The American
Association of Colleges of Nursing (AACN), representing 530 baccalaureate and
graduate nursing education programs in senior colleges and universities, the American
College of Nurse Practitioners representing 25,000 nurse practitioners through
member, state, and national affiliate organizations, and the National Organization
of Nurse Practitioner Faculties, representing over 892 faculty members in nurse
practitioner programs, urge that Medicare funds now focused on entry level nursing
education be redirected for clinical training of graduate nurses. This innovation
would provide an on-going revenue source, not subject to the uncertainties of
the annual appropriations process, to expand the production of advanced practice
nurses, a vital resource for meeting future Medicare population needs.
As
the Commission examines Medicare funding and services for the nation's elderly,
Medicare's lesser-known side--the system's financial support of training for nurses,
physicians, and other professionals--is in dire need of reform. Medicare supports
the costs of training resident physicians with direct and indirect Graduate Medical
Education funds amounting to over $7 billion per year. With an estimated $290
million in 1997 and a projected $420 million by the year 2000, Medicare is the
largest single source of federal support to train America's largest health care
profession--registered nurses. Yet, according to HCFA, 70 percent of every Medicare
dollar for nursing education goes to hospitals that operate diploma programs that
produce entry level nurses. These payments are concentrated in Pennsylvania, New
Jersey, and Ohio, and hospitals there receive nearly half of the Medicare nursing
education funds. Hospital downsizing and other changes in the health care system,
resulting in sicker patients discharged to home, means that the care once provided
in a hospital setting with a myriad of sophisticated support systems must now
be provided by professional nurses prepared to work in home and community settings.
The increasing
number of Medicare patients who require primary care, and the accelerating drive
toward managed care, prevention, and cost-efficiency are spurring the nation's
continued need for advanced practice nurses (APNs). APNs are expert clinicians,
who, based on their areas of expertise, are trained to deliver primary care, manage
chronic multiple medical conditions, and/or address other needs of the Medicare
population. They include nurse practitioners, certified nurse midwives, certified
nurse anesthetists, and clinical nurse specialists. There has been much discussion
on how Medicare redesign may ultimately affect funding for physician residencies
in the nation's teaching hospitals. Nursing and other health care leaders are
focusing on the complementary concern of equal importance--the need to produce
sufficient supplies of advanced practice nurses for an increasingly complex outpatient
world where the needs of current and future Medicare patients will lie.
Reforming
Medicare will require more effective targeting of Medicare dollars that support
the training of health professionals who provide that care. Since its creation
in 1965, Medicare has reimbursed hospitals for a portion of their clinical, classroom
and other costs to train nurses, physicians and other health personnel with the
aim of providing high-quality inpatient care for Medicare recipients. With recent
and dramatic shifts in where and how health care is delivered, the time is long
overdue to overhaul the other side of Medicare--its health professions education
expenditures that increasingly have become misdirected. In fact, Medicare funds
for nursing are almost impossible to track in terms of what they pay for once
the funds enter the recipient institution.
At
no additional cost to Medicare, money presently spent to prepare diploma nurses
with skills limited to basic hospital service could be used to educate APNs. APNs
are produced by graduate nurse education (GNE) programs accredited by nationally
and regionally recognized accrediting bodies. Redirecting Medicare funds to the
education of advanced practice nurses not only makes clear sense for a health
system dominated increasingly by the competing concerns of quality and cost, but
would support preparation of the nurses in greatest demand by today's Medicare
patients. Currently, APNs represent only 6.3% of the total RN population. Supporting
APN education would enhance the clinical decision-making capacity of nurses in
all settings. In 1965 at Medicare's inception, most categories of advanced practice
nursing had not yet emerged. In the years since, Medicare policy has not kept
pace with the growing prevalence and documented quality and cost-effectiveness
of APNs. Annually, the millions of Medicare dollars that could support the preparation
of the APN instead have funded the continued production of diploma graduates.
Reports from
other national organizations have called for the redesign of nursing education
to meet the greater demand for APNs. The Pew Health Professions Commission (1995)
called for reducing enrollments in diploma and associate degree programs and expanding
advanced nurse practice programs. The commission urged doubling the number of
nurse practitioner (NP) graduates by the year 2005 to offset the shortages of
primary care physicians in major metropolitan centers, rural sites, and inner
cities.
Among
their roles, NPs conduct physical exams; diagnose and treat common acute illnesses
and injuries; provide immunizations; manage high blood pressure, diabetes and
other chronic problems; order and interpret lab tests; and counsel patients on
adopting healthy lifestyles. NPs work in a variety of settings including: gerontological,
pediatric, family health, women's health areas, and some have independent practices.
In 48 states, nurse practitioners can prescribe medications, while several states
have given NPs authority to practice independently without physician supervision
or collaboration. NPs care for the nation's elderly in urban and rural practices
and in clinics, correctional facilities, the military and private practice settings.
