APRNs Boldly Form Medical Homes

Value-based purchasing encompasses three central tenets of the health reform bill to achieve a three-part aim: better care for individuals, better health for populations, and lower growth in healthcare expenditures. These aims are to be achieved by 1) investing in prevention and wellness, 2) maintaining long-term fiscal sustainability, and 3) improving patient safety and quality of care. The fee-for-service model creates a disincentive to lower costs and integrate and coordinate care. Doing it right is far less expensive than getting it wrong.

Value-based purchasing links lowering costs with improving quality through more coordination and integration, thereby reducing unnecessary waste and redundancy of time, energy, and resources. There is an emerging evidence base showing that highly integrated care for a defined population is far safer than the fragmented care typically seen in our fee-for-service system. The Affordable Care Act (ACA) provides for financial incentives to move towards this goal of seamless care. The largest payer of US health care, the US government, wants to move away from paying for care that does not measurably improve health. This shift to value-based purchasing represents a significant change in that it switches the financial risk away from the payor and onto the delivery system, which then takes on the risk for poor-quality, poorly integrated, and sketchy care. As illustrated in the graphic, delivery systems will have incentives and be actively working towards moving or keeping people to the left, thereby maximizing the healthy/low-risk bubble and not directing the majority of resources to the most severe disease.

ACOs are collaborative practices that become legal entities and accept shared responsibility for the care of a minimum of 5,000 Medicare patients. The ACO must publicly report 65 quality measures; if it meets targeted goals, the providers of the ACO share the savings that the Federal government would have paid had the care been traditionally delivered, ie, fragmented, uncoordinated, and with no quality reporting. In the first 2 years, the ACO must show at least a 2% improvement over the previous 2 years in cost and quality; in the third year, it must pay Medicare back if it cost more.

If you are familiar with the Veteran’s Administration, you are knowledgeable about the concept of a medical, or healthcare, home. It is an outgrowth of the chronic care model, in that it is team delivered primary care with emphasis on the health of the whole population as well as the individual. In terms of its evolution, the chronic-care model created the medical home, and the ACO builds in its legal and financial component.

The medical home is considered the foundational building block of an ACO. The ACA authorizes Health and Human Services to contract with community based interdisciplinary primary-care teams that coordinate care across settings and providers. This may be arranged as a capitated payment or other incentive to improve the management of chronic illness and to prevent rehospitalization and unnecessary emergency room use. It has a strong patient-centered—not providercentered—approach with clear patient activation, engagement, and feedback; expanded health information technology and access; and linkage of payment to performance. A compelling aspect of expanded access is the notion that it must include alternatives to in-person visits; smooth information transfer across health teams, location, and time; clear self-care plans; and help with lifestyle/behavior change for patients.

Medical homes are similar to ACOs in that they integrate and coordinate care, and both are beautifully matched to the skill set of nurse practitioners (NPs). ACOs place less emphasis on patient-centeredness, while medical homes are grounded in patient-centered primary care. Over time, it is expected that qualified medical homes will receive payment per person for services not traditionally covered in fee-for-service systems. Coordination of care is emphasized in both of these models of value-based purchasing, giving voice and authority to NPs and other advanced-practice registered nurses (APRNs). It was exciting to see NPs and other APRNs engaged in this way, demonstrating leadership, a pioneering spirit, and creativity to make healthcare experiences different from anything we have seen before. What came through in these presentations was the notion that they did not ask for permission; instead, they saw a community need, designed a practice, and did it. These are by no means easy journeys, but what shone through was their vision of what could be and an unwavering tenacity to make the vision come to life. These medical-home pioneers have bravely struck out and represented the APRN community in a bold and visible way.

Three days before the Nurse-led Medical Home conference, the Centers for Medicare & Medicaid Services (CMS) drafted an unfortunate set of regulations on ACOs. The APRN community was taken by surprise in early spring when CMS published rules on the ACO defining “assignment of beneficiaries to ACOs…only on the basis of primary care services provided by ACO professionals who are physicians.” This narrow definition goes against the spirit and letter of the ACA legislative language that uses the term “ACO professional,” which is first defined as “physician and practitioner,” and then further defined as NP, clinical nurse specialist, or physician assistant. Thus, expanded leadership roles for APRNs seemed apparent. Yet, while it is clear the intent of the law was to expand the ACOs more broadly, the rules specify ACO leadership narrowly to physicians only. It is hoped that a massive grassroots effort by APRNs commenting on the draft rules will broaden the ACO definition in the final set of rules. You will see information forthcoming from national organizations about a grassroots response to this narrow language.

Opportunities abound for APRNs to serve as highly visible leaders in value-based purchasing. Currently there are over 3,000 medical-home practices across the United States recognized by the National Committee for Quality Assurance (NCQA), and the number is growing rapidly. As Dr. Greg Pawlson of the NCQA said at the conference, “we must work towards value-driven health care. We need everybody and must drop the argument about who is providing the care.” There are no clinicians better prepared than NPs and other APRNs to promote evidence-based practice, lead quality and cost reporting and improvement efforts, and integrate new technologies, all wrapped into highly individualized patient-centered treatment. This approach includes coaching patients and caregivers in an environment; creating care plans; and providing transition, coordination, and integration of care and medication reconciliation.

NP and APRN leadership and our unique skill set could be the lynchpin to help ACOs and medical homes succeed. The future of value-driven health care will be healthcare neighborhoods in which all needs can be met in one place. Like the innovators of the nurseled medical homes, we must assume that it is our duty to insert ourselves into this evolving landscape and to assume that we are key players in any successful ‘hood. A re-imagining and transformation of our delivery system is at our feet.

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