The Patient Protection and Affordable Care Act, the health care reform legislation that was signed into law by President Obama in March, will expand health insurance coverage to 31 million uninsured Americans in 2014. This is indeed welcome news for the country, but we will face logistical difficulties in providing high-quality primary care services to newly insured citizens at a time when the nation's supply of primary care physicians is dwindling.
The shortage of primary care physicians who care for adults (in internal medicine and family medicine) is projected to reach 35,000 to 44,000 by 2025.1 The Centers for Disease Control and Prevention estimated in April that in 1999 to 2006, 45% of American adults had at least one diagnosed or undiagnosed chronic health condition associated with cardiovascular disease—hypertension, hypercholesterolemia, or type 2 diabetes2—and that number is virtually certain to increase, as will that population's ongoing health care needs.
But there's a solution to the looming gap in primary care services: nurse-managed health centers (NMHCs) staffed by advanced practice nurses.
NURSE-MANAGED HEALTH CENTERS WORK
The nation's 250 NMHCs record more than 2.5 million patient encounters annually and have the capacity to serve millions more.3 They are located throughout the country, primarily in places that are medically underserved, such as low-income urban neighborhoods and rural areas.
A National Nursing Centers Consortium (NNCC) study of 11 NMHCs in Pennsylvania found that these centers are of critical importance as safety net providers of care for the medically underserved.4 Safety net providers, as defined by the Institute of Medicine, are providers who by legal mandate or explicit mission care for patients regard less of their ability to pay and who serve a patient pool with a substantial proportion of vulnerable patients, including the uninsured and Medicaid recipients.5 In the communities where NMHCs have been established, they have a reputation for providing high-quality, cost-effective care and achieving high patient satisfaction rates.4
The NMHC model of care emphasizes wellness promotion, disease prevention, and management of chronic conditions such as asthma, hypertension, and diabetes. Many also provide dental, behavioral, and mental health; health education; environmental health risk reduction; and parenting education services. After several decades of regulatory reform, NPs now have prescribing privileges in all 50 states, making their scope of practice comparable to those of primary care physicians.3
Nurse-led models of care provide care at a significantly lower cost than that of a physician's office or an urgent care facility. An analysis in Health Affairs of one NP-staffed convenient care clinic in a Minnesota retail store found cost savings of $50 to $55 per episode compared with other health care settings.6 NMHCs are similarly cost-effective and, as the study of NMHCs in Pennsylvania found, their patients had higher rates of generic medication fills and lower rates of hospitalization than other safety net providers.4
THE MONEY PROBLEM
Nonprofit NMHCs serve the patients who are least likely to receive ongoing health care services. This population includes people of all ages who are uninsured, underinsured, or living in poverty. Patients who are unable to pay for care are charged on a sliding scale or treated for free. As a result, NMHCs often struggle to achieve fiscal sustainability.
The primary sources of money for NMHCs in poor communities are Medicaid and Medicare reimbursement, private grants, and government contracts and grants.4 Most are operated by schools of nursing, and some of these receive financial assistance from their parent organizations. However, being affiliated with a nursing school can work against an NMHC by limiting the federal funding available to it. Section 330 of the Public Health Service Act extends a number of financial benefits to facilities designated as federally qualified health centers (FQHCs)—public or private nonprofit practices in medically underserved areas or that treat vulnerable populations—including higher Medicare and Medicaid reimbursement, malpractice insurance coverage, and eligibility for grants.7 Although a considerable number of NMHCs meet the medical-services criteria for FQHCs, the latter must be governed by boards made up of at least 51% of the center's patients. Nursing school–affiliated NMHCs necessarily operate under the authority of the boards of their founding institutions,8 making them generally ineligible for FQHC status, though some have affiliated themselves with existing FQHCs to overcome this obstacle.
