Dear NNPEN Colleague and Friend: Our comments back to CMS Scope of Practice both 1) congratulates the Trump Administration for putting Full Practice Authority at stage center, recognizing it as the bipartisan issue it is; and 2) suggests ways CMS can uniquely contribute to value-based payment reform for advanced practitioners by encouraging advanced practitioners to accept the challenge of becoming informed risk-takers.  Happy reading to start out 2020!

PatientsOverPaperwork@cms.hhs.gov

Re: Scope of Practice response to a request for feedback from CMS regarding President Trump’s Executive Order 10/3/2019

January 16, 2020

Ladies and Gentlemen of the Patients Over Paperwork Initiative:

1. My name is Sandra Berkowitz and I am the CEO of NNPEN, a national network of Nurse Practitioners (NPs) who are owners of, and employees within, nurse-led clinical practices.  These NPs are included within MACRA’s QPP definition of “eligible clinician” and CPC+’s definition of “practitioner”.
2. My comments relate to Executive Order #13890 specifically, but also more broadly to how CMS can take the lead withother payers in the construction of infrastructure that facilitates the quickest uptake of, and access to, advanced practitioners into the Medicare provider network. Build outcomes and claims data set specifications, ensuring CMS actuaries will have the ability to compare longitudinal data quality and cost for physician and other advanced practitioners practicing at the top of their license. If CMS makes participation in databases mandatory the cost calculations are run on a leveled playing field.  The metaphor when Medicare sneezes everyone gets a cold is trite but true here. Think of this as the encore to our government’s funding technology development in early years by supplying the expensive hardware. 
3. As a general statement, NNPEN agrees that replacing a legislative/prescriptive definition of scope of practice with one that defers to the education and training of the designated practitioner’s license is a good thing.
4. Expecting that AANP and many other friends of NPs will also be responding, NNPEN restricts our other comments to preparing NPs to be informed risk-takers in Value Based Payment risk programs—a skillset that is not part of the NP’s cautious nature—and in fact, is not part of any practitioner’s training.
5. NP Scope of Practice success is a pyrrhic victory without NP access to Value-Based Payment arrangements that we know can reliably reward the NP outcomes that flow from the Nursing Process.  Executive Order #13890 gives this conversation—i.e., NP risk-taking skills required to succeed in Value Based Payment programs --new and significant urgency. 
6. Here are our comments detailing opportunities for CMS to level the SOP playing field short and long term:

#1—Preserve/extend the cost and quality benefits of the Nursing Process

• Uncontroverted literature of >100 peer-reviewed studies finds that NPs produce quality and cost outcomes as good or better than those of physician PCPs. Why? because of the integrated view of the patient that is the backbone of the Nursing Process. This hard-wired Nursing Process also explains why nurses are consistently viewed as the most trusted profession
• Yet the Nursing Process is desecrated by the dominant medical model pressure to “see”25-30 patients per day, squeezing patient office visits into 15 -minute segments
• To preserve the benefits of nurse-led care, NPs need many more sustainable independent practice options, that give consumers access to healthcare and preserve the benefits of the Nursing Process in all fifty states.  This Executive Order does that.

#2—Full Practice Authority (aka Independent Scope of Practice) will generate a much-needed NP primary care outcomes database

• As long as the NP is not the independent Primary Care Provider, no performance data is being separately attributed to the NP--- both syphoning NP value off to benefit the billing physician and allowing payers to resist exploration of VBP with NPs for “lack of credible data”. CMS can require collection of the longitudinal data that is essential to measuring and documenting the NP’s (and all other PCPs’) management of population health risk 

#3--Without NPs delivering primary care access across the nation, CMS will fail to meet its Triple Aim Goals

• We are losing primary care physicians at an unprecedented rate across the U.S., especially in rural areas where the needs are extremely high and opioid addiction/deaths are skyrocketing.  Many doctors are moving to "concierge" care models which leave out the poorest/sickest in the U.S.
• NPs are the fastest growing health care professional group by a lot. The American Association of Nurse Practitioners’ website reports there are 270,000 NPs in America in 2019.  According to the New England Journal of Medicine, “Between 2010 and 2016… growth in the NP supply accelerated to nearly 10% per year, whereas growth in the PA supply slowed to 2.5% and growth in physician supply slowed to 1.1%.”   n engl j med 378;25 nejm.org June 21, 2018

Armed with EO #13890, CMS has the power and gravitas with a top- of -license SOP vision to overcome the payer resistance and physician stonewalling that still confounds SOP progress in more than half of our 50 states.  The marketplace and the workforce are ready for SOP change that is refreshingly bipartisan.  The timing of EO #13890 couldn’t be better! 