As of January 1, 1998 NPs and CNSs became eligible for Medicare direct reimbursement
for their services, regardless of setting.
APN
Practice
In
a report recently released by the Institute of Medicine (IOM) on nurse staffing
in hospitals and nursing homes, an IOM panel urged that increasing numbers of
registered nurses with advanced practice skills be utilized in outpatient and
inpatient settings to meet the growing demand for RNs with management, leadership,
and supervisory abilities.
Data
from the 1996 National Nurse Practitioner Educational Survey show that in a sample
of nurse practitioner graduates the greatest number practice in federally designated
Health Professions Shortage Areas. The next greatest numbers of NPs choose to
practice in rural health clinics. Over half of the graduates are working in rural
or small urban areas. Some of the practice sites where these graduates can be
found are homeless clinics/shelters, migrant health centers, local health departments,
prisons, etc.
Data
from the past decade indicate that the decrease in hospital utilization has yet
to result in a decline in aggregate RN employment in hospitals. On the contrary,
the number of full-time equivalent RNs employed by community hospitals increased
by approximately 30 % between 1985 and 1994, despite a 10 percent decrease in
the number of hospital beds. The trend reflects both increased patient acuity
and a shift in RN positions from inpatient to outpatient units within hospitals.
As patient intensity continues to escalate coupled with a decrease in length of
stay within acute care hospitals, RNs with strong assessment skills, a copious
amount of technical skill, as well as comprehensive pre- and post hospital planning,
and intervention and coordination are required.
The
IOM panel noted that advanced practice nurses such as clinical nurse specialists
not only provide high-quality and cost-effective care, especially for patients
with complicated or serious clinical conditions such as Medicare patients, but
also are well skilled for the sophisticated levels of practice required in today's
hospitals. They work on multi-disciplinary teams and deliver a continuum of care
across settings rather than focus on a "single event" of hospitalization.
IOM also recommended that nursing home care be enhanced through increased presence
of gerontological nurse specialists and nurse practitioners. While Medicare's
role in nursing homes is limited, the patient population in these facilities is
primarily Medicare eligible. Recent research studies have demonstrated the cost
effectiveness and improved health outcomes for geriatric patients receiving care
from geriatric nurse practitioners and clinical nurse specialists.
Recent
research supported by the National Institute of Nursing Research (NINR) has demonstrated
the effectiveness of advanced practice nurses in the care of the elderly patient
population on health outcomes and cost savings.
- Dorothy
Brooten, PhD, Dean, Case Western Reserve University, developed the Quality-Cost
Model of Nurse Specialist Transitional Care that has been tested in many patient
populations with various health-related conditions. This model has demonstrated
improvements in patient outcomes and decreases in costs of care. In the Quality-Cost
Model design, care is provided by advanced practice (master's prepared) nurse
specialists with clinical knowledge and skills matched to their patient populations.
Comprehensive discharge planning is developed for each patient group, and follow-up
in the home includes visits and telephone contacts.
- Mary
Naylor, PhD, at the University of Pennsylvania, tested Brooten's model of transitional
care, leading a multidisciplinary team specifically for Medicare beneficiaries.
The first study (1989-1992) examined elders (N=120) admitted to hospitals with
selected cardiac conditions to examine the effects of a discharge planning protocol.
The outcomes demonstrated a short-term reduction in hospital readmissions for
elders with medical cardiac conditions and suggested potential benefits of a more
intensive intervention targeted at the most vulnerable patients.
Service/Savings
Number of hospital
readmissions - 61% fewer - (6 weeks post discharge)
Hospital
charges for readmissions - 61% less
Average
cost of total health care services - 62% less
Number
of inpatient days for readmission - 70% fewer
- In
the second study (1992-1997), an APN directed discharge planning and home care
intervention was tested with elders at risk for poor outcomes and hospitalized
with common medical or surgical conditions. The outcomes identified were fewer
total re-hospitalizations, fewer patients with multiple admissions and lengthened
time between discharge and readmission. The interventions also generated savings
in Medicare reimbursement of almost $600,000 for the 177 beneficiaries in the
intervention group during the six months after the index hospital discharge. When
extrapolated to the number of adults hospitalized each year with similar conditions,
the potential patient benefits and savings to the Medicare system resulting from
this intervention are substantial, and APNs are the key.
Thus,
APNs often provide services of the type most needed by Medicare patients: primary
care at easily accessible, community based sites. These quality services are available
at lower cost than would be possible in a hospital setting.
