- Email: [email protected]
Effects of Medicare Changes on a Behavioral Health APN Practice
Effects of Medicare Changes on a Behavioral Health APN Practice
Kathleen McCoy, Michael Carter, Patricia D. Cunningham, Patricia M. Speck, and Cynthia Rector
ABSTRACT Background: This is a case study of an advanced practice nurse (APN) practice response to 2003 Medicare D-associated payer changes. Description: Case study of changes in population/services after implementation of Medicare D policy considerations Study design: Case study with data at 3 time points and analyzed using descriptive statistics/central measures of tendency/dispersion Results: Largest changes found to affect public sector recipients/practice solvency Conclusions: Unintended consequences of healthcare policy change affect APN practice/health of vulnerable populations. Recommendations for entrepreneur APNs include supportive policy in addition to business preparation, education, and tools that generate safe strategies for alternate income streams during policy/payer changes. Keywords: APN, APN entrepreneur, behavioral health, Medicaid waiver, Medicare, Medicare D, private practice, reimbursement strategies, TennCare
© 2010 American College of Nurse Practitioners
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rivate practices run by psychiatric mental health TennCare was a demonstration project from the 1965 (PMH) advanced practice nurses (APNs) have Medicaid program and continues as a jointly funded become more accepted in Tennessee, increasing cooperative between federal and state governments, helpfrom 0 to 3 in 2003 in the Upper Cumberland Region, ing states provide healthcare to eligible persons.2 effectively changing the local options for mental health TennCare was designed to enroll traditional Medicaidcare. Traditionally, the area had been served by a commueligible clients and expanded to include working poor nity mental health center and a handful of psychiatrists, and people who were ineligible for other private insurwith a clear need for more providers. New practices ance because of pre-existing illnesses.3 The program was opened by APNs availed the citizens of Tennessee to highly successful in enrollment but soon saturated availreceive the services of APNs as established by law and able funding and was restructured.2 Effective April 29, defined within the Nurse Practice Act, with prescriptive 2005, massive cuts to TennCare rolled back eligibility to authority since 1996.1 the initial 1994 requirements (Donaldson, personal comThe dynamics of establishing a practice and the daymunication, September 6, 2009).4,5 to-day operations are similar to those of other professions, Concurrently, in 2005, the Medicare Prescription although APN practices have distinct differences. New Drug, Improvement and Modernization Act of 2003 APN practices are relatively novel in concept as well as compelled adjustment of individual state Medicaid and low numbers, compared to physician (psychiatrist), social Medicaid waivers to comply with Medicare-D expanwork, and psychologist practice counterparts, and theresion, which included prescription benefits.6 These fore have fewer established support resources to draw changes affected healthcare delivery before, during, and upon. Challenges often rise from payer differences, lack of after the changeover period, which was between parity between professions providing the same or similar January 1 and April 30, 2006. Tennessee was in a unique services, and methods to generate funds to establish and position because, since 1994, the Title XI Medicaid continue a practice, all of which are highly influenced by Waiver of 19947 expanded eligibility exponentially policy. PMH APNs can provide psychodynamic services through incremental waivers for inclusion. A complex and medication management, services that are often either cascade of changes in reimbursement streams occurred inadequate or unavailable in rural communities. as payers tried to sort interconnected medicine and This case study documents the experiences of a sinservice coverage. This change was coupled with the gle APN behavioral health practice faced with navigatBureau of TennCare providing inconsistent communication about eligibility status,8 ing policy and payer changes leading to a groundswell of while meeting the needs of public uncertainty. patients and preserving the Public doubt about eligifinancial solvency of the pracCurrent reimbursement bility led to increasing worktice during sweeping, politicalpolicies do not offer loads in healthcare provider ly generated payer changes and clinicians incentives at any offices, massive increases in their unintended consequences missed appointments, nonadThe practice/study site was level to meet psychiatric herence, attrition from praclocated in rural Tennessee care needs in rural settings. tices, and ultimately, for some, within a poverty zip code. The psychiatric distress. practice was a non-grant-fundAdditionally, during the ed, single provider offering Medicare-D start up and the TennCare enrollment APN services including psychodynamic therapy and changes between April 29 and December 31, 2005, medication management. Primary care and specialty most dual-covered patients were denied medication providers referred to the practice. The practice used tradicoverage.9 TennCare, Medicare, and other third-party tional paper charts, billing created paper and electronic payers were the dominant players in the practice payer claims, and income came from fees for services. mix. The practice attempted to assimilate Buppert’s Historically, Tennessee implemented steps to reform model of APN practice solvency, which urged a balMedicaid in 1994 with a program known as TennCare.