We applaud President Trump and CMS for moving SOP to center-stage and look forward to working with CMS as it is rolled out.  Please let us know if NNPEN can be of any assistance.

On behalf of our NP entrepreneur membership and an America filled with consumers without access to primary care, NNPEN thanks you for our opportunity to comment on SOP today.

Sincerely,

/s/Sandy Berkowitz, RN, JD

Welcome to our new ‘hood! As NNPEN grows members, we are getting more requests for direct member-to-member interaction capabilities. This new website has been designed with that capability as one of our satisfaction metrics: demonstrate material growth in member-to-member direct interaction. Now the Blog, the Forum (discussion board) and the Membership Directory are 3 website tools NNPEN offers to support peer- to-peer dialogue with no “mother may I?’ tollgate. The key here is that these tools aim to support NNPEN members. Are you a member? If not, ask yourself: is becoming part of something bigger than you -- a growing NP entrepreneur advocacy network -- worth $144/year?

Your call to action is to try these tools out and give us feedback. Oh, and if you can’t access the forum and directory because you’re not a member, Join NNPEN today!

Many more things to talk about in 2020: a co-hosted Home-Based Primary Care Blueprint for Success conference in Phoenix in February and NNPEN’s Value-Based Payments survey, for instance. Get there in good health!

s/s Sandy Berkowitz

Co-Founder and CEO

NNPEN Partnering with American-APN/CareSpan for a Giant Step Forward

Back in my February 2019 blog to NNPEN’s members and friends, I introduced the question: “What’s ahead for the NP-owned practice?” At the time, I strongly suggested that small NP-owned practices may reach a certain revenue threshold and plateau. The small NP practice, as an economic buyer, does not have the fiscal clout to, for example, negotiate performance-based adjustments to the payer’s stingy FFS fee schedule. By aggregating NP-owned practices into a single signature contracting entity, NPs create critical mass and economic value. So, my No. 1 takeaway for indie NPs is the need to join a contracting entity that creates clout through aggregating practices – without NP practice owners losing control of their practices or brand. “Aggregate” is my fancy way of saying GO BIG.

Then, in June 2019, I blogged about why NNPEN has begun offering business services through partnerships with PRMS for revenue cycle management (RCM) and SBSC for credentialing. In short, we see NP practices needlessly leaving 20-30% of their collectibles on the table, most notably by letting claim denials go unchallenged due to lack of time or confidence – most likely both. NNPEN encourages NP practice owners to spend their time with patients, where there is reimbursable value – and outsource RCM and credentialing.

Now it’s September, and we invite NP practice owners to kick the tires on our recently formalized partnership with the American Advanced Practice Network (American-APN) and CareSpan. We three partners aim to accelerate a nurse practitioner’s ability to establish and operate a sustainable independent clinical practice! Read our official press release announcing the partnership on CareSpan’s website.

We know that NP practice owners want to:

• Spend more time with patients
• Grow revenue
• Be part of something bigger

Being part of something bigger can mean being part of a professional community that offers evidence-based practice guidelines, peer review and emotional support, as well as the capacity to offload backroom activities that interfere with patient care time. But it can also mean bulking up to a size that third parties – read payers – cannot ignore. From NNPEN’s perspective, that is the long-term play here we find irresistible.

An important NNPEN undertaking in this partnership is to identify nurse-led practices who 1) are new to independent practice and whose collectibles goals at 24 months exceed $100,000; or 2) are established owners but have growth aspirations that are not translating into collectible revenue. For these growth- oriented practices, American-ANP/CareSpan offer important options to explore, especially before investing or reinvesting in an EMR. An NP practice owner should be asking these questions:

• Is my practice up but not growing?
• Is my practice up-and- growing but placing a 24/7 demand on me that is not sustainable?

