Insurers’ Contracting Policies on Nurse Practitioners as Primary Care Providers: The Current Landscape and What Needs to Change

Hansen-Turton, Tine; Ritter, Ann; Begun, Heather; Berkowitz, Sandra L.; Rothman, Nancy L.; Valdez, Brian

doi:10.1177/1527154406294339

Cited by 14 publications

(8 citation statements)

References 2 publications

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“…The complex system of insurance agencies in North America creates barriers to the employment of nurses in certain roles [8], while leading to a proliferation of defined positions along a continuum from physicians assistant to nurse practitioner. The numbers of all these groups have been increasing [9,10], leading to tensions between the professional groups [11].…”

Section: Introductionmentioning

confidence: 99%

Following the funding trail: Financing, nurses and teamwork in Australian general practice

Pearce

Phillips

Hall

et al. 2011

BMC Health Serv Res

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BackgroundAcross the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate.MethodsThis three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies.ResultsDespite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice.ConclusionsInterprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice.

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Section: Introductionmentioning

confidence: 99%

Following the funding trail: Financing, nurses and teamwork in Australian general practice

Pearce

Phillips

Hall

et al. 2011

BMC Health Serv Res

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“…This is similar to previous reports in the literature on the credentialing practices of MCOs. 9,10 Nonrespondents included 134 HMO representatives who declined to participate, and 103 HMOs where, after repeated contacts, the authors were unable to reach a representative who could describe credentialing and reimbursement practices.…”

Section: Methodsmentioning

confidence: 99%

“…Many managed care organizations (MCOs) have historically refused to credential NPs as primary care providers. Hansen-Turton and colleagues 9,10 reported MCO credentialing rates of 33% in 2005 and 53% in 2007. Moreover, among those MCOs that do credential NPs as primary care providers, many continue to reimburse NPs at a lower rate than primary care physicians for the delivery of this care.…”

Section: Introductionmentioning

confidence: 99%

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

Hansen-Turton

Ware

Bond

et al. 2013

Population Health Management

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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.

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“…In 2006, PPNP published an article exploring insurers' policies and practices regarding the role nurse practitioners (NPs) as primary care providers (Hansen-Turton et al, 2006). In this issue, Tine Hanson-Turton, Ann Ritter, and Rebecca Torgan, writing in "Insurers' Contracting Policies on Nurse Practitioners as Primary Care Providers: Two Years Later," report the results of a follow-up study on this subject, noting areas of progress as well as continuing challenges.…”

Section: In This Issuementioning

confidence: 95%

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Policy, Politics, & Nursing Practice

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Insurers’ Contracting Policies on Nurse Practitioners as Primary Care Providers: The Current Landscape and What Needs to Change

Cited by 14 publications

References 2 publications

Following the funding trail: Financing, nurses and teamwork in Australian general practice

Following the funding trail: Financing, nurses and teamwork in Australian general practice

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

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