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Report17 promoted the vision further with a blueprint to transform the entire behavioral healthcare delivery system as endorsed in commentary by Hoge et al.16 and Druss et al.18 Whitcomb19 urged acceptance of APN providers in all settings as a means to meet the national crisis of unmet and growing healthcare needs. Widespread fragmented care and inadequate reimbursement in community behavioral healthcare delivery are described in a review of literature13 that outlines delivery and payment problems of the current payment structure. APNs are subject to federal and state laws and third OBJECTIVES party payer policy(s), which vary in all 50 states. ComThe objectives of this case study were to chronicle the plicating the momentum for inclusive behavioral health response of a PMH APN-owned practice to policy-genercare, APNs are typically included but at lower reimburseated changes that impact comment rates for the same or simiplex and enmeshed reimburselar physician services.10 ment streams while accommoKaiser Family Foundation APN education, practice dating patient needs. The practice has tracked declining fees for payer review covers 14 months mental health; historically payer startup, and continuation and includes baseline data before issues emerge as salient enough expenses are inherently the 2005 TennCare changes and to block even the best efforts to affected by governing at 2 other points and follows the coordinate care.20 The recent dynamic transition to re-stabilizaMedicare-D restructuring of policies and intimately tion with Medicare-D in place. medication payers has shifted the influenced by the purse The case study isolates unique burden a bit, causing adjuststrings attached. patient needs during payer ments in state funding for the changes and specific APN-pracsame services as shown in the tice challenges, while specifying shifts of declining coverage for the working uninsured during that time.4 The quality of essential skills sets generic to PMH APN private- practice behavioral health has reduced, as evidenced by the National management over and above clinical skill. These essential Alliance for the Mentally Ill (NAMI) State Report Cards, abilities include specific business skills, political navigation, which show that there has been continued overall reducand process acumen, which may not be included in acation of PMH services since 2006. demic preparation. In 2006, Tennessee held an overall grade C and has regressed to a current overall grade of D21 in the assessLITERATURE REVIEW ment. The Mental Health Parity Act will help privateHistorical pay recipients, but it has little current effect on publicNumerous studies support expansion of PMH care both sector recipients with the exception of setting as a specialty and integrated into primary care, including precedent.22 Despite an overabundant supply of patients The Milbank Quarterly12 and the National Conference for 13 Community Behavioral Healthcare. The support gained needing services, few private psychiatric practices are momentum with former Surgeon General Satcher’s14 accepting public-sector patients. Archaic Centers for vision and mission to improve public responsibility for Medicare and Medicaid Services (CMS)23 and rural national mental health. In the 1990s the Annapolis PMH payer strategies continue to sanction rural PMH Coalition purposed to define provider preparation by provider claims, resulting in a 50% reduction of fees determining generic skills needed by all mental health reimbursed. These current reimbursement policies do not providers15 and an action plan in which to operationalize offer clinicians incentives at any level to meet psychiatric the workforce.16 The New Freedom Commission care needs in rural settings. New healthcare reform initiaance of income streams by balancing the mix of payers.10 Despite the balance of multiple payers, the established streams were upset by new policies and interconnectedness of payers that resulted in income shrinkage, requiring modifications in practice delivery. Thus, the case study practice, which received 224 payer panels, had challenges with consistent reimbursement.11 During this time of program change, innovative steps to cover the medication needs of patients were taken by the APN practice.
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tives are specified in the Nursing Community letter to Pelosi and Reed,24 capturing and synthesizing concerns and solutions from over 30 nursing organizations to effect changes that would mobilize the ability of nursing, including APN practices, to serve the larger needs of Americans through broad, sweeping policy initiatives, including behavioral health considerations.
retrospective review of active charts and billing materials. The retrospective review included records generated during the specific time identified for the most affected period by policy changes. The project used protected health information in de-identified and aggregate form; no human subjects were included. A case study carefully modulates accounts of events, seen through multiple points of view to understand the Nurse Entrepreneurship context of each contribution, and focuses on a single EBSCO, OVID, Pub Med, and CINAHL host searches unit, such as a single PMH APN practice.25 This case were performed using the words “nurse-owned practice,” study integrates coincidental events within a confluence “advance practice nurse,” and “nurse entrepreneur” yieldof time that affected the manner in which business was ing 8 articles, with none exploring individual APN pracconducted to serve a targeted group of consumers. The tice data in non-grant-funded time period under study private practices. There were included 90 days immediately publications exploring the subbefore the first 90-day period ject breadth, including philoof TennCare disenrollment on APN knowledge should be sophical materials and clinical May 1, 2005: January 31–April expanded to include and practice guidelines. No 30, 2005. The second 90-day development of multiple publications were found related period was July 3–September income streams necessary to services rendered and 30, 2005, a period of intense fee/reimbursements collected in payer adjustment. The third 90to protect practice solvency. primary care or in non-grantday period was January funded PMH practices. A 1–March 31, 2006, the first 90 Google search using the same terms did not yield addidays of Medicare-D. All time periods were associated tional publications. with swift policy-generated changes in reimbursement An additional search of readings was conducted relatfor behavioral health clients. The practice was dependent ed to general business concepts, nurses, and APN business upon income (and loss thereof) influenced by the changventures. The results yielded readings from business, ing financial streams from payers during these changes. nurse-based businesses, and publications concerning No specific instruments were created for this study, and behavioral health and scholarly journals. The authors data were recorded into Excel spreadsheets. excluded literature from comparative disciplines such as The study compared three sets of data collected from medicine (psychiatry), social work, and psychology active charts and billing materials at three different time because of discipline-specific differences in reimburseperiods. Period 1 data covered the 90 days before the ment, policy, and practice that influence profit. TennCare changes and were considered a baseline for reimbursement. These data were entered into an Excel STUDY DESIGN spreadsheet. Period 2 data included a 90-day transition This is a case study of an APN-owned behavioral health period to reflect the post-TennCare change. The second practice responding to the economic dynamics and presdata set added items that included the changes in sures from dramatic external policy changes. The changes TennCare status. Period 3 data reflect the adjustment to occurred between January 30, 2005, and March 31, 2006. the TennCare changes with Medicare-D information and The study examines the manner in which the practice include a 90-day transition period between the second operated before external changes, evolved through a tranand third data sets. sitional period, and modified its day-to-day operations in The three data sets were examined for progressively response to payer changes. changing information commensurate with program This project was submitted to Institutional Review changes. The Excel sheet design captured demographic Board, and exemption was granted and approved for a information in aggregate form. The data sets are grouped 710
