TOURING OUR NEW REIMBURSEMENT AND PAYMENT MODELS PAGE THROUGH THE LENS OF SIZE MATTERS!

SOME OF US WILL MAKE IT TO AANP NEW ORLEANS, COLLECT OUR CHATCHKES, HAND OUT QR CODES THAT LEAD TO TREASURE AND HANG WITH THE HUNKS AT THE NNPEN BOOTH. BUT SOME OF US AREN’T THAT LUCKY, SO I’D LIKE TO RECREATE RIGHT NOW, THE QR CODE EXPERIENCE WE WOULD BE CREATING AT OUR BOOTH FOR YOU.

• 1.    WITH THE VBP QR CODE, YOU CAN LINK TO OUR NEW REIMBURSEMENT AND PAYMENT MODELS WEBSITE PAGE
• 2.   OPEN THE TWO MINUTE VIDEO EXTRACTED FROM OUR APRIL 2023 CONFERENCE ABOVE. JUST ONE BAR GRAPH CAPTURES THE NP PRACTICE OWNER’S DILEMMA: IF SIZE MATTERS, IS THE VBP JUICE WORTH THE SQUEEZE
• 3.    IF YOU ARE EXCITED BY THE COMING TOGETHER SUGGESTED BY THE VIDEO, EXPLORE NNPEN’S NEW REIMBURSEMENT AND PAYMENT MODELS PAGE THAT YOU HAVE JUST LANDED ON. CHECK OUT LINKS TO OUR BLOG POSTS EXAMINING HOW WELL VALUE-BASED CARE MODELS ALIGN WITH THE NURSING MODEL.  
• 4.   YOU’LL ALSO FIND AN EMAIL TO NNPEN PRACTICE OWNERS AND TO ALL 4/1 CONFERENCE ATTENDEES, DEPUTIZING THEM TO INTERVIEW   REACH ACOS IN THEIR SERVICE AREA, ARMED WITH POSSIBLE QUESTIONS [THANK YOU DR LINDSEY MALONEY, APRN] TO KICK THE TIRES OF A FEW NP-FRIENDLY VALUE-BASED REACH ACOS IN YOUR STATE—AS OF JANUARY 1 2023 THERE ARE MORE THAN 100 REACH ACOS NATIONWIDE AND ALL RECOGNIZE NPS AS PCPS!  NNPEN WILL MAKE THE REACH INTERVIEW FEEDBACK AVAILABLE TO MEMBERS AND NON-MEMBERS ALIKE. THIS REQUIRES NO COMMITMENT TO EITHER NNPEN OR THE ACO REACH.

WITH THE SIZE MATTERS VIDEO MESSAGE IN MIND NNPEN INVITES YOU TO DEDICATE SOME SERIOUS MINDSHARE TO THESE QUESTIONS: IS THE JUICE OF VBP WORTH THE SQUEEZE AND IF YES, WHAT WILL IT TAKE? HOW DO I EDUCATE MYSELF?  AND WHAT SHOULD NNPEN’S ROLE BE? 

AT NNPEN WE TOO ARE FOCUSED ON ANSWERING THESE QUESTIONS.  WE THINK THE ANSWER IS EMBEDDED IN THE ONE BAR GRAPH IMAGE THAT IS THE STAR OF OUR VIDEO.  WHAT IS IT SAYING TO YOU?

SB

You Are Deputized to Kick the Tires of an ACO REACH

Hi!  You read about or attended NNPEN’s April 1 2023 [In]Visibility to Value conference and know NNPEN is encouraging NP practice owners to get to know NP-friendly

REACH ACOs in their service areas.  REACH ACOs do recognize NPs as PCPs and can offer NP practices a glidepath from inadequate FFS reimbursement to Value-Based Payments which make NP outcomes and costs visible—and that’s a good thing!

This is an opportunity to “kick the tires” of a CMMI NP-friendly Medicare ACO model without having to make a commitment, creates an open database of REACH ACO interviews feedback, and equally important helps you determine your own willingness to transition to value-driven payment to access shared savings, and under what conditions.

NNPEN is enclosing an assortment of REACH interview Qs [courtesy of member Lindsey Maloney] and a CMS list of provisionally accepted REACH ACOs by state**[ links below] to tell you whether the ACO’s Medicare population is 1) high needs [typically HCCs of 4.0/homebound] or 2)all other seniors  and its URL.  From there you can contact the provider network officer of REACH ACOs that interest you.  All REACH ACOs must play by the same rules, but they will vary on important things like E  HR requirements and risk flexibility in early years.

**  https://innovation.cms.gov/media/document/aco-reach-provisional-applicants-aug2022 [provisional REACH  ACOs for 2023]

* https://innovation.cms.gov/media/document/gpdc-model-participant-summary   [formerly direct contracting model ACOs that will convert to REACH] This is useful because it  has the URLs of the formerly direct contracting ACOS that you can match with the REACH ACOs listed in the link above.

Once you’ve completed an interview, document your feedback in five yes/no questions by following the link here https://omgfnkony4f.typeform.com/to/DYAi2QxR

Or the QR code on our homepage, www.nnpen.org .  This invitation is addressed to the many NP practice owners we have encountered.  Share this invitation with a friend. You do not have to be an NNPEN member. You do need to be interested in how NP practice owners can come together to safely transition out of FFS and into Value-Based reimbursement.

Questions/comments?  See my email below.

Let’s Do This!

Sandy B

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?

• o   You keep your non-REACH patients and bill them as usual, direct to Medicare
• o   Monthly care management payments
• o   Monthly payment advances to support cash flow [“capitation”]
• o   Value-based payer contracting and population health program management
• o   Downside risk protection
• o   Access to shared savings
• o   Opportunity to erase the 15% differential with the Medicare physician rate schedule

There are 3 types of ACO REACH but all abide by same CMS/CMMI rules.   How do I tell these REACH ACOs apart? 

• o   High needs beneficiaries only: typically HCC >4.0; minimum ACO size=500 attributed lives
• o   Standard: established Medicare expertise; 5000 attributed lives
• o   New Entrant: New as Medicare providers; 3000 attributed lives with growth timeline

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

• 1.      Interviews with ones in your state; are they NP -friendly? Do they understand your questions? Have they shown willingness to negotiate a cap on downside risk? Have they elected to offer the NP Services Enhancement Benefits?
• 2.      Understand their timelines and match against yours
• 3.      Follow NNPEN’s REACH reporting and strategy to build a critical mass of like-minded NP practices
• 4.      Remember One and Done: Primary care providers cannot participate in >1 REACH at a time, but can withdraw
• 5.       Join us April 1, 2023 in person or virtually for our spring conference: [In]Visible* to Value, which will focus on creating NP visibility as a precondition to NP success in VBP, and hear how peers assess the downside risk of this migration.  Here’s the link to the NNPEN 2023conference landing page: https://mailchi.mp/2ed382004d0e/je04wxx0yw 

See you April 1 [no fooling!]

SB

POST 2022 SUMMIT BLOG

NP VBP: IS THE JUICE WORTH THE SQUEEZE?

NNPEN hosted its first Value-based Payment Summit on February 11^th and 12^th 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

NNPEN 

•   WHY VALUE BASED PAYMENT IS NOT A NO-BRAINER FOR NP PRACTICE OWNERS

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 11^th and 12^th.  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

Co-founder and CEO NNPEN