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Angela K. Golden, RN, DNP, FNP-C, FAANP, treats a pregnant woman at her NP from Home practice in Munds Park, Ariz.
Angela K. Golden, RN, DNP, FNP-C, FAANP, treats a pregnant woman at her NP from Home practice in Munds Park, Ariz.
(Mark Henle/The Arizona Republic)

Answering the call

Healthcare reform will make life busier for some NPs

Monday January 13, 2014
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Much of the focus in healthcare reform has been on getting people insured. But as a mandatory insurance requirement goes into effect this year and Medicaid is expanded in some states, the next step is making sure people actually get care. That’s where nurse practitioners come in.

Recent reports suggest nurse practitioners can help meet the primary care needs of patients in rural, urban and suburban areas, particularly in light of a projected physician shortage. But barriers remain in the form of state, federal and private payer regulations that restrict APRN practice or reimbursement.

“The needs of patients will continue to be the same,” said Taynin Kopanos, RN, DNP, NP, vice president for health policy and state government affairs for the American Association of Nurse Practitioners. “And nurse practitioners are prepared to be providers of primary care. The biggest variable will be state laws.”

Nurse practitioners traditionally have cared for large numbers of uninsured and underinsured patients in rural and urban areas. How health insurance reform will affect those NPs depends largely on the laws in states where they practice, Kopanos said. In states that allow NPs to practice without physician supervision and that are expanding Medicaid, NPs are poised to help absorb an expected increase in demand for healthcare services, she said.

Nurse-managed health centers in states that are expanding Medicaid to those at 133% of the federal poverty level anticipate caring for more patients as the previously uninsured sign up for Medicaid and subsidized insurance programs that include these centers as providers, said Tine Hansen-Turton, MGA, JD, FCPP, FAAN, CEO of the National Nursing Centers Consortium in Philadelphia. States with health insurance exchanges that include NPs also will allow patients to have an NP as their primary care provider, Kopanos said.

However, in states with more restrictive practice laws or with exchanges that do not include them, nurse practitioners might not be in position to alleviate the anticipated increase in demand for primary care providers and ease a projected physician shortage, Kopanos said.

In states that have chosen not to expand Medicaid, nurse-managed centers may not see the increased numbers of insured patients they were expecting. In states with expanded Medicaid but with more restrictive practice laws, physicians who hire NPs may choose not to take on new Medicaid patients and the NPs they collaborate with would not be able to see those patients, Kopanos said.

We asked NPs in different parts of the country how they were preparing for the insurance mandate and other aspects of healthcare reform. This is what they told us.

Watching and waiting

Deborah C. Varnam, RN, MSN, FNP-BC, FAANP
CEO, Varnam Family Wellness Center, Shallotte, N.C.

In Shallotte, N.C., a rural coastal community of about 2,000, some people pay for part of their healthcare with eggs or shrimp. Many do not have health insurance and come to Varnam’s health center only when something is seriously wrong.

She has seen first-time patients with metastasized cancer, and others with worsening chronic conditions who went for months without medication that would help them because they couldn’t afford it.

“We’re seeing patients wait and wait because they don’t have the money to come in,” she said.

Varnam and another nurse practitioner see about 3,000 patients, newborn through geriatric, from Shallotte and surrounding areas. Although Varnam hopes the new law will help some of her patients get some sort of insurance, most tell her they can afford only high-deductible or catastrophic plans, and many say even the cheapest options still are too expensive. Some patients with private insurance have told her their plans are being replaced with options they cannot afford. She said she could end up seeing more rather than fewer uninsured patients.

Varnam is trying to steer those who are eligible to sign up for subsidized plans through the new health insurance exchanges. But suspicion of the Affordable Care Act runs high in her area, she said. Many people are angry about feeling forced to buy insurance, are philosophically opposed to taking government assistance and are very confused. North Carolina is not expanding Medicaid at this time so those who would have qualified for Medicaid will have no help buying insurance. She has heard people say they will pay the tax penalty and remain uninsured.

Varnam said she has no plans to expand her practice or hire new people. She is adding wellness classes, but is not sure whether she will have participants pay for those through insurance or a small out-of-pocket fee. She also is concerned about what could happen if the physician with whom she collaborates sells his practice or retires. Like all NPs in North Carolina and other states with restrictive practice laws, she cannot see patients without a physician collaborator.

