220648 Insurer policies regarding nurse practitioners as primary care providers: Implications for the health care safety-net

Tuesday, November 9, 2010 : 5:30 PM - 5:50 PM

Ann Ritter, JD , National Nursing Centers Consortium, Philadelphia, PA
Tine Hansen-Turton, MGA, JD , National Nursing Centers Consortium, Philadelphia, PA
Rachel E. Kotok , School of Nursing, University of Pennsylvania, Philadelphia, PA
Background and Issues: Nurse-managed health centers are community-based health centers where advanced practice nurses (predominantly nurse practitioners) are the primary providers of care. They have served vulnerable populations throughout the United States for more than three decades. Nurse-managed health centers use a sliding scale to collect fees from uninsured patients, but this does not cover the actual cost of care. This shortfall is exacerbated by the fact that many insurers do not recognize nurse practitioners who act as primary care providers. Nurse-managed health centers are an essential part of the health care safety-net, but they face barriers to fiscal sustainability that physician-led centers do not. One such barrier is the refusal of many insurers to credential and reimburse nurse practitioners as primary care providers. Description: Since 2005, researchers have conducted a biennial survey of insurer policies regarding nurse practitioner primary care providers. Using a defined protocol, surveyors contact leading insurers in all 50 states to request information about credentialing and reimbursement policies. Data are then analyzed with attention to selected state and federal laws (including laws regarding nurse practitioner practice authority). This session will summarize the 2009 survey findings and compare them to previous results to illustrate the current reimbursement environment for nurse practitioners. Lessons Learned: Managed care insurers have largely only recognized physicians as primary care providers. Many do not include nurse practitioners in provider networks as primary care providers despite nurse practitioners' legal authority to perform this role. Many insurers do not consider nurse practitioners to be the equal of primary care physicians and laws designed to ensure fair treatment of non-physicians provide little protection to nurse practitioners who feel they have been victims of discrimination. Recommendations: Insurer policies contribute to the financial instability of nurse-managed health centers and threaten the health care safety-net. To achieve change, nurse practitioners must approach insurers as partners, educate insurers about the high quality of nurse practitioner care, and demonstrate the value that nurse practitioners can add to insurers' provider networks.

Learning Areas:
Administration, management, leadership
Public health or related nursing

Learning Objectives:
Attendees will be able to 1) identify emerging trends regarding nurse practitioner reimbursement; 2) describe policy barriers standing in the way of insurers’ recognition of nurse practitioner primary care providers; and 3) discuss how insurer policies impact the health care safety-net.

Keywords: Nurse Managed Centers, Managed Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I oversee policy research and analysis efforts regarding nurse-managed health centers and barriers to their long-term fiscal sustainability.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.