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Table 1. Payer Sources Before, During, and After Changes* Collection 1 1/31/05 to 4/30/05
Collection 2 7/03/05 to 9/30/05
Collection 3 1/1/06 to 3/31/06
TennCare
45
46
23
Dual covered (TennCare & Medicare)
32
35
23
Private pay
43
52
52
Medicare & private pay
8
8
8
Medicare
4
6
4
Self-pay
5
10
4
Veterans Administration
2
2
2
Payer
* Demographics of payer sources of subjects divided into three time frames
for demographics and payer status. Descriptive statistics were used to summarize gender, age, referring agent, missed appointments, and insurer data. Where measures of central tendency were applicable, descriptors were compared in each data set. The implications of policy change have been inferred according to dates of policy changes and shifts in the population served. Changes in the practice were recorded in a chronologic narrative to reflect changes in payer streams. RESULTS Sample Characteristics within the Practice The study includes 263 patients, 170 females and 93 males. There were 214 adult patients 18 years or older and 49 pediatric patients age 17 or younger. The average age of all patients was 37.6 years; the average age of a pediatric patient was 11.5 years. Of the 214 adult patients, there were 154 females and 60 males, with the average age at 44.5 years. The standard deviation for all ages is 17.28 years. The most frequent referral source (N = 164) was Primary Care, with remaining referrals acquired from specialists (N = 99). There were 445 recorded noshows, averaging 1.7 no-shows per patient during the specified data collection times. No-shows ranged from 0 for 74 patients and 12 for one patient. The standard deviation of all patient no-shows was 1.848. Of the total patients, 35% (N = 92) were co-managed or casemanaged with agency oversight (e.g., Department of Children’s Services). Table 1 clarifies payer-source differences applicable to each time period. The most evident shift is the progressive reduction of TennCare-covered patients across time, reduced www.npjournal.org
to half by the study end. Dually covered patients reduced from 32 to 29, and private-pay patients increased from 43 to 52. Medicare-only patients increased slightly and then returned to baseline. Self-pay patients doubled from 5 to 10, then decreased to 4 after being absorbed into other payers. Veterans Administration (VA) patients remained unchanged. Table 2 breaks out medication supply. Of 29 patients approved for patient-assistance program (PAP) medications, five did not follow up to receive their medicines, an attrition rate of 0.17. Sixteen patients actively participated in the PAP, and 13 were absorbed back into other benefits. By March 31, 2006, of 263 patients, 176 received some type of medication supply or discount totaling 0.617, nearly two-thirds of the group. The practice office generated five involuntary admissions during the last data collection period, with two readmissions in this period. During the study, the involuntary inpatient admissions totaled eight in 9 days, exceeding the historical practice total. Table 2. Medication Supply Sources Throughout Study* Patient recipients Patient assistance program
29
Samples/discount coupons
176
Medicare D
41
Medicaid
37
Private insurance/self-pay
56
Veterans Administration
4
*Note: There was overlap of insurance and coupons/samples. Some patients receiving any payer coverage of services or medicine received samples/ coupons/vouchers as a result of expressed duress of medication, coverage, copays, etc., and rising costs of brand-name medicines. Numbers do no necessarily equal N of 263 because of overlap of medication supply sources.
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CASE CONCLUSIONS Champion efforts were required of the APN and staff to maintain optimal service and care to patients in the midst of multiple external changes. The largest attrition rate emerged from TennCare patients who self-selected out of care when benefits were lost, regardless of multiple options offered by the practice. Examples of assistance are fee reduction, medicine samples, and PAP, all made available by the practice. Despite changes in payer status, the typical diagnostic profile of the group and breakdown by age and gender remained consistent, demonstrating that the mentally ill need continuous care. Confusion related to benefit changes resulted in increased attrition in all payer groups. Medication acquisition was a central patient need, and patient destabilization was common during payer changes in all payer groups. No-shows for appointments resulted in a reduction in the billable hours and accounts receivable, when 9 of 10 patients did not show during the period of major policy shift. No-shows increased overhead because of an increase in patient distress, acuity, and need for continuous care for non-billable support services.
In this case study, policy shifts undermined the status quo for APN private practices with unintended consequences. To better prepare future APN entrepreneurs for dynamic changes in health policy that influence practice, core competencies within nursing curriculums should include more knowledge and skill for business ownership. Understanding and recognizing the potential for vulnerability with shifting political and policy winds, and embedding prevention and intervention strategies in APN practice business plans from startup and throughout the life of the entrepreneurial effort, are crucial to building and maintaining a practice. Pools of entrepreneurial APNs should organize in collaborative supportive organizations with a common goal of supporting individual practice success and promoting individual practice longevity. APN knowledge should be expanded to include diverse payer sources and development of multiple income streams necessary to protect practice solvency when payer changes result from policy and legislation. Optimizing payment and reimbursement streams will strengthen the APN position in the healthcare delivery system, but more importantly, successful APN practices will improve access and equity to the most vulnerable populations with comorbid and mental RECOMMENDATIONS AND POLICY CONSIDERATIONS health diagnoses. Sweeping policy changes that support eduThe expenses of APN higher education, practice startup, cational reimbursement, fund support for individual practice growth, and continuation are inherently affected by the startup and continuation, and improve reimbursement (parpolicies governing each and are intimately influenced by the ticularly in light of the 50% payment of rural mental health purse strings attached. APNs must have a financial safety net services by Medicare) need to be incepted for APNs willing before practice startup, and financial backing may not be so to treat this underserved population.23 easily found or sustained during payer lapses from policy APNs historically serve the poor, underinsured, and changes. Reimbursement limitations slow down the capture uninsured, the most vulnerable populations.26 Control by of such to satisfy overhead. Higher education makes efforts outside interest groups (e.g., insurance companies, hospito empower graduates with tal/healthcare corporate strucpolitical and business acumen, tures, organized medicine) and but political changes often lawmakers (e.g., legislated superThe financial and policy require the ability to support a vision requirements and policy practice while waiting for payers limitations in Medicare and barriers for APNs effectively to readjust for extended periods. Medicaid) puts the health of deny equity in care to patients This situation again requires a these populations at risk. APNs who are most vulnerable and financial cushion that may be as entrepreneurs in underserved disadvantaged. very difficult to secure, dependand disadvantaged communities ing upon myriad influences, improve equity and ultimately the health of those served by including the state of the econosuccessfully adjusting to incremental policy change. my. This leads the authors to conclude that broad-sweeping Supporting changes by exploring, exposing, and neutralizpolicy changes are essential to support the growth of indiing moves that incrementally decrease control on APN vidual APN practices, especially those serving primarily practices27 helps meet healthcare needs of the underserved. mental health patients. 712
