As part of the national healthcare reform mandate, accountable care organizations are slated to roll out next year. And though the proposed rules have yet to be finalized, nurses are trying to understand, and assert, their roles within these new entities.
ACOs in principle appear straightforward — better coordination and communication of care across all disciplines will result in reduced cost and improved clinical outcomes, and cost savings will be shared with providers via increased Medicare reimbursement. If providers fail to meet performance standards, they will be penalized. What is not straightforward is exactly how nurses will fit into these organizations.
Although some nursing experts appear to embrace the general tenants of the proposed ACO rules, some are less enthused and issues remain unresolved.
Case management and care coordination concerns
“The focus is that we support the goals of nursing integration into ACOs, but the language specific to care coordination is a concern. We feel that it has neglected to recognize the contribution of nursing,” said Lisa Summers, CNM, DrPH, senior policy fellow, department of nursing practice and policy, American Nurses Association.
“Care coordination is a building block on which much of the ACO quality improvement and cost control provisions are built. And care coordination is a core competency for the nursing profession; it is what nurses do. Yet the proposed rule largely disregards the contributions of professional nursing in both clinical services and patient management, and as a result, loses the opportunity for real cost savings,” Summer said.
Another professional organization that includes nurses has a different take on the issue of care coordination: “We strongly support the emphasis placed by [Centers for Medicare and Medicaid Services] in the proposed rule on the importance of improving care coordination for Medicare beneficiaries,” said Patrice V. Sminkey, RN, chief staff executive, Commission for Case Manager Certification. “Our position is that a board-certified case manager is uniquely positioned to improve care coordination performed in an ACO by implementing plans of care.”
The difference in positions is that not all certified case managers are nurses; they can include many healthcare professionals that “practice independently,” such as social workers. The difference hinges on the emphasis of RNs’ role in care coordination.
The ANA’s position is: “The care coordinator should be a health professional from any of several different disciplines for most patients; however, for many, a registered nurse is often the best care coordinator.”
Nurse practitioners not pleased
Another concern is the role nurse practitioners may play in ACOs. Susan Apold, NP, PhD, director for health policy at the American College of Nurse Practitioners, said, “As it is currently written, nurse practitioners are not recognized as fully authorized primary care providers. Given this, I am not sure where nurse practitioners will stand. It may be that patients within an ACO must see a physician first, even if they previously had been seen by a nurse practitioner for primary care.”
Dave Mason, a lobbyist and healthcare consultant, echoed that concern. “ACOs may be more exclusionary of nurse practitioners and nurse practitioners who are not in an ACO may not be able to provide the care that they have historically. This devalues the nurse practitioner.”
Mason also is concerned about how “primary service areas,” that is, the ratio of primary care providers to patients in geographical regions where ACOs operate, are calculated. The fear is that NPs will not be included, which will give a skewed view of what the primary service area is really like.
“The rule’s interpretation arbitrarily restricts the assignment of beneficiaries to ACOs, particularly in geographic areas where there is a shortage of primary care physicians, and it effectively bars nurse practitioners from forming their own ACOs,” Mason said.
Apold said the language, as written, will confuse patients and hinder their access to quality primary care. “We need to shift the discussion from a physician-centric perspective to a patient-centric and interdisciplinary perspective,” she said. “We don’t want the public to think they can only use physicians as primary care providers.”
Cost of communication
An additional issue that crops up when discussing ACOs and nursing is health information technology. As CMS notes that some of the most significant functions of ACOs will be in decreasing medical errors, increasing care coordination and interdisciplinary communication, it is clear HIT and electronic health records will play a large role. How will nurses fare with this change?
“It appears that nurse practitioners are positioned similarly to physician groups with respect to HIT: the amount of investment necessary is high, especially in the context of an ACO,” Mason said. “Unfortunately, it is another disincentive for providers to be part of an ACO.”
For RNs, Summers said, “Nursing care is fairly well reflected in EHRs. But, as EHR vendors and healthcare organizations look at the interoperability piece of EHRs, nursing care must be fully represented. It is not enough to have an EHR talk to another EHR — you need the human, that is nursing, interactions represented. A computer talking to a computer does not care coordination make.”
What is a nurse to do?
As the changes to healthcare delivery and payment wrought by ACOs are likely to affect all nurses, regardless of title or area of employment, what should nurses do to ensure they are fairly represented? “It may be hard for nurses to understand how real this is. It is absolutely critical that nurses weigh in on these changes,” Summers said.
Apold agreed. “Nurse practitioners need to keep abreast of these regulations. Frankly, they need to pay attention. The implications of not being at the table are significant.”
Both the ANA and the ACNP agree with Mason’s statement, “Nurses need to be actively engaged in the discussion via their national organizations.” He further said, “They also need to communicate with physicians in their practice areas to ensure that nurses’ perspective is recognized.”
As the final rule for ACOs is due out later this year, nurses still have time to engage in the discussion. Although it is not clear exactly how nurses will fit into ACOs, it is clear that their input is critical to ensure they are fairly represented in these new healthcare organizations.
