How To Understand The Difference Between A Nurse Practitioner And A Physician

Transcription

1 Nurse Practitioners: Defining Our Role in ACO s and Other Quality-Based, Cost-Effective Initiatives Wendy L. Wright, MS, RN, APRN, FNP, FAANP, FAAN Adult/Family Nurse Practitioner Owner Wright & Associates Family Amherst, NH Concord, NH Owner Partners in Healthcare Education, PLLC Objectives Upon completion of this session, the participant will be able to: Discuss definition of ACO and other quality and cost based programs Identify implications of nurse practitioner exclusion from ACO s Identify opportunities to work with payers to form/develop/alter ACOs and other models of care Disclosures Speaker Bureau: Novartis, GSK, Sanofi- Pasteur, Merck, Takeda, Vivus Consultant: Vivus, Sanofi-Pasteur, Takeda Wright,

2 What Are ACO s: According to CMS Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients Goal: Coordinated care which provides timely and appropriate care without duplication of services accessed Background Patient Protection & Affordable Care Act signed March 30, 2010 (Affordable Care Act) Section 3022 required Secretary to: Establish the Medicare Shared Savings Program Intended to encourage the development of ACO s within Medicare Purpose of cost-savings and quality care delivery while avoiding duplication of services accessed Why Become Involved? When an ACO provides high-quality care and uses its healthcare dollars wisely, all members of the ACO share in the savings of the program As such, many hospitals have begun to form ACO s together, even though they are technically competing facilities 2

3 Medicare Have a number of different ACOs Medicare Shared Savings Programs Advanced Payment ACO Model Pioneer ACO model 33 Quality Metrics Downloads/ACO-Shared-Savings-Program-Quality-Measures.pdf accessed Where Medicare/CMS Goes. So Does Everyone Else! 3

4 Many Organizations Have Formed ACOs 60-accountable-care-organizations-to-know.html accessed Issues Now At Hand Sustainability: very expensive to form, organize and run an ACO Many organizations, who had originally expressed desire and intent to form have begun to back away? If ACO s will begin to sunset. Modify ACO Language 4

5 Accountable Care Organizations Nurse practitioners are authorized to be ACO professionals Patients who are assigned to this program cannot be counted as beneficiaries if they choose a nurse practitioner for their primary care provider It prevents NP patients from being assigned to a Medicare ACO, and the gleaning of any subsequent benefits that result from such participation Statutory change to reinstate assignment of patients of all ACO professionals i.e. nurse practitioners by adding (h) (1)(B) to Section1899 (c) NP Barriers Issue%20Brief%20-%20Recognize%20NP%20Practices.pdf accessed Accountable Care Organizations Language excludes independently-owned nurse practitioner practices In NH, this affects approximately 50,000 covered lives Approximately Medicare recipients Effectively eliminates the group of providers who are providing millions of patient visits for Medicare recipients Language should allow NP s to form ACO without collaborative or supervisory association with MD 5

6 This federal legislation excludes all Nurse Practitioners in independent practice! American Association of Nurse Practitioners Issue%20Brief%20-%20Recognize%20NP%20Practices.pdf accessed What Have We Done in New Hampshire? 6

7 Anthem Patient Shared Savings Patient Centered Primary Care Program started January 2013 There are financial incentives within this program: 1. There is a per member per month fee paid to office based on the collective severity of illness of patients 2. There is an incentive based on shared savings of cost which is calculated at the end of each year. This incentive is calculated by those practitioners working in a combined risk pool. The larger the risk pool the lower the risk become when there is a catastrophic risk Sean Lyon APRN Needs to be given credit for the foresight.. He was at the table/on panel Asked for NP s to be grouped together for aggregate data collection And.it began what will hopefully be some amazing information about NP s and our participation in ACO s We Are Evaluated. Based upon our own scores but also our medical panel Medical panel in 2013: 50% NP patients Medical panel in 2014: 61% NP patients 7

8 January 2013 Prior to program, we received our score card from Anthem We used this scorecard to carefully dissect our practice Looked at what we were doing well and what we needed to work on This was the push we needed to ensure that we were providing best care possible and meeting reporting requirements 22 Here Is What I Sent to Our Staff Similarities: A. Both offices STINK with pediatric preventive care. WE need to run: year olds and call them for PE s year olds and do the same B.Branded Medications Both offices are using more than standard of BRANDED nasal steroids and BRANDED SSRI s (this should not be needed as they are all generic); will encourage providers to consider generics 23 Here is What I Sent to Our Staff C. Differences: Concord Weaknesses: 1a. Med adherence/statins/ace 2a. Branded Stimulants 3a. Diabetic eye examinations 4a. SNRI branded 5a. ER visits 4 avoidable! Amherst Weaknesses: 1a. Med adherence: statin/ace 2a. Branded sleep agents 3a. Hospitalizations/ER 4 visits 24 8

9 We Used This As Our Starting Point! Here is what we have done so far: Run reports of all children and looked at last wellvisit Called in for well-child visits Created care planning initiative Partnered with Simmons Graduate Nurse Practitioner Students to look at our diabetes metrics Partnered with a Doctoral NP Student to work on medication adherence initiative When We Started This. We realized that the scorecard provided to us from Anthem was wrong For instance, we were told that there were numerous children and adolescents who had not had WCC within previous year In fact, Anthem had paid us checks on the majority of these kids for WCC. We submitted days, children s names and check numbers to Anthem who recognized a glitch Only pediatricians were being counted as being appropriate providers We Are Doing This for All Four Thousand Patients 9

