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Here we go again. Planning for NNPEN’s April 2024 conference is already underway and we are asking ourselves this question: will NP leaders feel that the healthcare delivery system, and NPs as a profession, are better off now than 12 months ago? Are we any closer to quantifying NP value? And if not, does it still matter?
From the outside, it is hard to “hear” movement from “silence to voice,” as authors Buresh and Gordon labeled nursing’s challenge in 2013 -- ten years ago. A few years later, here is what we thought NP disruptors would sound and look like, based on eight-year-old keynote slides from NNPEN’s Inaugural Boston conference in 2017:
Attributes of an NP Market Disruptor
Can we declare “mission accomplished!”? Yes, and no…
I would argue that inside the NP community there is an unmistakable restlessness for change being channeled by NP entrepreneurs in increasing numbers. NP entrepreneurs take the road less travelled, color outside the lines, and make good trouble, in a nutshell are market disruptors. We will open our 2024 conference with case studies of NP entrepreneurs who are showing us disruption first-hand:
1] “call me doctor” litigation brought by 3 NPs against the CA Board of Nursing
2] a fact check challenge to the AMA’s disturbing put-down of NPs as primary care equals
3] an academic proposal to move nursing out from under the bed rate to financial accountability as a free-standing revenue center, be it in a corporate setting or health system or nurse-led clinics.
This year, NNPEN aims to open NP eyes to the possibility that NP practice transition to a growth mode and risk readiness is already underway. Indeed, we can find evidence of NPs as disruptors in two of our 2017 disruptor attributes list: [Understands what is driving change in health care? Check! Identifies business models available to NPs and the skillsets needed to survive? Check!
Do NPs see the FPA struggle as a classical competition struggle that history tells us NPs will win? Maybe.
Do NPs feel confident in the business case for NPs as independent practitioners? No.
Have we translated the impact of the nursing model, our patient-centered north star, into dollars as well as clinical value?
Not yet. There is clearly work to do.
Market disruption is not the only growth tale to unfold on April 13 at our conference. Two of our favorite NP-literate attorneys Justin Marti and Dena Castricone will share their views on how growth uncertainties can be managed even as we encourage NP entrepreneurs to color outside the lines. To top off the day, in-person attendees will sign up for consecutive breakout sessions that explore the everyday challenges to, and collaboration proposals for, making NP entrepreneurship sustainable by joining forces—not practice absorption but practice networking to make 2+2=5. Ponder one very encouraging data point from our 2023 survey of 1200 independent NPs in Connecticut: 65% of the NP respondents indicated interest in “collaborating with other nurse-led practices to access the benefits of value-based reimbursement.
Change comes when entrepreneurs and intrapreneurs become disruptors who color outside the lines TOGETHER. Bring an NP entrepreneur buddy with you so that your aspiration to “be the boss of me” does not die at the end of the day. We will supply the crayons!
Be there: April 13, 2024, at the Hartford CT airport’s convenient and safe Sheraton Hotel venue.
On June 8, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary primary care model –improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health-related social needs (HRSNs) such as housing and nutrition. CMS is working with State Medicaid Agencies in the eight states to engage in full care transformation across payers, with plans to engage private payers in the coming months. CMS will begin accepting applications for the model in late summer 2023. https://innovation.cms.gov/innovation-models/making-care-primary
The Making Care Primary (MCP) Model is a 10.5-year multi-payer model with three participation tracks that build upon previous primary care models, such as the Comprehensive Primary Care (CPC), CPC+, and Primary Care First (PCF) models, as well as the Maryland Primary Care Program (MDPCP). MCP aims to improve care for beneficiaries by supporting the delivery of advanced primary care services, which are foundational for a high-performing health system. The MCP Model will provide a pathway for primary care clinicians with varying levels of experience in value-based care to gradually adopt prospective, population-based payments while building infrastructure to improve behavioral health and specialty integration and drive equitable access to care. State Medicaid agencies will commit to designing Medicaid programs to align with MCP in key areas. This model will attempt to strengthen coordination between patients’ primary care clinicians, specialists, social service providers, and behavioral health clinicians, ultimately leading to chronic disease prevention, fewer emergency room visits, and better health outcomes.
NNPEN’s conclusion: the VBP cauldron is bubbling; stay engaged and bring your colleagues with you! Curious NP PCPs in these eight states should evaluate the number of Medicare FFS patients they serve in aggregate as the threshold for application for this model—NOT whether they currently possess value-based payment experience: Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina, and Washington.
REACH FOR IT!