Samuel S. Sprague, PT, is the owner of Liberation Medical, a medical services consultancy.
ACOs in principle appear straightforward — better coordination and communication of care across all disciplines will result in reduced cost and improved clinical outcomes, and cost savings will be shared with providers via increased Medicare reimbursement. If providers fail to meet performance standards, they will be penalized. What is not straightforward is exactly how nurses will fit into these organizations.
Although some nursing experts appear to embrace the general tenants of the proposed ACO rules, some are less enthused and issues remain unresolved.
Case management and care coordination concerns
“The focus is that we support the goals of nursing integration into ACOs, but the language specific to care coordination is a concern. We feel that it has neglected to recognize the contribution of nursing,” said Lisa Summers, CNM, DrPH, senior policy fellow, department of nursing practice and policy, American Nurses Association.
“Care coordination is a building block on which much of the ACO quality improvement and cost control provisions are built. And care coordination is a core competency for the nursing profession; it is what nurses do. Yet the proposed rule largely disregards the contributions of professional nursing in both clinical services and patient management, and as a result, loses the opportunity for real cost savings,” Summer said.
Another professional organization that includes nurses has a different take on the issue of care coordination: “We strongly support the emphasis placed by [Centers for Medicare and Medicaid Services] in the proposed rule on the importance of improving care coordination for Medicare beneficiaries,” said Patrice V. Sminkey, RN, chief staff executive, Commission for Case Manager Certification. “Our position is that a board-certified case manager is uniquely positioned to improve care coordination performed in an ACO by implementing plans of care.”
The difference in positions is that not all certified case managers are nurses; they can include many healthcare professionals that “practice independently,” such as social workers. The difference hinges on the emphasis of RNs’ role in care coordination.
The ANA’s position is: “The care coordinator should be a health professional from any of several different disciplines for most patients; however, for many, a registered nurse is often the best care coordinator.”
Nurse practitioners not pleased
Another concern is the role nurse practitioners may play in ACOs. Susan Apold, NP, PhD, director for health policy at the American College of Nurse Practitioners, said, “As it is currently written, nurse practitioners are not recognized as fully authorized primary care providers. Given this, I am not sure where nurse practitioners will stand. It may be that patients within an ACO must see a physician first, even if they previously had been seen by a nurse practitioner for primary care.”
Dave Mason, a lobbyist and healthcare consultant, echoed that concern. “ACOs may be more exclusionary of nurse practitioners and nurse practitioners who are not in an ACO may not be able to provide the care that they have historically. This devalues the nurse practitioner.”
Mason also is concerned about how “primary service areas,” that is, the ratio of primary care providers to patients in geographical regions where ACOs operate, are calculated. The fear is that NPs will not be included, which will give a skewed view of what the primary service area is really like.
“The rule’s interpretation arbitrarily restricts the assignment of beneficiaries to ACOs, particularly in geographic areas where there is a shortage of primary care physicians, and it effectively bars nurse practitioners from forming their own ACOs,” Mason said.
Apold said the language, as written, will confuse patients and hinder their access to quality primary care. “We need to shift the discussion from a physician-centric perspective to a patient-centric and interdisciplinary perspective,” she said. “We don’t want the public to think they can only use physicians as primary care providers.”
Cost of communication
An additional issue that crops up when discussing ACOs and nursing is health information technology. As CMS notes that some of the most significant functions of ACOs will be in decreasing medical errors, increasing care coordination and interdisciplinary communication, it is clear HIT and electronic health records will play a large role. How will nurses fare with this change?
“It appears that nurse practitioners are positioned similarly to physician groups with respect to HIT: the amount of investment necessary is high, especially in the context of an ACO,” Mason said. “Unfortunately, it is another disincentive for providers to be part of an ACO.”
For RNs, Summers said, “Nursing care is fairly well reflected in EHRs. But, as EHR vendors and healthcare organizations look at the interoperability piece of EHRs, nursing care must be fully represented. It is not enough to have an EHR talk to another EHR — you need the human, that is nursing, interactions represented. A computer talking to a computer does not care coordination make.”
What is a nurse to do?
As the changes to healthcare delivery and payment wrought by ACOs are likely to affect all nurses, regardless of title or area of employment, what should nurses do to ensure they are fairly represented? “It may be hard for nurses to understand how real this is. It is absolutely critical that nurses weigh in on these changes,” Summers said.
Apold agreed. “Nurse practitioners need to keep abreast of these regulations. Frankly, they need to pay attention. The implications of not being at the table are significant.”
Both the ANA and the ACNP agree with Mason’s statement, “Nurses need to be actively engaged in the discussion via their national organizations.” He further said, “They also need to communicate with physicians in their practice areas to ensure that nurses’ perspective is recognized.”
As the final rule for ACOs is due out later this year, nurses still have time to engage in the discussion. Although it is not clear exactly how nurses will fit into ACOs, it is clear that their input is critical to ensure they are fairly represented in these new healthcare organizations.
Samuel S. Sprague, PT, is the owner of Liberation Medical, a medical services consultancy.
Send comments to editor@nurse.com.