Trends
in APN Education
Historically,
schools of nursing have responded relatively quickly to imbalances between supply
and demand. As health policy recommendations and market trends recognized NPs
as an integral part of the primary care team, nursing schools expanded their focus
to master's NP programs. According to an AACN report, national enrollments in
graduate nursing programs have increased significantly from 1991-92 to 1996-97,
but have actually decreased in the last 2 years. Graduations from these programs
also have leveled off.
The
need for RNs without preparation for advanced practice is expected to decline
by about 10 percent over the next ten to fifteen years as the reduction in numbers
of hospital beds declines. Additionally, the demand for APNs is expected to continue.
This refocusing of nursing education would not require expansion of APN programs
except to meet specific local or regional needs but allow for consolidation of
support for existing programs in order to develop a larger portion of the existing
nursing workforce. O'Neil and Coffman (1998) in their review of current projected
nursing workforce needs support these recommendations.
Clearly,
nursing education must be redesigned in order to prepare students for ambulatory
practice roles. Currently, over half of RNs working in ambulatory settings are
prepared at only the diploma or associate level. APNs account for only 8 percent.
It will not be sufficient to simply move student learning experiences from hospital
to ambulatory settings. Students must learn to practice across systems of care
and to shift their focus from providing direct, hands-on care to managing and
coordinating care for individuals, families, and populations.
Recommendations
This
current analysis supports redirecting Medicare funding for hospitals operating
diploma programs into APN education. The following Medicare changes would provide
a greater benefit to the Medicare population:
Redirecting
eligibility to add "jointly operated" programs and to phase out Medicare
funding of diploma programs.
Since
the inception of Medicare, nursing education has shifted from hospital on-the-job
training almost entirely to community colleges, senior colleges, and universities.
At present, Medicare reimbursement for nursing education programs is limited by
the "provider-operated rule," which directs most of the funding to hospitals
that operate diploma programs that produce entry level nurses who are trained
in hospital oriented care. Most APNs represent categories of providers not in
existence when Medicare educational payment policies were designed, such as nurse
practitioners, clinical specialists, and others. Educational costs of these new
providers are, with one exception (nurse anesthetists), not eligible for Medicare
reimbursement now. Consequently, reimbursement eligibility requirements should
be changed to include "jointly-operated" (provider-academic) programs
that incur costs for APN education. To be eligible for reimbursement, Medicare
providers (hospitals) would have to: 1) demonstrate that they incur clinical costs
for the support of graduate nurse education programs, and 2) have a written contractual
agreement with the program's academic partner institution. These requirements
would provide some accountability for where the money is going and that it addresses
demonstrable clinical costs.
Cost
items for determination of Medicare's share of reimbursement could include student
stipends, costs of nursing clinical faculty, and supervision of APN students at
the clinical site. (Now the students, school, and clinical sites bear these costs.)
Determination of the specific cost of education would be based on a modest stipend,
an appropriate ratio of training faculty to students, and faculty and supervisory
salaries.
Major
problems for APN education are the need for resources to cover costs of clinical
faculty and the availability of clinical training sites. A 1995 Lewin-VHI study
"Expanding the Capacity of Advanced Practice Nursing Education-Final Report"
identified several factors affecting the ability of APN programs to expand.
The
availability of sites for appropriate clinical education is the single most significant
factor in determining a program's ability to expand its APN capacity. According
to the study, sites are becoming limited due to competition with other APN programs
and graduate medical education programs; effects of managed care; and practical
limitations on the distance between schools and clinical sites.
A
major concern is the effect of managed care on clinical training of health practitioners
in community sites. As managed care systems proliferate, providers have increased
their panel sizes in order to meet the demand to be more productive. This results
in a loss of qualified preceptors, as providers are unwilling to take time away
from seeing patients in order to coach students. NP faculties have reported that
the requirement to see more patients per day has become a major barrier in recruitment
of preceptors.
AACN
member schools in Arizona, Maine, New York, and Ohio report that their APN programs
are competing with medical schools, residency programs, and physician assistant
programs for clinical sites and do not fare well, because these other health professional
programs are reimbursing the sites or providing tuition vouchers. Nursing schools
report that, in some cases, practitioners who have traditionally agreed to precept
students are turning away nursing students and taking students from programs that
can reimburse them for their preceptor role.
Another
factor affecting the ability of APN programs to expand is the availability of
clinical faculty, including clinical coordinators and preceptors. Redirection
would facilitate APN programs and clinical facilities to hire additional clinical
faculty to expand the number of APNs in training, and would help to eliminate
today's waiting lists for many graduate nurse programs. Medicare reimbursement
for APN clinical education would give practice sites an incentive to take on additional
APN students for clinical training, particularly if the numbers of specialty physician
residencies are reduced. If the clinical site were being reimbursed for these
faculty costs, the burden would be lifted from both that site and the school of
nursing. The lifting of restrictions on Medicare funding for nursing education
would result in increasing (both in terms of number and their program completion
time) the production of APNs in settings with Medicare patients, making cost-effective
care more readily available to the Medicare population.