She is going over her fee schedules and making sure she is charging her patients a fair price for their care, she said, maintaining the delicate balance between helping her community and paying her staff and making a living. She is waiting and watching to see what health reform will bring to her community and practice.

“In January, everyone is not going to have healthcare,” she said. “There’s still going to be a disparity between the haves and the have-nots. And I’m seeing a lot more have-nots than I used to.”


Golden tends to a patient at her NP from Home practice.
(Mark Henle/The Arizona Republic)
Emphasis on prevention

Angela K. Golden, RN, DNP, FNP-C, FAANP
President of the American Association of Nurse Practitioners; family nurse practitioner, North County HealthCare, Flagstaff, Ariz.; owner, NP from Home, Munds Park, Ariz.

Golden has two practices. One is at a community health center in Flagstaff, where she sees mostly families and adults under 65 in an integrated setting that includes dental and behavioral health and physical therapy. The other is a private practice out of her home in Munds Park, about 30 minutes outside of Flagstaff.

She visits people of all ages in a rural community of about 2,500 year-round residents, seeing them on weekends and evenings, in their homes or in a room at the local fire station, whichever is most convenient for them. Many patients in both practices did not have insurance in 2013. About 30% of her clinic patients and 10% of her home-visit patients did not have insurance in 2013, she said.

As more people get insured, Golden looks forward to implementing more wellness and prevention services in both practices.

Arizona is expanding Medicaid under the ACA, and most of Golden’s patients are receptive to getting either public or private insurance under the new law, she said. “I talk to them a lot about what the advantages are of having it both for themselves and their kids.”

She said that even catastrophic and large-deductible plans pay the entire cost of many preventive services, including well-child visits, vaccinations, mammograms and blood pressure screenings. These are services many uninsured and underinsured people have forgone because they couldn’t afford them.

In Arizona, one of the biggest changes will be that low-income single adults can get health coverage through expanded Medicaid, she said. In more affluent areas, she expects more people will get private insurance through the subsidized exchanges. Colleagues in urban areas have told her they are gearing up for an increase in newly insured people seeking care. But because she already sees the uninsured population, both in her home practice and the community clinic, Golden doesn’t expect to see many new patients.

The change, she hopes, is she will see people earlier for preventive care and be more likely to diagnose and treat conditions such as hypertension or diabetes when they still can be managed with lifestyle changes and antihypertensive medication.

Golden is working with the Munds Park fire chief on a project to create a model community wellness program at the local fire station — “our town hall,” she said. They are looking at getting a grant through the ACA to fund the program, and possibly recruiting paramedics, retired nurses and other community members to teach classes that could include diabetes education and modified exercise sessions for people with COPD. Along with hypertension, those are the most common conditions in the community, Golden said.

“My hope is that eventually we’ll see some decrease in chronic conditions, or at least delays in their impact,” she said. “I think that’s one of the pieces of the law that has the ability to benefit every patient.”

Disappointed with Medicaid policy

Donna L. Torrisi, RN, MSN
Network executive director, Family Practice & Counseling Network, Philadelphia

Torrisi’s nurse-managed health center, based in Philadelphia, has been cited as a model for the nation by the U.S. Department of Health and Human Services. Family Practice & Counseling Network serves 19,000 patients at six clinics, three of which offer mental health and dental services in addition to primary care. Another is in a retail clinic. The practice emphasizes wellness, education and management of chronic conditions, and many patients come from underserved urban neighborhoods.

Nurse-run health centers have been touted by some health policy analysts as one of the best ways to provide cost-effective, quality care to people who desperately need it. But because they largely serve uninsured and underinsured patients, many are not fully compensated for the care they provide and struggle to survive. FPCN receives some federal funds to serve public housing residents through a grant that must be renewed every five years.

About 25% of FPCN’s patients are uninsured, 55% are on Medicaid and the rest have private insurance or Medicare. The health centers charge on a sliding scale for visits, but no one is turned away.

When the ACA passed in 2010, Torrisi believed the centers finally would have a way to be sustainable without depending on grants. Theoretically all patients would have either public or private insurance to pay for care and more people would be seeking care. “What more could we want?” she thought. The center renovated two clinics to add more space and hired new staff.

