Are Managed Care Organizations in the United States Impeding the Delivery of Primary Care by Nurse Practitioners? A 2012 Update on Managed Care Organization Credentialing and Reimbursement Practices

Abstract

In 2014, the Affordable Care Act will create an estimated 16 million newly insured people. Coupled with an estimated shortage of over 60,000 primary care physicians, the country's public health care system will be at a challenging crossroads, as there will be more patients waiting to see fewer doctors. Nurse practitioners (NPs) can help to ease this crisis. NPs are health care professionals with the capability to provide important and critical access to primary care, particularly for vulnerable populations. However, despite convincing data about the quality of care provided by NPs, many managed care organizations (MCOs) across the country do not credential NPs as primary care providers, limiting the ability of NPs to be reimbursed by private insurers. To assess current credentialing practices of health plans across the United States, a brief telephone survey was administered to 258 of the largest health maintenance organizations (HMOs) in the United States, operated by 98 different MCOs. Results indicated that 74% of these HMOs currently credential NPs as primary care providers. Although this represents progress over prior assessments, findings suggest that just over one fourth of major HMOs still do not recognize NPs as primary care providers. Given the documented shortage of primary care physicians in low-income communities in the United States, these credentialing policies continue to diminish the ability of NPs to deliver primary care to vulnerable populations. Furthermore, these policies could negatively impact access to care for thousands of newly insured Americans who will be seeking a primary care provider in 2014.

To What Extent Are State Scope of Practice Laws Related to Nurse Practitioners’ Day-to-Day Practice Autonomy?

“…This analysis of nationally representative survey data is the first to highlight the amount of variation in day-to-day practice autonomy that NPs experience within the three main scope of practice categories: independent practice and prescription authority, independent practice but restricted prescription authority, and restricted practice and prescription authority. To the extent that variation is observed, particularly among NPs working in fully independent states, it may suggest that factors other than state scope of practice laws, such as payer and institutional policies, influence NP practice (Hansen-Turton, Ware, Bond, Doria, & Cunningham, 2013).…”

Nurses in advanced roles in primary care

“…Among Medicaid (which covers primarily low-income adults and children and is administered by the individual U.S. states), reimbursement varies by State, ranging from 75 to 100% of the rate that is paid to a physician for the same services provided (Chapman et al, 2010). Moreover, NPs are not always recognised as primary care providers across the United States (Hansen-Turton et al, 2013). Approximately 25% of the major U.S. health maintenance organisations do not recognise NPs as primary care providers, thereby limiting patients' access to NPs.…”

Nurse practitioner role in home healthcare: Challenges and opportunities

“…It has been documented that NPs provide safe and effective care that is comparable to that of physicians within homecare and other settings. [6,7] 2 Current Medicare rules on home healthcare…”

“…The American Academy of Family Physicians President's position is that although they work with nurse practitioners, it should be a physician directing the team. [8] However, multiple studies have shown that the care given by NPs and physicians within home care settings is comparable, [6,7] and the history of homecare services really started with nursing. Lillian Wald and the thousands of visiting nurses who have come after her make up the traditional workforce in homecare.…”