American-APN/CareSpan is probably not an option for an NP practice satisfied seeing fewer than 10 patients a day. Nor is it the right choice if you are not planning to add a virtual practice (telemedicine) component to your repertoire. But NNPEN sees positive work/life balance relief, managed care contracting leverage, and other economies of scale in this first creation of an NP network, and NPs need practice management choices for NP-led practices.

Information is power. NNPEN is dedicated to informing NP practice owners about emerging practice management choices. We already offer ala carte options – specifically for stand-alone revenue cycle management and credentialing – but none of these get at NPs’ needs for a network that creates critical mass in negotiations with payers. American-APN/CareSpan does.
This is a call to action for NP practice owners: Get Big! Contact us: businessservices@nnpen.org.

I’m hoping you’ve been on NNPEN’s website recently and found our new menu tab: Business Services. But maybe you haven’t. In any event, NNPEN wants you to know why we are moving into this space, and the role we think NNPEN can play to make practice start-up easier.

First: Why?

Like every good business owner, you want to ensure your practice is running as smoothly and efficiently as possible. However, with the numerous requirements and nuances they don’t teach you in nursing school, it can seem daunting to run a successful business on top of providing top-notch care.

NP business owners need to rely on trusted third parties to remain compliant and keep the doors open. NNPEN has identified two areas where a small investment in outsourcing will yield big dividends on your part: revenue cycle management (aka billing and collections) and credentialing.

Revenue Cycle Management

Because so many dollars and hours are at stake, revenue cycle management (RCM) is a priority for NP practice owners to investigate outsourcing. RCM’s aim is to maximize your reimbursement revenue. One stage in RCM where NP practice owners fall short is challenging claim denials; they’re not what NPs know, they can require aggressive moves, and they take time.

NNPEN partners with PRMS, a firm that is particularly comfortable challenging insurer denials because their medical record professionals are grounded in the patient’s medical record. We like this sweet spot: the industry estimates that between delays in hiring providers due to protracted credentialing timelines and the failure of providers to challenge claim denials, 30% of your gross collectable revenue is conceded to insurers here. This is money from your pocket just going free! Don’t be penny-wise and pound foolish; face up to the money you are leaving on the table!

Credentialing

Credentialing is important to understand but not to do yourself because the rules are arcane. Even small oversights/errors in the application process means the insurer will send your application back to square one. The longer the credentialing and contracting process takes, the longer it will take you to start generating revenue, whether it be for your services or for a new NP you want to hire. A credentialing service will track your application from beginning to end so that the needed badgering is done without sucking the energy out of your practice.

NNPEN’s partnership with nurse-owned credentialing service SBSC negotiated a material discount for a la carte credentialing services, priced at a $295 one-time provider set-up fee plus a $100 -per- application fee. Assuming you manage five applications through this system, $800 is the cradle-to-grave credentialing services cost that the NP needs to weigh against the value of her or his time.

What’s NNPEN’s Role?

NNPEN is not employing professionals with specific business services expertise, such as SBSC and PRMS. Our business model is that we find the best thoroughbreds and invite them into our stable as independent contractors. We are air traffic controllers with respect to their service delivery to you. We envision that we are a concierge service for you to find the right fit between vendors and you, and to be your mouthpiece when things go awry.

This business model of concierge services is not unique to NNPEN, but we embrace it – both because in our view it’s the right way to run our business and because it passes our smell test as a way NNPEN can earn the revenue we need to grow while furthering the business sustainability goals of our clients.

Next post will focus on the most developed business services NNPEN offers: Consulting with the Founders. WHAT we four gals know is valuable, and WHO we know is priceless. Need to know more right now? Contact us at businessservices@nnpen.org.

SB

CEO

On Feb. 2, 2019, NNPEN hosted a half-day conference in Columbia, MD, titled Innovative Business Models for NP Practice: Do It Your Way! as an introduction to CareSpan, a digital healthcare platform, and AAPN, a CareSpan-aligned NP Group Practice Without Walls (GPWW). AAPN is the first NP-owned professional LLC to aggregate NP practices and negotiate NP managed care contracts as a single taxpayer identification number (TIN).