Because many NMHCs are unable to access the financial resources available to other safety net providers, third-party reimbursement must cover much of the cost of providing care to the uninsured. However, a national survey conducted by the NNCC in 2009 found that 48% of all major managed care insurers don't credential or reimburse NPs as primary care providers.9 Federal laws that prohibit Medicaid and Medicare managed care insurers from discriminating against NPs acting as primary care providers currently go unenforced.10
Another policy challenge facing NP-led practices is whether they'll be officially recognized as medical homes. The medical home is a team-based practice model in which patients see a primary care provider who coordinates all of their care. Having a medical home improves patient outcomes, especially among patients with chronic illnesses.11 While NP-led practices are well suited to serving as medical homes, physician groups such as the American Academy of Family Physicians and the American Academy of Pediatrics have sought to confine sole provider status at medical homes to physicians only.12 The National Committee for Quality Assurance, one of the nation's leading health care practice certification bodies, doesn't recognize NMHCs as medical homes because its standards stipulate that physicians must lead practices.13 Unfortunately, recognition as a medical home is increasingly required to qualify for the enhanced reimbursement and funding available to primary care providers.
NURSE-MANAGED SCHOOL-BASED HEALTH CENTERS
A particular kind of NMHC that could help to significantly improve the health of American children builds on the success achieved with school-based health centers (SBHCs). Schools are being asked to accept a greater degree of responsibility for ensuring the academic, emotional, and physical well-being of students, and the number of SBHCs has increased dramatically since the 1990s.
According to the National Assembly on School-Based Health Care (NASBHC), an advocacy group promoting SBHCs and their funding, there are more than 1,900 on-site SBHCs and mobile programs, the latter of which rotate among schools. Nearly 1,100 provide at least primary care services. Fifty-seven percent of SBHCs are located in urban areas and 27% are in rural areas.14
A 2007–2008 NASBHC survey of SBHCs revealed that management models vary significantly. Those that provided only primary care services typically were staffed by an NP or physician's assistant with medical supervision by a physician, whose role was primarily administrative. Others also offered mental health services provided by qualified professionals, and some offered primary and mental health care and additional services such as health education.14
Most of the health care services needed by children and their families fall within the scope of the basic preventive services typically offered by SBHCs, and these programs can help to remedy the racial, ethnic, and socioeconomic disparities that the Agency for Healthcare Research and Quality reports continue to hamper these populations' access to care and its quality.15 SBHCs reduce the need for parental work leave, limit the amount of classroom time missed for health care appointments, promote health and the use of preventive strategies, improve follow-up and compliance with treatment plans, and provide care regardless of the ability to pay for it.16
SBHCs are also increasingly being used as sources of care for other populations. According to the NASBHC, 36% of SBHCs in the academic year 2007–2008 served only the children in a particular school, down from 45% in 2005–2006. SBHCs are also serving students from other schools in the community, school faculty and employees, students' families, and other community members.14
Most SBHCs bill at least one form of public health insurance, such as Medicaid and the Children's Health Insurance Program, for their services. Most also bill commercial insurers, and more than a third bill students' families directly. Other funding comes from the states and the federal government, school districts, private foundations, and sponsor organizations, which include local health care organizations, nonprofit groups, academic institutions, and school systems.14
Nurse-managed SBHCs (NMSBHCs) are developing as a viable subset of the SBHC movement, and their numbers are likely to increase in light of NMHCs' proven ability to deliver high-quality, cost-effective care. School nurses have cared for children since the early 1900s,16 and a study conducted in Boston's public schools estimated that children made eight times more visits to school nurses than to primary care providers.17 There is a dearth of research on NMSBHCs specifically, but one survey of patient satisfaction with the care provided by a single pediatric NP at a middle school in Michigan found that the 190 adolescent respondents were highly satisfied with how the NP listened and explained things to them, and they reported being treated with respect. Both sexes of first-time and repeat users of that health center were highly satisfied overall.18
Organizations including the NASBHC, the American School Health Association, and the National Association of School Nurses must continue to lobby for expanding both the number of and the scope of treatments offered by SBHCs, and they should ensure that NMSBHCs are included as a core element in providing essential health care services to our nation's children. These advocacy groups scored a significant victory with the new health care legislation, Section 4101 of which authorizes a federal SBHC grant program and an emergency appropriation of $200 million for SBHCs to acquire and improve facilities and equipment between 2010 and 2013.19
SUCCESS IS IMMINENT
Despite barriers to establishing and funding NMHCs and NMSBHCs, such facilities are thriving. For example, 11th Street Family Health Services of Drexel University, a NMHC serving public-housing residents in Philadelphia, has been nationally recognized for providing its patients with comprehensive primary care services. In addition to the NPs who provide care at the health center, other staff conduct health screenings, exercise classes, and outreach programs to improve the health of the community.20
In recent years policymakers have also increased their support for NMHCs. In June U.S. Department of Health and Human Services secretary Kathleen Sebelius announced $15 million in new funding for NMHCs as part of the new health care legislation.21 Soon after, in a speech delivered to the American Nurses Association, President Obama told the audience, "We're going to provide resources for clinics run by registered nurses and nurse practitioners. Without these nurses, many people in cities and rural areas would have no access to care at all."22
Just how the country's growing population of patients seeking primary care services will ultimately be satisfied has yet to be seen, but it's clear that NMHCs and NMSBHCs have the potential to play a significant role, particularly for low-income and medically underserved groups. It's critical that policy issues be resolved at all levels of government to ensure that NMHCs get the funding that's crucial to their continued existence and expansion. They're a realistic and proven way to ease the strain on our already overtaxed health care delivery system. Now that the country has made the decision to extend health care coverage to a significant proportion of the uninsured, we must make certain that we have the resources to provide the high-quality, low-cost care we all need.