March 2023 Blog
What a Difference a Year Makes
Last year when NNPEN polled NP Value Summit attendees, they didn’t see Value Based Payment [VBP] at their doors for 10 years: Not a surprise. No payers were offering VBP contracts to NPs, and NPs felt a very low sense of urgency to leave FFS, the devil they knew. But 12 months later, as of January 1, there are >100 payers willing to contract with NPs on VBP terms—a payer or two in most states.
Q: Who are these payers? A: REACH ACOs
REACH ACOs are the new Medicare payers for NPs, a five year pilot of CMMI focused on delivery of primary care services that create health equity and extend the reach of primary care into underserved populations—an NP sweet spot. [ REACH stands for Realizing Equity, Access and Community Health.]
And they are the NP friendliest of the CMS ACO models thus far—for one threshold reason [aside from NP’s love affair with seniors, especially high needs homebound beneficiaries]: REACH ACOs level the playing field for all eligible PCPs, docs and NPs alike—with a claims-based assignment system called Attribution also known as Alignment]. Attribution means eligibility for any auto-assigned revenue stream associated with traditional Medicare patients for the NP and any ACO s/he is part of. By recognizing the NP in larger numbers through claim-based auto assignment [in addition to current voluntary assignment] as both the treating and billing provider, REACH creates visibility for NP PCPs and data to quantify NP value.
We already have that with our traditional Medicare patients that we see in our nurse-led practices…right? Not really. NPs are still stuck in a FFS payment system that is fiscally unfair, not patient-centered and affords little opportunity to grow into a practice big enough—visible enough—to leverage payers into reimbursement contracts that value NP quality and cost outcomes.
Like other ACOs, REACH creates critical mass leverage by aggregating—but not owning—small practices, creating a powerful Double AA battery of Attribution and Aggregation. And with CMS as overseer and financial reconciler, REACH offers transparency and training wheels to accepting both risk and reward for your panel’s health .
How does REACH support the NP’s shift to value?
There are 3 types of ACO REACH but all abide by same CMS/CMMI rules. How do I tell these REACH ACOs apart?
REACH ACO Nurse Practitioner Services Benefit Enhancement New in 2023
Wait—one more NP friendly change! One of NNPEN’s members points to another way REACH ACOs will impact both the NP and the beneficiary, and in a much more immediate way. Through the Nurse Practitioner Services Benefit Enhancement 2023 the NP can certify the need for hospice, diabetic shoes, cardiac rehabilitation and several other therapies WHICH STILL REQUIRE PHYSICIAN CERTIFICATION FOR MEDICARE BENEFICIARIES NOT ALIGNED WITH AN ACO REACH. This is a benefit the REACH ACO can elect to offer in an effort to streamline both quality and cost for seniors. This benefit enhancement works for the patient [diabetic shoes today!] and also supports ongoing collection of quality and cost data starting this program year, and we know that data is what we need to change policy more broadly! See page 75 in this link for a complete list of enhancement services: https://innovation.cms.gov/media/document/aco-reach-rfa
If you’ve railed against the barriers created by the physician certification of need requirements, recognize the REACH Nurse Practitioner Services Benefit Enhancement effective 2023 as another opportunity to create the visibility NPs need to lay the foundation for quantifying NP Value.
Best ways to learn more about REACH ACOs
See you April 1 [no fooling!]
POST 2022 SUMMIT BLOG
NP VBP: IS THE JUICE WORTH THE SQUEEZE?
NNPEN hosted its first Value-based Payment Summit on February 11th and 12th with attendance of 30+ like-minded professionals, all focused on NPs getting paid for the nursing model’s value add . Together the Summit ROCKED on content, every session recorded to reach a much larger audience. NNPEN experts agreed that a fee-for-service model is unsustainable for nurse-led practices and NPs need to understand the benefits associated with an at- risk payment strategy. With a focus on health promotion and disease prevention under a nursing model of health care delivery, the NP can survive and benefit from a value-based payment arrangement. Our narratives built one on another and made sense together: how often does that happen? We think this summit marks the beginning of a ground-up mapping to critical mass numbers! Many, many thanks to our subject matter expert speakers: researchers, payers, practice owners and educators.
We owe equal gratitude to the robust support NNPEN received from first-time sponsors, topped off with exhibits by the Emory Nursing Experience, a professional development initiative for nursing and Medical Advantage, a practice management company supporting NPs. These sponsors see the value of NPs in this space, even while we recognize NPs lag behind for many reasons revealed during the Summit sessions: lack of knowledge, small panel size and lack of incentives, to name a few.
