 1960s, were originally defined by primary-care practice. Five decades later, modern NPs have adapted and are practicing in every imaginable sector of health care. There is widespread agreement that our nation’s primary-care infrastructure is crumbling and in great need of investment.

A number of health-reform provisions directly address primary care and impact NPs working in a primary-care capacity. In addition, three recent exciting visionary reports breathe new life and vitality into the subject of NPs and primary care and predict that the demand for NPs will likely surge in the future.

Health Reform Provisions
The following health reform provisions in the Affordable Care Act signed into law in March pertain to strengthening primary care. 

Expansion of the National Health Service Corps. In particular, eligibility is expanded from only family NPs (FNPs) to include NPs certified as adult care, geriatrics, pediatrics, psychiatry, and women’s health NPs. 

Grant programs.

Programs for scholarships and loans that promote primary-care clinicians, including 3-year grants to employ and provide training to FNPs who provide primary care in federally qualified health centers and nursemanaged health clinics

Grants for nurse-managed health centers operated by advanced-practice nurses (APNs) who deliver primary care to vulnerable populations

Grants to develop healthcare home teams

Graduate Nursing Education. This program appropriates $150 million to establish a graduate-nurse education demonstration program in Medicare. Up to five eligible hospitals will receive Medicare reimbursement for educational costs, clinical instruction costs, and other direct and indirect costs of an eligible hospital’s expenses attributable to the training of APNs with the skills necessary to provide primary and preventive care, transitional care, chronic-care management, and other nursing services appropriate for the Medicare-eligible population. The hospitals selected will partner with community-based care settings (eg, federally-qualified health centers and rural health clinics) and accredited schools of nursing to undertake the demonstration program. For the purposes of this demonstration, the term “advanced practice nurse” includes clinical nurse specialists, NPs, certified registered nurse anesthetists, and certified nurse-midwives. 

Accountable Care Organizations (ACOs). Beginning in 2012, this program will allow providers to organize as ACOs that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program. To qualify as an ACO, organizations must agree to be accountable for the overall care of their Medicare beneficiaries, to practice evidence-based medicine, to report on quality and costs, and to coordinate care.

Josiah Macy Foundation
The Josiah Macy Foundation is a private philanthropic organization with a mission to invest in the fundamental aspects of health, sickness, and methods to relieve suffering. Macy convened the nation’s thought leaders on the current primary care crisis to explore the complex issues around primary care in the United States.

The remarkably diverse panel developed bold recommendations to strengthen both the infrastructure and the quality and quantity of our primary-care workforce. The report derived from the panel’s work—“Who Will Provide Primary Care and How Will They be Trained?”—was cochaired by Linda Cronenwett, PhD, RN, FAAN, and Victor J. Dzau, MD.¹ The report stresses: 1) the urgency in developing a well-trained primary-care workforce that functions as a team, 2) the need to transform the educational and delivery systems currently in place, and 3) the fact that the nation has under-invested in primary care for a long time, a practice that must be reversed. They agreed that the public values having a provider with whom they maintain an ongoing relationship and who has comprehensive knowledge of them as individuals and of their health problem—a “whole-person” perspective. The following panel recommendations, which were selected as being the most pertinent to NPs, are bold and forcefully recommend that drastic measures be taken to build and improve the nation’s primary-care infrastructure. 

Recommendation 1. Create financial and other incentives for the development of innovative models of primary care and the advancement of knowledge about outcomes that allow us to identify best practices in the achievement of high value primary care.

Recommendation 2. Coupled with efforts to increase the number of physicians, NPs, and PAs in primary care, both state and national legal, regulatory, and reimbursement policies should be changed to remove barriers that make it difficult for NPs and PAs to serve as primary-care providers and leaders of patient-centered medical homes or other models of primary-care delivery. All primary-care providers should be held accountable for the quality and efficiency of care as measured by patient outcomes. 