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In light of the increasing physician shortage, the authors believe it is unacceptable to oppose the efforts of nursing and other professions that meet gaps in healthcare for underserved Americans.19 This commentary is directed at both acceptance of the increase in numbers and the scope of APN practices, especially those who are or will be in private entrepreneurial practices. POLICY CONCLUSIONS Healthcare provider practices are expensive to develop and to operate. Services in office-related billing are available, at an increase to overhead. In addition, reimbursement for APNs is markedly less than that awarded to physicians who provide the same or similar care. Office costs are similar for physicians and APNs, but disparity in reimbursement results in a lack of parity for practice operation.23 Effectively, this lack of parity in reimbursement and infrastructure startup and maintenance costs will ensure APNs incur substantial financial risks while serving in impoverished areas with disadvantaged and never-served populations who have complex co-morbid mental health and medical needs.28 The financial and policy barriers for APNs effectively deny equity in care to those most vulnerable and disadvantaged. Laws, rules, and regulations, along with funding policies, must change to accommodate the APN’s practice in optimal and varied settings and in settings of the APN’s choosing.27 Until then, APNs remain in a chokehold, prevented from fair payment for their services as a discipline. APNs are essentially shut out of providing financially reliable health care as a result of complex, ever-changing, and noninclusive regulations. Furthermore, patients, particularly those with comorbid mental health diagnoses or tenuous private health insurance, will experience more vulnerability because there is a lack of equity in healthcare delivery that stems from the limitations and barriers inherent in contemporary payer strategies. This being said, nothing short of policy promoting sweeping changes will effectively turn around the current practice challenges facing APNs in private practices, whether the practices are mental-health focused or otherwise. Hope seems to be dawning with recent healthcare reform initiatives inclusive of the broad interests of nurses, from education to practice equity. One comprehensive document is the Nursing Community Consensus Letter on Health Care Reform to Pelosi and Reed.24 Contained therein are the seeds to remediation of initial www.npjournal.org
practice cost defrayment through reduced overhead and discriminatory reimbursement, as well as broadly supportive policy changes. References 1. Tennessee Board of Nursing. Rules of the Tennessee Board of Nursing. 2009; 1st - 4th:Chapter 1000-1004-1001 to 1000-1004-1003. Available at http://tennessee.gov/sos/rules/1000/1000-04.20090625.pdf. Accessed September 4, 2009. 2. TN CODE 71-5-102. TennCare. 71-5-1022009. 3. Ozmibnkowsk R, Aizer A, Smith G. The value and use of the Qualified Medicare Beneficiary program: Early evidence from Tennessee. Health and Social Work. 1997;22(1):12-19. 4. Kaiser Family Foundation. Tennessee: Distribution of the nonelderly uninsured by federal poverty level (FPL), states (2006-2007), U.S. (2007) 2007. Available at http://www.statehealthfacts.org/profileind.jsp? ind=136&cat=3&rgn=44. Accessed September 4, 2009. 5. Mann C, Artiga S, Guyer J. Assessing the role of recent waivers in providing new coverage. 2003. Available at http://www.kff.org/medicaid/loader.cfm?url=/ commonspot/security/getfile.cfm&PageID=28336. Accessed August 27, 2009. 6. U.S. Congress. Medicare Prescription, Drug, Improvement and Modernization Act of 2003 Eligibilty, Enrollment and Provision. PL 108-173. 1 ed. Washington D.C.2003:1-6. http://www.medicare.gov/medicarereform/ 108s1013.htm 7. U.S. Congress. To amend title XXI of the Social Security Act to make technical corrections with respect to the definition of qualifying state, 108th Congress of the United States of America, 1st Session. Vol 2009. 108th Congress ed2003. 8. de la Cruz B, Wadhwani A, Paine A. Tenncare staredown. The Tennessean November 11, 2004. 9. Donaldson L. Health Coverage & Uninsured Nonelderly Uninsured Distribution by Federal Poverty Level 2003-2004. In: McCoy K, ed. Excel ed. Washington D.C.: Kaiser Family Foundation; 2009:1. 10. Buppert C. The primary care provider's guide to compensation and quality: How to get paid and not get sued. Sudberry, MD: Jones and Bartlett; 2005. 11. Buppert C. Nurse practitioner's business practice & legal guide. 2nd ed. Sudberry, MD: Jones and Bartlett; 2004. 12. Milbank Memorial Fund. Tracking state oversight of managed care. 1999. Available at http://www.milbank.org/reports/stateoversight/ 990918soihs.html#revision. Accessed August 27, 2009. 13. Mauer B. Background paper: Behavioral health/primary care integration models, competencies, and infrastructure. 2003. Available at http://www.machc.com/Documents/Reports/Intergrative%20Behavioral%2 0Health%20Care/Supplemental%20Tools/SectionI%20Intergrative%20Care .pdf. Accessed August 27, 2009. 14. Satcher D. Closing the gap: A national blueprint to improve the health of persons with mental retardation: Report of the Surgeon General's conference on health disparities and mental retardation in U.S. 2002. Available at http://www.surgeongeneral.gov/topics/ mentalretardation/ retardation.pdf. Accessed Sept. 4, 2009. 15. Hoge M, Paris M, Hoover A, et al. Workforce competencies in behavioral health: An overview Administration and Policy in Mental Health and Mental Health Services Research. 2005;32(5-6):593-631. 16. Hoge M, Morris A, Daniels A, Stuart G, Huey L, Adams N. An action plan for behavioral health workforce development: A framework for discussion. 2007; 347. Available at http://208.106.217.45/pages/images/ WorkforceActionPlan.pdf. Accessed September 4, 2009. 17. Mental Health Commission. President’s New Freedom Commission on Mental Health. President's New Freedom Commission on Mental Health. 2007. Available at http://www.mentalhealthcommission.gov/. Accessed October 23, 2009. 18. Druss B, Goldman H. New freedom commission report: Introduction to the special section on the President's New Freedom Commission Report 2003. Available at http://psychservices.psychiatryonline.org/cgi/reprint/ 54/11/1465.pdf. Accessed September 3, 2009. 19. Whitcomb M. The shortage of physicians and the future role of nurses. Acad Med. 2006;81(9):779-780. 20. Kaiser Daily Health Policy Report. New York Times Examines Declining Fees for Mental Health Therapists Coverage and Access 2006. Available at http://www.kaisernetwork.org/daily_reports/ print_report.cfm?DR_ID= 36242&dr_cat=3 Accessed September 17, 2009. 21. Aron L, Honberg R, Duckworth K, et al. Grading the states 2009: Overview: A report on America’s health care system for adults with serious mental illness. 2009. Available at http://nami.org/Content/
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22.