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2. Fryar CD, et al. Hypertension, high serum total cholesterol, and diabetes: racial and ethnic prevalence differences in U.S. adults, 1999-2006
. Hyattsville, MD: National Center for Health Statistics; 2010 Apr. NCHS data brief, no. 36; http://www.cdc.gov/nchs/data/databriefs/db36.pdf
3. Ritter A, Hansen-Turton T. The primary care paradigm shift: an overview of the state-level legal framework governing nurse practitioner practice. Health Lawyer
4. Hansen-Turton T, et al. The nursing center model of health care for the underserved
. Philadelphia: National Nursing Centers Consortium; 2004 Jun. http://www.nncc.us/research/RE.html
5. Lewin ME, Altman SH, editors. America's health care safety net: intact but endangered
. Washington, DC: National Academy Press; 2000. http://www.nap.edu/openbook.php?isbn=030906497X
6. Thygeson M, et al. Use and costs of care in retail clinics versus traditional care sites. Health Aff (Millwood)
7. Rural Assistance Center. Federally qualified health centers: frequently asked questions
. 2009. http://www.raconline.org/info_guides/clinics/fqhc.php
8. King ES. A 10-year review of four academic nurse-managed centers: challenges and survival strategies. J Prof Nurs
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11. Beal AC, et al. Closing the divide: how medical homes promote equity in health care. Results from the Commonwealth Fund 2006 Health Care Quality Survey
. New York: The Commonwealth Fund; 2007 Jun. http://www.commonwealthfund.org/usr_doc/1035_Beal_closing_divide_medical_homes.pdf
12. Schram AP. Medical home and the nurse practitioner: a policy analysis. J Nurse Pract
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14. Strozer J, et al. 2007-2008 National school-based health care census
. Washington, DC: National Assembly on School-Based Health Care; 2010. http://www.nasbhc.org/atf/cf/%7Bcd9949f2-2761-42fb-bc7a-cee165c701d9%7D/NASBHC%202007-08%20CENSUS%20REPORT%20FINAL.PDF
15. Agency for Healthcare Research and Quality. 2009 national healthcare disparities report
. Rockville, MD: U.S. Department of Health and Human Services; 2010 Mar. AHRQ Publication No. 10-0004. http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf
16. Gustafson EM. History and overview of school-based health centers in the US. Nurs Clin North Am
17. Schainker E, et al. School nursing services: use in an urban public school system. Arch Pediatr Adolesc Med
18. Benkert R, et al. Satisfaction with a school-based teen health center: a report card on care. Pediatr Nurs
19. U.S. Congress. H.R. 3590. Patient protection and affordable care act. Title V—health care workforce, sec. 5208: nurse-managed health clinics. Washington, DC; 2010.
20. Ferrari A, Rideout B. The collaboration of public health nursing and primary care nursing in the development of a nurse managed health center. Nurs Clin North Am
21. U.S. Department of Health and Human Services, HHS Press Office. Sebelius announces new $250 million investment to strengthen primary health care workforce [press release]. 2010 Jun 16. http://www.hhs.gov/news/press/2010pres/06/20100616a.html
22. Obama B. Remarks by the President to the American Nurses Association. Jun 16, 2010. http://www.whitehouse.gov/the-press-office/remarks-president-american-nurses-association