But after the Supreme Court ruled states could opt out of Medicaid expansion, Pennsylvania declined to expand its program and an expected increase in reimbursement from Medicaid did not occur. Torrisi estimates 5% of her uninsured patients might get health insurance through the state exchange. The rest can’t afford the cheapest plans, even with subsidies, or ironically are too poor to qualify for subsidies (due to language in the ACA that limits subsidy eligibility to those with incomes between 100% and 400% of the federal poverty level. When the law was written, before expanding Medicaid became optional for states, the thinking was that everyone with income lower than 100% of federal poverty would qualify for Medicaid.)

Because one FPCN is affiliated with a “third-tier” hospital, insurance premiums for an exchange plan that includes it are more expensive.

“We’re suffering financially right now,” said Torrisi, who has had to cut three positions. “Things are very unsure. It’s really disappointing.”

Pennsylvania could expand Medicaid eventually, she said, giving those making less than 100% of federal poverty access to health insurance. If Medicaid visits increased by even 5% or 6% “we’d be in much better shape.” She and others are pressuring state lawmakers — holding demonstrations, meeting with legislators — but she doesn’t expect the situation to change under the current governor.

In the meantime, clinic staffers are working as fast as they can to get people signed up for whatever health insurance they can afford. “We’ll go on, but whether we go on in the same manner as we currently are, I don’t know,” Torrisi said. “You can’t sustain a deficit forever.”

'Eager to step up'

Ashley Guiliani, RN, BSN
DNP candidate in the family nurse practitioner program at the University of Kentucky College of Nursing, Lexington

As an ICU nurse, Guiliani has seen too many patients with complications from chronic conditions who might have stayed out of the hospital with good preventive care and disease management. The experience has strengthened her resolve to go into primary care. “I like being able to follow through with my patients,” said Guiliani, who will graduate in May and begin looking for work as a nurse practitioner. As a new NP, she’s willing to work with any patient population in almost any setting.

But she is not interested in setting up an independent practice in the foreseeable future. “I don’t know that I want the responsibility of independent practice,” she said. Too many variables, including a Kentucky law that requires physicians to sign off on NP prescriptions, make independent practice a risky career venture, she said. She has heard stories about independent nurse practitioners who find themselves in a bind if their state requires physician oversight and a collaborating physician sells a practice or retires. She is also concerned a small independent practice may not have the resources to compete with larger groups.

Since she doesn’t want to leave the Kentucky, Guiliani is looking for a more stable situation. She hasn’t ruled out working for an established NP-run practice, but would prefer a salaried job at a medical group or large health corporation, which would give her job security, benefits and a set collaborative agreement for prescribing.

She also would like to work with other NPs who can serve as mentors and offer support, especially during her first years of practice. She looks forward to demonstrating how NPs can be productive primary care providers, especially as Kentucky expands its Medicaid program and newly insured patients are expected to seek care.

“I think there will be a need for primary care providers and Kentucky is going to be looking to nurse practitioners to fill that void,” she said. “I think nurse practitioners are eager to step up.”


Cathryn Domrose is a staff writer. Send comments to editor@nurse.com or post comments below.
CNMs, CRNAs might not see major changes immediately

Unlike nurse practitioners, who as gatekeepers of care see large numbers of uninsured patients, certified registered nurse anesthetists and certified nurse midwives probably will not see an immediate impact from the Affordable Care Act’s mandatory insurance requirement and state Medicaid expansion, according to representatives of their professional associations.

“We expect some changes that will vary by location, but those are guesses,” said Frank Purcell, senior director of federal government affairs for the American Association of Nurse Anesthetists.

Since nurse anesthetists generally work as part of a facility, any increase or change in their patient workload will depend on what happens within the facility. That probably will take some time to register, Purcell said.

Because pregnant women have been covered by Medicaid for years, it is unlikely state Medicaid expansion to those at 133% of the federal poverty level will affect nurse midwives’ practice significantly, said Jesse S. Bushman, director of advocacy and government affairs for the American College of Nurse-Midwives. Women newly covered by private insurance might be more likely to decide to have children, he said, but that probably will not result in any immediate change.

Possibly the ACA’s greatest impact for nurse anesthetists this year will come from a provision prohibiting insurers from discriminating against non-physician licensed healthcare providers, Purcell said. That provision might result in more demand for CRNAs and other APRNs, depending on the state laws where they practice, he said.