Recommendation 3. Recognize the need to include representatives of all primary care providers in the leadership of delivery systems and in groups that are responsible for developing healthcare policies at the state and federal level. 

Recommendation 4. Recognizing that current payment systems create incentives for under-investing in primary-care services, implement payment reforms that more appropriately recognize the value contributed by primary care through such mechanisms as global payments linked to patient complexity and accountability for the provision of healthcare services, including preventive services, care coordination across settings, chronic disease management, and 24/7 accessibility. Improved costs and quality-of-health outcomes for patients and populations should be rewarded. In addition, implement legislation that will standardize reporting requirements for insurance reimbursement to reduce administrative costs inherent in a multipayer system.

NPs Featured Prominently in May 2010 Issue of Health Affairs
The final piece of exciting news in the primary-care arena is the May edition of Health Affairs on reinventing primary care. The issue is chock-full of innovative ideas on how the future of primary care could look. This is relevant to NPs since Health Affairs is read by a very wide audience, especially policymakers. Two of the articles are specifically about NPs. Our very own Charlene (Chuckie) Hanson coauthored “Unleashing nurse practitioners’ potential to deliver primary care and lead teams” with Joanne M. Pohl, Jamesetta A. Newland, and Linda Cronenwett.² This article beautifully describes how many of the state nurse-practice acts limit the ability of APNs to fully care for patients. In the context of a looming primary-care shortage, these irrational regulations limit access to care and add to its cost. Moreover, a case is made that although team-delivered care is by far the highest-quality care, some states have twisted the term collaboration into regulatory supervisory language, losing the spirit and meaning of true collaboration.

The authors recommend substantive changes in the way all primary-care providers are trained, educated, and held accountable for the care they deliver. The article stresses the importance of true collaboration among providers, patients, and communities and states that unless and until this happens, we are unlikely to see lowered costs and improved outcomes.

The second Health Affairs article that prominently features NPs is “The role of nurse practitioners in reinventing primary care,” by Mary D. Naylor and Ellen T. Kurtzman.³ These authors review the growing body of evidence demonstrating the importance of NPs to high-value primary care. The authors note that more effective use of the NP workforce could occur if unwarranted practice restrictions were removed, practice acts were standardized across all of the states, and NP performance results were publicly reported. They conclude that NPs must be held more directly accountable for the care they provide and that Medicare’s graduate medical education program should be redirected to NPs in primary care. They state clearly that the potential of the NP workforce has been largely overlooked as a solution to the growing chronic illness epidemic in our nation and the subsequent surge in demand for high-value primary care.

Changing the Infrastructure

A compelling case has been made for reinvesting in and rebuilding a robust primary care workforce and delivery system and instituting payment reform. We can look to other nations to see how wobbly our primary-care infrastructure is. They build their primary-care infrastructure first. Then, as they gain more resources, they move to secondary and tertiary care systems that are built on a solid primary-care foundation. We, on the other hand, currently have a top-heavy system that is heavily invested in tertiary-care and a fragile and weak primary-care system. Despite the dire state of primary care in this country, there is a consensus emerging that NPs are integral to a reformed system and that primary care is too important to fail. Remembering our roots and firm grounding in primary care, NPs can influence this unstable, upside-down triangle and work toward building a firm primary-care base. Let’s turn this backwards pyramid upside down.  Let the renaissance begin. 

References

1. Cronenwett L, Dzau V. In: Culliton B, Russell S, editors. Who Will Provide Primary Care and How Will They Be Trained? Proceedings of a Conference Sponsored by the Josiah Macy, Jr. Foundation; 2010; Durham, N.C. Josiah Macy, Jr. Foundation; 2010. Available at www.josiahmacyfoundation.org
2. Pohl JM, Hanson C, Newland JA, Cronenwett L. Analysis & commentary. Unleashing nurse practitioners’ potential to deliver primary care and lead teams. Health Affairs (Millwood). 2010;29(5):900-905.
3. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Affairs (Millwood). 2010;29(5):893-899.