23.
24.
25. 26.
27. 28.
NavigationMenu/Grading_the_States_2009/Overview1/Overview.htm. Accessed August 26, 2009. Centers for Medicare &Medicaid Services. The Mental Health Parity Act. 2008. Available at http://www.cms.hhs.gov/healthinsreformforconsume/ 04_thementalhealthparityact.asp. Accessed March 20, 2009. Centers for Medicare & Medicaid Services. Medicare Part B Physician Assistant, Nurse Practitioner & Clinical Nurse Specialist Billing Guide 2004. 2004. Available at http://www.acnpweb.org/files/public/ Medicare_PartB_PA_NP_CNS_Billing_Guide_Sept04.pdf. Accessed September 4, 2009. AANAC, Academy of Medical-Surgical Nurses, American Academy of Nurse Practitioners, et al. Nursing Community Consensus Letter on HCR Conference. Washington D.C.: Nursing Community; January 6, 2010. Weiss CH. Evaluation: Methods for studying programs and policies. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 1998. Policastro D. Hearing on health reform in the 21st century: Proposals to reform the health sysytem. Committee on Ways and Means. 6 ed. Washington D.C.: American Nurses Association; 2009:5. Longest B. Health policymaking in the United States 3rd ed. Washington, DC: Association of University Programs in Health Administration; 2002. Committee on the Future of Rural Health Care: Board on Health Care Services. Improving the quality of health care for mind and substanceuse conditions: Quality Chasm Series. Washington, DC: National Academies Press; 2005.
Kathleen McCoy, DNSc, APRN, PMHNP-BC, PMHCNS-BC, FNP-BC, is an assistant professor in the Department of Primary Care & Public Health Graduate Program at the University of Tennessee Health Science Center College of Nursing in Memphis. She is triple ANCC certified as a family psychiatric mental health nurse practitioner, a clinical nurse specialist in adult psychiatric and mental health nursing, and as a family nurse practitioner. She can be reached at [email protected]. Michael Carter, DNSc, DNP, APN, FNP-BC, FAAN, is a University Distinguished Professor in the College of Nursing. Patricia D. Cunningham, DNSc, APN, PMHNP/CNS-BC, FNP-BC, is an associate professor and coordinator of the family psychiatric DNP option in the college. Patricia M. Speck, DNSc, APN, FNP-BC, SANE-A/P, DF-IAFN, FAAFS, FAAN, is an assistant professor in the family psychiatric DNP option at the college. Cynthia Rector, MD, is the medical director of Lifecare Family Services in Nashville, TN. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Acknowledgment The authors would like to thank and acknowledge Ms. Gail Spake for her invaluable contribution and editorial revisions to this manuscript. 1555-4155//$ see front matter © 2010 American College of Nurse Practitioners doi:10.1016/j.nurpra.2010.02.025
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Kathleen McCoy, Michael Carter, Patricia D. Cunningham, Patricia M. Speck, and Cynthia Rector
ABSTRACT Background: This is a case study of an advanced practice nurse (APN) practice response to 2003 Medicare D-associated payer changes. Description: Case study of changes in population/services after implementation of Medicare D policy considerations Study design: Case study with data at 3 time points and analyzed using descriptive statistics/central measures of tendency/dispersion Results: Largest changes found to affect public sector recipients/practice solvency Conclusions: Unintended consequences of healthcare policy change affect APN practice/health of vulnerable populations. Recommendations for entrepreneur APNs include supportive policy in addition to business preparation, education, and tools that generate safe strategies for alternate income streams during policy/payer changes. Keywords: APN, APN entrepreneur, behavioral health, Medicaid waiver, Medicare, Medicare D, private practice, reimbursement strategies, TennCare
© 2010 American College of Nurse Practitioners
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rivate practices run by psychiatric mental health TennCare was a demonstration project from the 1965 (PMH) advanced practice nurses (APNs) have Medicaid program and continues as a jointly funded become more accepted in Tennessee, increasing cooperative between federal and state governments, helpfrom 0 to 3 in 2003 in the Upper Cumberland Region, ing states provide healthcare to eligible persons.2 effectively changing the local options for mental health TennCare was designed to enroll traditional Medicaidcare. Traditionally, the area had been served by a commueligible clients and expanded to include working poor nity mental health center and a handful of psychiatrists, and people who were ineligible for other private insurwith a clear need for more providers. New practices ance because of pre-existing illnesses.3 The program was opened by APNs availed the citizens of Tennessee to highly successful in enrollment but soon saturated availreceive the services of APNs as established by law and able funding and was restructured.2 Effective April 29, defined within the Nurse Practice Act, with prescriptive 2005, massive cuts to TennCare rolled back eligibility to authority since 1996.1 the initial 1994 requirements (Donaldson, personal comThe dynamics of establishing a practice and the daymunication, September 6, 2009).4,5 to-day operations are similar to those of other professions, Concurrently, in 2005, the Medicare Prescription although APN practices have distinct differences. New Drug, Improvement and Modernization Act of 2003 APN practices are relatively novel in concept as well as compelled adjustment of individual state Medicaid and low numbers, compared to physician (psychiatrist), social Medicaid waivers to comply with Medicare-D expanwork, and psychologist practice counterparts, and theresion, which included prescription benefits.6 These fore have fewer established support resources to draw changes affected healthcare delivery before, during, and upon. Challenges often rise from payer differences, lack of after the changeover period, which was between parity between professions providing the same or similar January 1 and April 30, 2006. Tennessee was in a unique services, and methods to generate funds to establish and position because, since 1994, the Title XI Medicaid continue a practice, all of which are highly influenced by Waiver of 19947 expanded eligibility exponentially