10 Care Planning Pre-visit Preparation Improving clinician visit and improving patient outcomes Our model of care: Longer visits with comprehensive care What This Means: we attempt to address all preventive and acute needs at every visit, every time Pre-visit Preparation Two days before visit: check out sheet is completed by staff member working with particular provider Focus is on HEDIS/Quality measurements Address: Mammograms Bone density Colonoscopy Immunizations Diabetes measurements A1C Foot examination Microalbumin Eye examination 10

11 Check-out/Care Planning Sheet Here is what has happened Began implementing early 2013 Billables have increased significantly More vaccines are being given More A1C, microalbumin testing is being done More preventive visits/procedures are being booked Mammograms/colonoscopies procedures that were overdue are being booked Staff books these at check-out Serves two purposes: Gets accomplished Provides excellent malpractice defense 32 Here is what has happened Specifics: Amherst: Two of the past 5 months have been the highest billable months in the history of our practice No new staff has been added (providers) Number of patient visits is NOT higher Means that more vaccines, A1C s, microalbumins are being done Concord: Highest five months of billables in three year history of practice Still with one provider Big change was implementation of care planning 33 11

12 Ultimately, Most Important Goal Good patient care Improved outcomes Happy customers 34 Simmons College Partnership: Graduate NP Program Project Ran report of all individuals with Diabetes enrolled as patients within both sites Provided report to graduate NP students Four graduate NP students and faculty instructor came on site and reviewed each patient individually for a number of quality metrics 36 12

13 Project started June 1, 2013 Diabetes Metrics A1C < 7.0% LDL < 100 Microalbumin within 1 year Diabetic retinal examination with in 1 year Foot examination within 1 year Percent of individuals adherent with medication > 80% of days 37 Results of Project: Completed August 2013 Diabetes Metrics A1C < 7.0%: 83.95% (whose A1C should be < 7.0%) LDL < 100: 62.34% Microalbumin within 1 year: 80.72% Diabetic retinal examination with in 1 year: 63.85% Foot examination within 1 year: 73.49% Percent of individuals adherent with medication > 80%: 83.14% 38 What Do We Do From Here. We have set reminders in individual charts of all at risk individuals i.e patient overdue for eye examination i.e. patient overdue for microalbumin We have sent messages to MA inbox to have MA call patients to book eye examination for them We have done NP education re: need to do foot examination at every visit and annually monofilament and reflexes 13

14 Here Is One Message MA sends patient message on patient portal MA: You are overdue for your eye examination, can I please schedule this for you? Patient: No, I am fine. Thank you My response to patient via portal: I am getting reminders from Anthem that you are overdue and we are all concerned about your eyes. Patient: Oh.I am sorry, I didn t know they were bothering you. Sure, I am off on 9/12/2013 go ahead and book. WHATEVER IT TAKES Staff Education We have realized as a result of this that: Lab interface does not turn LDL/Lipid profile red unless LDL > 130 Requires NP to look more closely at LDL Continued Project in

15 Comparison of Data: 2013 versus 2014 Year Mean A1C Level A1C Less Than or Equalto 7.0 A1CWithin 1 Year LDL Less Than or Equal to 100 LDL Level Within1 Year % 96.6% 59.3% 92.8% % 92.9% 79.7% 81.8%* Year Urine Micro- Albumin Within 1 Year Dilated Eye Exam Within 1 Year Dilated Eye Exam Within 2 Years Diabetic Foot Exam Within 1 Year Compliance With Diabetes Medications % 63.9% 72.3% 73.5% 87.1% % 77.8%* 87.9%* 75.8% 92.3% * Results are statistically significant WAFHC vs. National Data National A1C Mean Value WAFHC vs. National Data National A1C drawn <1 year Eye exam <1 year Foot exam <1 year 15

16 Doctoral NP Project Doctoral student: Additional Initiatives. Is looking at all women 40 years of age and older for mammogram within past one year If not present, message is sent to MA to call patient to book If patients states, it has been done.we are calling local facilities to obtain report Additional Initiative Look at potential causes of poor medication adherence Develop brochure for our patients on importance of medication adherence Deliver lecture to staff/patients on medication adherence and impact on health Project is still being defined and will continue over the next two years 16

17 Additional Initiatives at WAFHC When Booking an Appointment or at Check-in Have had urgent medical care since your last visit? Use this as an opportunity to obtain records from ER/urgent Can use transition into care (part of meaningful use) Prior to Clinician Visit MA to obtain vitals, spirometry, ECG, A1C, immunizations, microalbumin, lipid, INR prior to clinician entering room Train MA s to anticipate needs of clinician Care is coordinated and integrated Emphasis is on patient and prevention at every visit Allows patients to spend more face-face time with providers 17

18 Optimizing Clinician Visits Take time at outset to build templates We have 1 clinician and 1 MA responsible for templates Schedule quarterly long staff meeting, MA and NP work on building and modifying templates to meet needs of providers Must put time in up-front to create useable templates Optimizing Clinician Visits Offer prescription refills during visits Serves two purposes Attest to ERX requirements for CMS/medicare patients Cuts down on calls into office which increases staffing demands Discuss medication adherence at these visits Utilize Reminders Here are three examples of our reminder system to enhance patient care and improve outcomes 18

19 Utilize Reminders Diabetes: Recommended Hepatitis Series for all individuals with diabetes < 60 years of age Utilize Reminders Hepatitis C screening So..What Happened to WAFHC? 19

20 Amherst Office Office vs. Panel Anthem Paid Out 3.6 million dollars in 2014 for this project NP practices earned: $125,000 $80,000 $50,000 $30,000 20

21 Thank You! I would be happy to entertain any comments or questions you may have Contact Information: WendyARNP@aol.com 21