The Summit concluded with these questions: How can we do this? How will we raise the value-based payment participation rate of nurse-led practices—and in turn, give NP practices agency over how they deliver the services their patients need, create sustainability both financially and clinically for their practices, and act with urgency? NPs as a workforce cannot waste this opportunity to leverage the pandemic’s access crisis in each of the 50 states!
We have several takeaways to hold close as we push to construct the roadmaps to NP VBP model participation:
1. NP attendance at the Summit tells us there’s more work to be done to move the value- based payment needle for NPs – not in 10 years’ time [the most common chat response on timing of VBP’s arrival for nurse-led practices] but starting now. Policy wonks, including CMS, peg the transition timeline closer to 3-5 years.
2. VBP covers services that are patient-centered, not volume driven, and aligns with the patient-centered nursing model. Sharing values with payers bodes well for patient-centered partnerships—not so much with FFS payers that reward volume
3. Our biggest risk is NOT down-side risk, but NP failure to plan for a transition to VBP that will be here, championed by Medicare and employers, in the frequently cited timeline of 3-5 years.
4. We know that nurses are bottom-up problem solvers [because there has always been resource constraint in conflict with what our patients need?]. So, we need to get local NP organizations talking with each other, with a common agenda, to ultimately answer this one meta question: IS THE JUICE [THE TRANISITION TO VBP] WORTH THE SQUEEZE? WHO DECIDES? Remember if we are not at the table, we are on the menu!
How will this happen? NNPEN will edit the recorded Summit sessions, summarize a bit, and then invite partners on a local level to draft a consensus vision for NP VBP and to propose next steps, including sources of funding, that fit the region and that will lead to region-specific answers to our meta question, “Is the VBP Juice worth the Squeeze?”.
We are also looking for other stakeholders who see the need for action to join us. Is this too much to ask? We don’t think so.!!
Sandy Berkowitz, Lynn Rapsilber, and Lorraine Bock
Value based payment (VBP) can be scary. Many NP practice owners have grown up under the fee-for-service (FFS) reimbursement structure. As we are seeing and will continue to see, payment is shifting to value-based payment (VBP) models. The goal of VBP is to control costs through keeping patients healthy-- preventing disease and optimizing level of wellness. Does this sound familiar? Nursing is rooted in health promotion and disease prevention-- the hallmarks of VBP. So then why are more NP practice owners not embracing this more sustaining (clinically and financially) payment model? Let’s look at some of the reasons.
First, NP practice owners start their businesses with small patient panels, perhaps working just one day a week. This inhibits NP practice owners from reaching the critical mass necessary to participate in VBP programs.
Second, NPs tend to be bottom-up problem solvers. Being on the front line of care delivery, we focus on the immediate solution that works for the patient. That is also how we solve problems with our practices. NP practice owners need to know their practices will not be compromised, fearful of consolidation efforts that have not worked for other providers. We have slim margins and fear being corralled into the potential for financial loss . Currently, there exists no incentive for NP practice owners to create critical mass to participate in VBP programs. We don’t yet see that the potential for gain is increased, not decreased, by the patient-centeredness of our shared nursing model.
Lastly, NPs have a tendency to “make-do”. For this reason, nursing’s blessing is also its curse. With our nature to make do, we preserve the status quo. We miss out on opportunities that capitalize on the value that the nursing model truly offers.
How do we elevate NP practice owners to risk takers and valued participants in VBP? What creates enough incentive for NP practice owners to color outside the lines of FFS? How do we leverage what we know about how nurses problem-solve to produce informed risk takers?
These are the very questions we will confront together at NNPEN’s NP VBP Virtual Summit on February 11th and 12th. These are questions we must answer; our time is NOW. So here’s my first message as NNPEN’s CEO to Nurse Practitioner practice owners and the resources that support them:
BE A PART OF THE START!! Join the Summit's payment conversation and post-Summit building of road maps to nurse-led practice sustainability; we need you NOW! Here’s the Summit information link: CLICK
Dr. Lynn Rapsilber
February 11, 2022 Friday Afternoon
& February 12, 2022 Saturday Morning
It’s not that often that change and I see eye to eye—but welcoming NNPEN co-founder Dr. Lynn Rapsilber as NNPEN’s CEO on July 1, 2021 is one of those times. Lynn is my dream-come -true to take the baton: DNP, healthcare policy wonk, sought-after national Billing & Coding presenter, GI practitioner and tested consensus-builder! And she knows that nurse-led start-ups have the power to solve the primary care access crisis in America. She will drive NNPEN to answer this question: How will that NP practice ownership explosion happen?