AAPN, the NP-owned PLLC, is the logical product of familiar forces converging in our healthcare marketplace:

• No primary care physician supply in face of growing healthcare demand;
• High NP primary care supply;
• Full confidence that, because of underlying nursing process, quality and cost outcome measurement will reward NP PCP practices for the value they create;
• Value aggregators like AAPN are how NPs negotiate value-based payment terms with 800 lb. payers

The Feb. 2 room was filled—nearly 80 registrants, wow! That tells us NP entrepreneurs are still looking for an ownership model that works for them. CareSpan’s Integrated Network, including AAPN, may be that model. It offers indie NPs access to a basket of business support services, including access to better managed care contracts because AAPN aggregates NP practices under a single TIN to create negotiation leverage.

From our Feb. 2 speakers JoEllen Koerner (CareSpan CNO) and Kate Fiandt (AAPN CEO), I enclose a link to AAPN, which outlines what the next steps would be to evaluate your practice future as part of AAPN. This assessment has value whether you go forward with AAPN or not. Right now, AAPN is focused on attracting established NP practices with established revenues—so that there is cash flow ballast to enable onboarding newbie practices without developed revenues.

A point made by many of our speakers is that AAPN is not for everyone. (For example, if you do not foresee virtual practice as part of your business plan, this practice model may not be for you.)
But this much is true: Some NP practice aggregator alignment will be in your future; that’s how NPs will create contract leverage. AAPN/CSIN is the first (but not the last) NP-focused aggregator for you to consider. For their foresight, we applaud them. NNPEN’s role here (we think) is to encourage the growth of additional aggregator options for you and be right there with you to evaluate the fit as you consider this question: What’s Ahead For My Practice?

Are we on the right track? Say it by joining us at www.NNPEN.org.

SB

WHY NP PRACTICES NEED “VALUE AGGREGATORS”: LET’S TALK MONEY

NP practice owners are entrepreneurs who want to be independent—to be free-standing.  But best case, these independents will each see 1500 patients, and a 1500 patient panel is too small to create contracting leverage, even with remarkable outcomes that are reliably great.  But if 10 NP practices, each with 1500 patient panel, combine their quality data, 15,000 lives begins to have credibility. Who collects the data and leverages these 10 NP practices’ outcomes into some share of the savings flowing to the NPs?  Who supports the business end of the 10 practices so the NPs can do what they love?  Below I propose the not-so-new idea of a value aggregator as the entity that brings the necessary capabilities to the table to give those 10 practices “the independence they want and the support that they need”.  What will success of an NP value aggregator look like?  I vote for negotiation of payment models that leverage the quality and cost value the nursing process invariably produces.

At NNPEN’s second annual conference, Minneapolis 2018, we saw an independent (indie) NP practice profile developing: maybe no brick and mortar office space, outsourced backroom functions, digital clinical platform, and miserly (even in FPA states) commercial insurer payments, based on an unsustaining Fee For Service schedule at 85% of Medicare’s Physician rate.  And adding insult to injury, payments offered no opportunity to boost the NP practice’s FFS revenue base with either or both of two enhancements health insurers offer every primary care physician: 1) care coordination fees and 2) shared savings (SS) programs that encourage the provider to benefit from better than average quality of outcomes and cost-effectiveness.  The economic implications of this for a small 1 FTE NP practice with a patient panel of 1500, are not chopped liver.  Modeling done for NNPEN for our Summer 2018 NPE Conference conservatively estimates a Shared Savings impact of $9,000 annually for our hypothetical 1 FTE NP practice.

How do nurse-owned practices negotiate for these fairly modest concessions—essentially, a leveling of the reimbursement playing field? Bring numbers to the table!  # of PCPs, # of patients, a depth and breadth of coherent data detail.  Aggregation generates value.   NNPEN’s position is that payment reform requires NPs looking beyond their individual practices to imagine what being part of a “single signature” contracting entity—an “aggregator”– might look like.  Is it a PC?  Is it an IPA? Is it a Management Services Organization (MSO)? Is it owned by the providers themselves? Does it offer a solution to the business acumen deficit most practice owners experience and, as noted earlier, want to outsource to a trusted MSO?

We see both national and local solutions emerging here.  Fortunately, the first “single signature” contracting entity opportunity for indie NP practices –the first “value aggregator”– is at our doorstep: CareSpan, a digital healthcare company.  .

NNPEN wants to be right there with our members in evaluating the fit between aggregators like CareSpan and independent NP practices.  SO: over the next few months NNPEN is scheduling live sessions with CareSpan and interested NP Entrepreneurs: the first will be in Baltimore, MD area in the first quarter of 2019—Saturday February 2, 2019 1:00pm to 4:30pm, to be exact.  Program information coming soon.