policy. PMH APNs can provide psychodynamic services through incremental waivers for inclusion. A complex and medication management, services that are often either cascade of changes in reimbursement streams occurred inadequate or unavailable in rural communities. as payers tried to sort interconnected medicine and This case study documents the experiences of a sinservice coverage. This change was coupled with the gle APN behavioral health practice faced with navigatBureau of TennCare providing inconsistent communication about eligibility status,8 ing policy and payer changes leading to a groundswell of while meeting the needs of public uncertainty. patients and preserving the Public doubt about eligifinancial solvency of the pracCurrent reimbursement bility led to increasing worktice during sweeping, politicalpolicies do not offer loads in healthcare provider ly generated payer changes and clinicians incentives at any offices, massive increases in their unintended consequences missed appointments, nonadThe practice/study site was level to meet psychiatric herence, attrition from praclocated in rural Tennessee care needs in rural settings. tices, and ultimately, for some, within a poverty zip code. The psychiatric distress. practice was a non-grant-fundAdditionally, during the ed, single provider offering Medicare-D start up and the TennCare enrollment APN services including psychodynamic therapy and changes between April 29 and December 31, 2005, medication management. Primary care and specialty most dual-covered patients were denied medication providers referred to the practice. The practice used tradicoverage.9 TennCare, Medicare, and other third-party tional paper charts, billing created paper and electronic payers were the dominant players in the practice payer claims, and income came from fees for services. mix. The practice attempted to assimilate Buppert’s Historically, Tennessee implemented steps to reform model of APN practice solvency, which urged a balMedicaid in 1994 with a program known as TennCare.
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Report17 promoted the vision further with a blueprint to transform the entire behavioral healthcare delivery system as endorsed in commentary by Hoge et al.16 and Druss et al.18 Whitcomb19 urged acceptance of APN providers in all settings as a means to meet the national crisis of unmet and growing healthcare needs. Widespread fragmented care and inadequate reimbursement in community behavioral healthcare delivery are described in a review of literature13 that outlines delivery and payment problems of the current payment structure. APNs are subject to federal and state laws and third OBJECTIVES party payer policy(s), which vary in all 50 states. ComThe objectives of this case study were to chronicle the plicating the momentum for inclusive behavioral health response of a PMH APN-owned practice to policy-genercare, APNs are typically included but at lower reimburseated changes that impact comment rates for the same or simiplex and enmeshed reimburselar physician services.10 ment streams while accommoKaiser Family Foundation APN education, practice dating patient needs. The practice has tracked declining fees for payer review covers 14 months mental health; historically payer startup, and continuation and includes baseline data before issues emerge as salient enough expenses are inherently the 2005 TennCare changes and to block even the best efforts to affected by governing at 2 other points and follows the coordinate care.20 The recent dynamic transition to re-stabilizaMedicare-D restructuring of policies and intimately tion with Medicare-D in place. medication payers has shifted the influenced by the purse The case study isolates unique burden a bit, causing adjuststrings attached. patient needs during payer ments in state funding for the changes and specific APN-pracsame services as shown in the tice challenges, while specifying shifts of declining coverage for the working uninsured during that time.4 The quality of essential skills sets generic to PMH APN private- practice behavioral health has reduced, as evidenced by the National management over and above clinical skill. These essential Alliance for the Mentally Ill (NAMI) State Report Cards, abilities include specific business skills, political navigation, which show that there has been continued overall reducand process acumen, which may not be included in acation of PMH services since 2006. demic preparation. In 2006, Tennessee held an overall grade C and has regressed to a current overall grade of D21 in the assessLITERATURE REVIEW ment. The Mental Health Parity Act will help privateHistorical pay recipients, but it has little current effect on publicNumerous studies support expansion of PMH care both sector recipients with the exception of setting as a specialty and integrated into primary care, including precedent.22 Despite an overabundant supply of patients The Milbank Quarterly12 and the National Conference for 13 Community Behavioral Healthcare. The support gained needing services, few private psychiatric practices are momentum with former Surgeon General Satcher’s14 accepting public-sector patients. Archaic Centers for vision and mission to improve public responsibility for Medicare and Medicaid Services (CMS)23 and rural national mental health. In the 1990s the Annapolis PMH payer strategies continue to sanction rural PMH Coalition purposed to define provider preparation by provider claims, resulting in a 50% reduction of fees determining generic skills needed by all mental health reimbursed. These current reimbursement policies do not providers15 and an action plan in which to operationalize offer clinicians incentives at any level to meet psychiatric the workforce.16 The New Freedom Commission care needs in rural settings. New healthcare reform initiaance of income streams by balancing the mix of payers.10 Despite the balance of multiple payers, the established streams were upset by new policies and interconnectedness of payers that resulted in income shrinkage, requiring modifications in practice delivery. Thus, the case study practice, which received 224 payer panels, had challenges with consistent reimbursement.11 During this time of program change, innovative steps to cover the medication needs of patients were taken by the APN practice.