In this win-win, Sandy relinquishes CEO responsibilities and takes on Priority #1 for me personally, and NNPEN derivatively, which is NP Payment Reform. To lean into this initiative, the post July 1 Sandy is tasked with driving an NNPEN payment strategy whose goal is expanded NP practice participation in risk-based Alternative Payment Models (APM). Say what???
We have worked tirelessly to reduce barriers to NP entrepreneur [NPE] practice ownership: finding collaborating physicians, health benefits options for NPEs and their families; and business basics course work accessible 24/7that lays a foundation for the developing NPE business brain ...with more to come.
Looking back at earlier blogs, the need for payment reform has been lurking since NNPEN’s beginning. To be concrete: out of a total of 15 website blogs I’ve written since March 2018, payment reform appears 9 times. Why?
Because NO MARGIN NO MISSION. When we first birthed NNPEN and put those words on a slide as our call to action, the return was puzzled looks from NPs. The battle was/is Full Practice Authority [FPA] in all 50 states. But the potential for practice ownership in FPA states soon ran into this reality: even with FPA, Fee For Service reimbursement is not a sustaining revenue base. “Sustaining” as in paying your bills including your own salary, and having money left over [the margin] to invest in your mission of growing your practice, offering patient services you were educated to view as a piece of patient-centered primary care – not indulgences. And having time to engage with your patients!
We know there are barriers to negotiating sustaining payment for NPs. The big three are:
“I believe it is important to look at what risk allows you to accomplish
in terms of delivering better value to decide how and when to proceed.”
NP practice owners recognize the gap between what patient-centered services their training would dictate for their patients and the scope of patient-centered services FFS payments allow. You will become informed risk-takers when delivering a broader basket of patient services is the only path forward consistent with the analytics of the nursing model.
So I have my work cut out for me—and that works for me. Lynn says ditto.
How grateful we are that the NNPEN board was and is unanimous that the time to lean in, to invest in accelerating the pace of sustainable nurse-led practice growth, is now.
Here we go!
It’s 2021 and NNPEN is still vertical. And eager to act, to kick covid in the butt.
As painful as the past year has been, covid has been good to NNPEN in that instead of non stop travel the founders suddenly had time to collaborate even as covid changed everything around us. Demand for healthcare services as a result of covid has highlighted the NP’s ability to create access to healthcare services while delivering better care at lower overall cost than physician PCPs. Many states waived scope of practice constraints like physician supervision on NP freedom to practice autonomously on an emergency basis and have not looked back. On January 4th, 2021, Massachusetts, a restricted state blessed NP autonomous practice with bipartisan FPA (Full Practice Authority) legislation. Last July Florida, the second-largest Medicare market in the country, granted FPA status to NPs in primary care.
NPEs are kicking in the FPA door state by state, and it is swinging open. It is a call to action for NP entrepreneurs (NPEs) –for you, our members. In turn, What support can our members expect from NNPEN in 2021?
Our Goal #1 is acceleration of the pace of nurse-led practice startups, which in turn will lead to broader access to patient-centered health care services in America. In short, we have made substantial progress [during lockdown!] developing tools to accelerate our members’ transition from the pre-contemplation question of “Am I an Entrepreneur?”, through the Owner Go/No Go decision, to the satisfaction [and terror ] as a practice owner that at last “I am the boss of me.” We now offer Business Basics learning experiences that are modestly priced, taught by subject matter experts both in and outside of nursing and accessible 24/7 These offerings fill a content void created by the flawed thinking that dismisses the need for an orientation to business in nursing education, and introduces NP practice owners to a like-minded NP owner community that supplements the member services NNPEN currently can provide. Recall that NNPEN was created in 2017 in response to this question:
To preserve the benefits of nurse-led care the number of nurse-led start-ups must grow substantially and operate sustainably…How will that happen?