Pay attention.

SB

There was a lot of re-imagining to be had at the 2018 Midwest Region Dual Track NP Entrepreneurship  Conference in Minneapolis.  For one thing, we 4Mothers (Lynn, Lorraine, Beth and me) are beginning to think of NNPEN as industry “Conveners” and we like the way that fits us!  And I have some conference takeaways on the content side that challenge our vision of the future.

I moderated a Rural/Urban nurse-led practice session that looked at Minnesota Nice, Inc a commercial Direct Primary Care model in urban Minneapolis that is co-owned by 2 NPs and a medical economist, and sells medically necessary primary care services  to employers on a subscription basis.  This DPC does not take  commercial insurance.  And it does not have a brick and mortar component; instead it relies on telehealth imaging and home visits, including delivery of the meds they prescribe.  They provide all the backroom services the mobile practice needs.  They are considering franchising the model, including the  back room services and the marketing to local employers/consumers.  Now compare that mobile nurse-led primary care practice model in MN with S Dakota State University School of Nursing’s MSO [management services organization ] vision [and grant]to support rural South Dakota NP indie practices  that may have no brick and mortar base.  Like MN Nice, Inc., the MSO will provide a digital platform that becomes the virtual brick and mortar, allows the practices to share data and contract as one Virtual Group for value-based reimbursement contracts with payers.  And like MN Nice, Inc, the MSO offers NP practices an outsourced backroom function and an organizational structure that is poised for the best aggregation and leveraging of NP cost-effective and quality outcomes with payers.

We recognized several common features embedded in both these Midwest primary care models–the commercial DPC in MN and the academic MSO in South Dakota — that may foreshadow what a sustainable indie NP-led practice will look like in a few years—and maybe what we should be working toward now:

• No brick and mortar
• Telehealth platform (needs to integrate w/ multiple E H R versions )
• Back-room functions delegated
• Not insurance company reliant
• Openness to, but balance in, cash medicine product mix
• NP Virtual Groups created for payer contracting

I haven’t even gotten to the NP Value in Value-based Reimbursement session takeaways.  Or the HUGE popularity of our Getting Started Speed Dating 10 minute “Ask Anything” sessions with NPE heavy-hitters!  We Owe You More—but it’s mutual.  You need a Convener and we need you and your critical mass to make us smart. Please commit to membership and join NNPEN now!

Sandy Berkowitz

Co-Founder and CEO of NNPEN

I’m home a few weeks or so following the first of NNPEN’s Regional NP Entrepreneurship Conference, in Minneapolis.  So many lessons to learn!  Who knew that we put conferences together for our members but without supportive sponsors we will never break even?  [A projected $9K loss is not a good thing for our start-up’s first year but NEVER did we contemplate cancelling the day.]  In our defense, we also know much more about what kind of sponsors and exhibitors most naturally align with you, the NPE “market.”   Not just product alignment: e.g., cash medicine products and services.  But also alignment of vision as to who NPEs are:  a burgeoning workforce of small practices together capable of innovation that will disrupt how and where primary care services are rendered?  An emerging group of primary care practice owners with purchasing power—NPE buyers creating the same –and different–commercial opportunities that young physician practices once did?  We might want to start with how bank lending officers underwrite independent NP primary care practice startups vs independent primary care physician practice start-ups….

I’m reminded that for now, every project we do tells us something new about ourselves.  Nothing is just “work”.  Right now, it’s all good and that’s a good time to stop for just a bit to savor rewards like this one, tucked into an attendee’s post-conference follow-up to NNPEN:

“20 years ago a group of us had a dream.  20 years later YOU and your team have given it wings! Thank you!  Thank you!  Thank you!”

A CALL TO ACTION

For NNPEN, hearing from conference attendees and speakers that the NP Entrepreneurship practice gauntlet is being passed to us is reward but it’s also sobering.  Like you, we are an NP-led start-up that thinks we can make a difference.  Like you, we completed our post conference evaluation form and had to answer the concluding question:

“What step or steps toward ownership will you be taking in the next 12 months as a result of attending this NP Entrepreneurship Conference? “

We will host an Office Ours call for open discussion of attendees’ feedback on this question.  As of September, Office Ours will be a Members Only event, so join NNPEN now to ensure your place at the table.  We need you!