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tives are specified in the Nursing Community letter to Pelosi and Reed,24 capturing and synthesizing concerns and solutions from over 30 nursing organizations to effect changes that would mobilize the ability of nursing, including APN practices, to serve the larger needs of Americans through broad, sweeping policy initiatives, including behavioral health considerations.
retrospective review of active charts and billing materials. The retrospective review included records generated during the specific time identified for the most affected period by policy changes. The project used protected health information in de-identified and aggregate form; no human subjects were included. A case study carefully modulates accounts of events, seen through multiple points of view to understand the Nurse Entrepreneurship context of each contribution, and focuses on a single EBSCO, OVID, Pub Med, and CINAHL host searches unit, such as a single PMH APN practice.25 This case were performed using the words “nurse-owned practice,” study integrates coincidental events within a confluence “advance practice nurse,” and “nurse entrepreneur” yieldof time that affected the manner in which business was ing 8 articles, with none exploring individual APN pracconducted to serve a targeted group of consumers. The tice data in non-grant-funded time period under study private practices. There were included 90 days immediately publications exploring the subbefore the first 90-day period ject breadth, including philoof TennCare disenrollment on APN knowledge should be sophical materials and clinical May 1, 2005: January 31–April expanded to include and practice guidelines. No 30, 2005. The second 90-day development of multiple publications were found related period was July 3–September income streams necessary to services rendered and 30, 2005, a period of intense fee/reimbursements collected in payer adjustment. The third 90to protect practice solvency. primary care or in non-grantday period was January funded PMH practices. A 1–March 31, 2006, the first 90 Google search using the same terms did not yield addidays of Medicare-D. All time periods were associated tional publications. with swift policy-generated changes in reimbursement An additional search of readings was conducted relatfor behavioral health clients. The practice was dependent ed to general business concepts, nurses, and APN business upon income (and loss thereof) influenced by the changventures. The results yielded readings from business, ing financial streams from payers during these changes. nurse-based businesses, and publications concerning No specific instruments were created for this study, and behavioral health and scholarly journals. The authors data were recorded into Excel spreadsheets. excluded literature from comparative disciplines such as The study compared three sets of data collected from medicine (psychiatry), social work, and psychology active charts and billing materials at three different time because of discipline-specific differences in reimburseperiods. Period 1 data covered the 90 days before the ment, policy, and practice that influence profit. TennCare changes and were considered a baseline for reimbursement. These data were entered into an Excel STUDY DESIGN spreadsheet. Period 2 data included a 90-day transition This is a case study of an APN-owned behavioral health period to reflect the post-TennCare change. The second practice responding to the economic dynamics and presdata set added items that included the changes in sures from dramatic external policy changes. The changes TennCare status. Period 3 data reflect the adjustment to occurred between January 30, 2005, and March 31, 2006. the TennCare changes with Medicare-D information and The study examines the manner in which the practice include a 90-day transition period between the second operated before external changes, evolved through a tranand third data sets. sitional period, and modified its day-to-day operations in The three data sets were examined for progressively response to payer changes. changing information commensurate with program This project was submitted to Institutional Review changes. The Excel sheet design captured demographic Board, and exemption was granted and approved for a information in aggregate form. The data sets are grouped 710
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Table 1. Payer Sources Before, During, and After Changes* Collection 1 1/31/05 to 4/30/05
Collection 2 7/03/05 to 9/30/05
Collection 3 1/1/06 to 3/31/06
TennCare
45
46
23
Dual covered (TennCare & Medicare)
32
35
23
Private pay
43
52
52
Medicare & private pay
8
8
8
Medicare
4
6
4
Self-pay
5
10
4
Veterans Administration
2
2
2
Payer
* Demographics of payer sources of subjects divided into three time frames
for demographics and payer status. Descriptive statistics were used to summarize gender, age, referring agent, missed appointments, and insurer data. Where measures of central tendency were applicable, descriptors were compared in each data set. The implications of policy change have been inferred according to dates of policy changes and shifts in the population served. Changes in the practice were recorded in a chronologic narrative to reflect changes in payer streams. RESULTS Sample Characteristics within the Practice The study includes 263 patients, 170 females and 93 males. There were 214 adult patients 18 years or older and 49 pediatric patients age 17 or younger. The average age of all patients was 37.6 years; the average age of a pediatric patient was 11.5 years. Of the 214 adult patients, there were 154 females and 60 males, with the average age at 44.5 years. The standard deviation for all ages is 17.28 years. The most frequent referral source (N = 164) was Primary Care, with remaining referrals acquired from specialists (N = 99). There were 445 recorded noshows, averaging 1.7 no-shows per patient during the specified data collection times. No-shows ranged from 0 for 74 patients and 12 for one patient. The standard deviation of all patient no-shows was 1.848. Of the total patients, 35% (N = 92) were co-managed or casemanaged with agency oversight (e.g., Department of Children’s Services). Table 1 clarifies payer-source differences applicable to each time period. The most evident shift is the progressive reduction of TennCare-covered patients across time, reduced www.npjournal.org
to half by the study end. Dually covered patients reduced from 32 to 29, and private-pay patients increased from 43 to 52. Medicare-only patients increased slightly and then returned to baseline. Self-pay patients doubled from 5 to 10, then decreased to 4 after being absorbed into other payers. Veterans Administration (VA) patients remained unchanged. Table 2 breaks out medication supply. Of 29 patients approved for patient-assistance program (PAP) medications, five did not follow up to receive their medicines, an attrition rate of 0.17. Sixteen patients actively participated in the PAP, and 13 were absorbed back into other benefits. By March 31, 2006, of 263 patients, 176 received some type of medication supply or discount totaling 0.617, nearly two-thirds of the group. The practice office generated five involuntary admissions during the last data collection period, with two readmissions in this period. During the study, the involuntary inpatient admissions totaled eight in 9 days, exceeding the historical practice total. Table 2. Medication Supply Sources Throughout Study* Patient recipients Patient assistance program
29
Samples/discount coupons
176
Medicare D
41
Medicaid
37
Private insurance/self-pay
56
Veterans Administration
4
*Note: There was overlap of insurance and coupons/samples. Some patients receiving any payer coverage of services or medicine received samples/ coupons/vouchers as a result of expressed duress of medication, coverage, copays, etc., and rising costs of brand-name medicines. Numbers do no necessarily equal N of 263 because of overlap of medication supply sources.