Putting one foot in front of the other has led us to some initial strategies. But how do we know if we’re on the right track? We measure. We know that 2/3 of our NPE members are not practice owners. Given our goal is to accelerate NPE transition into ownership we have to ask “Are We making a difference?” We will be answering that question using two metrics which we invite you to track with us—and even more important, to dialogue with us about what we could be doing better:
1 .25% growth year over year in our membership
2. Positive trend in % of members who transition into ownership after joining NNPEN
Our Goal #2 is Nurse-led practice participation in Alternative Payment Model arrangements. Full Practice Authority legislative success is pyrrhic victory if practices are not financially sustainable. Results from NNPEN’s 2019-2020 survey of NP practice owners, which we hope to see published in 2021, confirmed that NP practices typically choose inadequate FFS arrangements over APM options that pay performance bonuses but also carry modest financial risk. Not surprisingly, lack of education about managing payment risk soundly beat out lack of willing payer partners as the biggest barrier to APM participation As a result, preparation for risk-based payment reform has become one of our explicit goals for late 2021 and beyond. Watch for new NNPEN workshops that link NP quality and cost outcomes directly to the nursing process, and that explain why NNPEN sees the nursing process as your practice’s reliable profitability PPE. NPs who see RISK as a four letter word will become informed risk-takers because APMs make sense financially. Our bookies are betting on NP APM participation by 2023.
Finally, these goals are only two of the exciting developments that have been incubating since lockdown began. My role will be changing as will Lynn’s. We have brought on board Korrynn Lancaster as the staffer who keeps us connected to each other—and to you. Hang in there as we roll out ways of connecting with you and for you that we never dreamed possible two years ago. 2021 is going to be a great year!
Open Payments is a federal program, required by the Affordable Care Act, that collects information about certain payments that drug and device companies make to physicians and teaching hospitals for things like travel, research, gifts, speaking fees, and meals. It also includes ownership interests that physicians or their immediate family members have in these companies. This data is then made available to the public each year on openpaymentsdata.cms.gov. Guess who has been added to the list of Health Care Providers? Yep, we are! So, what does this mean?
Have you had to sign in for a speaker program, a lunch program, a dinner program or at a conference? Have you received an honoraria or speaker or advisory board fee? There is a value attached to the “gift” you just received. These monetary amounts will now be reported by the supplying party.
The Open Payments Search Tool https://openpaymentsdata.cms.gov/ records payments made by drug and medical device companies to physicians and teaching hospitals…and now US!
A Fun Fact: Connecticut was the first state to require tracking of payments to NPs as part of the Sunshine Act with passage of Full Practice Authority in 2014.
How will this affect NPs?
All the compensation we receive in goods, services, honoraria are tracked and reported to the public. This may deter NPs from participating in Pharma stuff. Yet, it may enlighten us in other ways.
The amount of $$ we receive in these “gifts” are far less than the MDs. Once we see some of these discrepancies, it can provide fuel to fight equal pay for equal work. It has always been my fight to be paid the same as the MDs for speaker honoraria: we learn the same slide deck, we present the same deck, yet we receive ~60% less than our physician colleagues. There is a fair compensation guide (anything but that) used by the drug companies to calculate this rate. This now makes it obsolete.
What you can do?
You can and should register to participate in Open Payments by clicking link https://www.cms.gov/OpenPayments/Program-Participants/Physicians-and-Teaching-Hospitals/Registration
Once you are registered you can look at what is listed under your name to insure it is accurate and true. You have until the end of the calendar year, in which the data is first published, to review and dispute the reported information. Changes that drug or device companies make to the data (because of your dispute) will be seen publicly in the data refresh (usually occurring in January of the next year).
Sometimes I feel like I have nothing “new” to report to blog readers—yes, we all get that. Then suddenly after a period of low profile, stars align and a clear re-visioning emerges that needs to be validated externally.
That’s been happening for NNPEN over the past 6 months. Our founding vision has been to connect NPEs w/ each other and with sustaining start-up resources. But that really doesn’t describe an outcome, more like a process. We shifted gears to update the vision to something measurable: a performance metric. Simply put, our vision has become to not only attract as members NPEs who are assessing their readiness to be owners and connect them with each other; it will also measure the NNPEN model as an accelerator in the transition of NPEs into practice owners.
We are betting the house on this re-visioning of NNPEN success. Covid crises are terrible things to waste, and we haven’t. During Q4 2020 we will greet a client’s inaugural NP cohort enrolled in a twelve-week Business Basics interactive online course developed by NPs and their advisors for NPs. The twelve-week course will be followed by a period of mentorship that lasts at least through opening the NP practice’s doors. Payor mix and sustainability of the practices will also be measured.
On the homepage of our website we share the question that has driven NNPEN from day one:
To preserve the benefits of nurse-led care, the number of nurse-led start-ups must grow substantially and operate sustainably…How will that happen?
We are getting closer to figuring out a cost-effective model to increase primary care access in this country: our beta partnership of hi-tech Business Basics learning and lo-tech hand-holding is about to begin! For all of us, it (hopefully)is a roadmap for proof of the concept that NPs’ cultural aversion to risk can be not only neutralized but leveraged to the practice and patients’ advantage.
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