• Have you been wondering what else NNPEN is up to, in addition to planning our signature NP Entrepreneur Conference in July and our monthly Office Ours calls?  Here’s where I pat NNPEN on the back. Right side, then Left side. 

  Why?  Because NNPEN took seriously CMS Innovation Center’s recent (May 25, 2018 deadline) Request for Information (RFI)/public comment on the desirability of standing up a Medicare Direct Provider Contracting advanced payment model, one that could 

• ·       be open to contracting with NPs as a Virtual Group and as independent PCPs, AND
• ·       offer nurse-led practices opportunity to learn critical Value-Based Payment (VBP) skillsets, AND
• ·       accumulate sustaining practice surplus. 

NNPEN has done preliminary analysis that leads us to believe strongly that the nursing model can be relied on to deliver less costly, quality health care outcomes and still generate Shared Savings, which in turn is the nurse-led practice’s only sustainable source of surplus.  To grow substantially and operate sustainably, we NEED access to shared savings (value-based) payment models, and clearly it’s a fight to get seats at the table.

We have said since our inception that NNPEN’s mission is to connect Nurse Practitioner Entrepreneurs (NPEs) with each other and with quality start-up resources.  But we have also been clear that a strong NPE network creates meaningful opportunities for NP participation in reimbursement negotiations.     In essence, NP professional associations’ best negotiation positions likely will present NP solutions to America’s health care access crisis--keeping focus on the patient, which is as deeply ingrained in nurses as the Hippocratic Oath is for physicians.  But NPEs also need advocates who see NPs as a powerful market and workforce, and that is a different message from focus on the patient. By forcing ourselves to respond to RFIs like this one, NNPEN is beginning to see an NP payment advocacy niche that we can fill for all NPs.  NNPEN is interested in your thinking: are we on the right track?  And if you agree that we’re on the right track, joining NNPEN gives us more power to speak on your behalf.

Read NNPEN’s DPC RFI response: https://www.nnpen.org/wp-content/uploads/2018/05/CMS-RFI-DPC-NNPEN.pdf

Worth joining in this fight?  I say yes; what say you?

SB

• March 20, 2018 was the real-time debut of NNPEN’s Office Hours to you, our potential NP Entrepreneur customers, and it was scary.  Here’s how we coped:

• ·       We learned not to fall apart when we didn’t meet a deadline (like when we blew our November 2017 roll-out date for Office Hours). 
• ·       We convinced ourselves that Office Hours would be a success even if only one person showed up (i.e., whether to one or one hundred, we have declared ourselves as LIVE to the outside world, both in real time and in digital format).
• ·       We prepped.  Brian, our IT guru, made NNPEN’s vision visible on rotating NNPEN info panels that filled the Zoom screen. 
• ·       We wrote a script. We timed each of our parts to be SURE that we left time for audience Q&A. We wrote questions to ask if no one in the audience asked any.
• ·       We laughed, even when our weekly NNPEN status call had already run 30 minutes overtime.

• In fact, many more than one NPE (NP Entrepreneur) joined our Office Hours debut, and you came from all over the country: Texas, Florida, Wisconsin, DC, Connecticut, Pennsylvania Minnesota. 

  So why am I telling you this? Recall that NNPEN is a start-up too.  If we can identify and share barriers to, and secrets of, success at one start-up (NNPEN), there’s a good bet that NPEs (NP Entrepreneurs) out there are encountering the same challenges and want to talk about it.  This blog, we hope, will be a forum for nurse-led start-up experience-sharing.

  Here are some takeaway from the Office Hours rollout:  

• ·       DON’T LET DELAYS OVERCOME YOU…and DON’T LOSE FOCUS
• ·       HAVE A PLAN
• ·       HAVE A BACK-UP PLAN  
• ·       LAUGH!!               

Join Office Hours every third Tuesday at 8:30-9:30 pm ET.  Our next call will be April 17, 2018.  Calls will be open to all until the end of July; at that time our monthly call will become members-only.  Join NNPEN now as a charter member; but first, come look us over: Click here TO FIND OUT MORE

Until next blog,

Mom (aka NNPEN CEO AND Co-Founder Sandy Berkowitz)