In
addition, the ability of programs to pay stipends for APN students to defray some
student living and education costs have demonstrated to be effective in moving
part-time students into full time study and toward a more rapid completion of
graduate nurse studies. (According to AACN's 1997-1998 Enrollment and Graduations
in Baccalaureate and Graduate Programs in Nursing, 70% of all masters' students
and nurse practitioner students are enrolled on a part-time basis.) In return
for a stipend, the graduate nursing student would provide care for the provider's
patients, much as physician residents do. Providing education programs with flexibility
to support APN students with stipends during their graduate preceptorships recognizes
the similarity of their training to physician resident training. Unlike medical
residency programs, most nursing programs pay their own clinical training faculty
or make arrangements with preceptors at clinical sites to provide clinical training
at patient care sites outside the schools' academic facilities. In almost all
cases, APN students are RNs licensed to practice in a variety of patient settings,
and most have practice experience as well.
Clarifying
"provider" definition to include outpatient facilities serving Medicare
patients
Medicare
defines "provider" as "hospitals, skilled nursing facilities, home
health agencies, and other facilities." With health care delivery for Medicare
populations evolving beyond the hospital to more accessible and lower cost, community
based sites, it is clear that ambulatory care facilities, as well as tertiary
care sites, should be reimbursed for costs incurred for clinical training of APNs.
As training evolves to other settings, hospital payments alone will be inadequate
to reimburse provider training costs. Support for training in these settings where
primary care is delivered is critical. The Medicare definition of "other
facilities" should be clarified to include those facilities that provide
health care to Medicare recipients, with or without links to acute care settings,
including, but not limited to, nurse managed centers, ambulatory care facilities,
community health clinics, health maintenance organizations, and public health
departments. Reimbursing clinical sites for training APN students recognizes the
value of their services to Medicare patient care. As the number of specialty resident
physicians is reduced, APNs are well positioned to deliver many services formerly
performed by resident physicians, as well as nursing care and case management.
Under this
proposal, facilities that incur clinical costs for support of APN education would
have access to Medicare funds, but only for the portion of the cost attributable
to the Medicare patient population. (This is the formula currently used.) Medicare
funding would provide resources for added clinical faculty to expand the numbers
of APNs in training, and promote quality service to the Medicare beneficiary.
National
Support for Medicare Funding for APN Education
Other
national organizations support the redirection of Medicare dollars to APN education.
The Institute of Medicine supported the redirection concept in April 1997 in its
report On Implementing a National Graduate Medical Education Trust Fund.
On page 16 the recommendation states, "Nursing DME (direct medical education)
should be structured like physician DME and be paid to sponsoring institutions
for the support of advanced practice, graduate clinical trainees. This provision
should be neutral with respect to the proportion of DME that has supported nursing;
diploma, undergraduate nurse education support should be phased out in 4 years
or less to allow present students to complete their training;"
In
April 1995 and again in February 1997 the Physician Payment Review Commission
(PPRC) recommended that advanced degree nursing programs operated by four-year
colleges and universities be eligible to receive Medicare funds that otherwise
would be available only to hospital-operated programs. In July 1995 the Association
of Academic Health Centers (AAHC) supported the allocation of funds for graduate
nurse education by directing Medicare funds towards APN programs. Supporting APN
clinical education with Medicare dollars also has been urged by the Graduate Nurse
Education Coalition, representing 11 national nursing organizations.
Summary
Redirection of the
current Medicare monies for nursing education to APN education will increase the
number of nurses educated at the advance practice level and will ensure that Medicare
patients will benefit from their skills in the future. For diploma nursing programs
that receive Medicare passthrough support, AACN agrees with IOM that a phase out
over five years would be equitable and would avoid harming current students in
those programs. The redirection of these funds to APN education requires no new
Medicare expenditures and could actually reduce expenditures. By recognizing only
clinical costs of APN education and limiting eligibility to full-time APN students,
costs would decrease substantially. Funding levels should not be reduced for those
APN programs that currently benefit from Medicare support, such as nurse anesthetist
programs. Redirection of funds would focus Medicare support on the preparation
of the nurse in great demand by the Medicare beneficiary population, and help
meet the needs of a health care delivery system that is changing for Medicare
and other patients.
With
an increasing proportion of older Americans and increasing incidence of chronic
illnesses, APNs are precisely the type of health professional the Medicare population
will need for its primary care, management of chronic medical conditions affecting
older people, and patient education to help this population avoid injury and expensive
hospitalization or nursing home care. The APN is a vital component in increasing
access to quality health care services for Medicare patients in a rapidly changing
health care environment. Now is the time to shift Medicare funding toward the
recognized need for advanced practice nurses.