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CASE CONCLUSIONS Champion efforts were required of the APN and staff to maintain optimal service and care to patients in the midst of multiple external changes. The largest attrition rate emerged from TennCare patients who self-selected out of care when benefits were lost, regardless of multiple options offered by the practice. Examples of assistance are fee reduction, medicine samples, and PAP, all made available by the practice. Despite changes in payer status, the typical diagnostic profile of the group and breakdown by age and gender remained consistent, demonstrating that the mentally ill need continuous care. Confusion related to benefit changes resulted in increased attrition in all payer groups. Medication acquisition was a central patient need, and patient destabilization was common during payer changes in all payer groups. No-shows for appointments resulted in a reduction in the billable hours and accounts receivable, when 9 of 10 patients did not show during the period of major policy shift. No-shows increased overhead because of an increase in patient distress, acuity, and need for continuous care for non-billable support services.
In this case study, policy shifts undermined the status quo for APN private practices with unintended consequences. To better prepare future APN entrepreneurs for dynamic changes in health policy that influence practice, core competencies within nursing curriculums should include more knowledge and skill for business ownership. Understanding and recognizing the potential for vulnerability with shifting political and policy winds, and embedding prevention and intervention strategies in APN practice business plans from startup and throughout the life of the entrepreneurial effort, are crucial to building and maintaining a practice. Pools of entrepreneurial APNs should organize in collaborative supportive organizations with a common goal of supporting individual practice success and promoting individual practice longevity. APN knowledge should be expanded to include diverse payer sources and development of multiple income streams necessary to protect practice solvency when payer changes result from policy and legislation. Optimizing payment and reimbursement streams will strengthen the APN position in the healthcare delivery system, but more importantly, successful APN practices will improve access and equity to the most vulnerable populations with comorbid and mental RECOMMENDATIONS AND POLICY CONSIDERATIONS health diagnoses. Sweeping policy changes that support eduThe expenses of APN higher education, practice startup, cational reimbursement, fund support for individual practice growth, and continuation are inherently affected by the startup and continuation, and improve reimbursement (parpolicies governing each and are intimately influenced by the ticularly in light of the 50% payment of rural mental health purse strings attached. APNs must have a financial safety net services by Medicare) need to be incepted for APNs willing before practice startup, and financial backing may not be so to treat this underserved population.23 easily found or sustained during payer lapses from policy APNs historically serve the poor, underinsured, and changes. Reimbursement limitations slow down the capture uninsured, the most vulnerable populations.26 Control by of such to satisfy overhead. Higher education makes efforts outside interest groups (e.g., insurance companies, hospito empower graduates with tal/healthcare corporate strucpolitical and business acumen, tures, organized medicine) and but political changes often lawmakers (e.g., legislated superThe financial and policy require the ability to support a vision requirements and policy practice while waiting for payers limitations in Medicare and barriers for APNs effectively to readjust for extended periods. Medicaid) puts the health of deny equity in care to patients This situation again requires a these populations at risk. APNs who are most vulnerable and financial cushion that may be as entrepreneurs in underserved disadvantaged. very difficult to secure, dependand disadvantaged communities ing upon myriad influences, improve equity and ultimately the health of those served by including the state of the econosuccessfully adjusting to incremental policy change. my. This leads the authors to conclude that broad-sweeping Supporting changes by exploring, exposing, and neutralizpolicy changes are essential to support the growth of indiing moves that incrementally decrease control on APN vidual APN practices, especially those serving primarily practices27 helps meet healthcare needs of the underserved. mental health patients. 712
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In light of the increasing physician shortage, the authors believe it is unacceptable to oppose the efforts of nursing and other professions that meet gaps in healthcare for underserved Americans.19 This commentary is directed at both acceptance of the increase in numbers and the scope of APN practices, especially those who are or will be in private entrepreneurial practices. POLICY CONCLUSIONS Healthcare provider practices are expensive to develop and to operate. Services in office-related billing are available, at an increase to overhead. In addition, reimbursement for APNs is markedly less than that awarded to physicians who provide the same or similar care. Office costs are similar for physicians and APNs, but disparity in reimbursement results in a lack of parity for practice operation.23 Effectively, this lack of parity in reimbursement and infrastructure startup and maintenance costs will ensure APNs incur substantial financial risks while serving in impoverished areas with disadvantaged and never-served populations who have complex co-morbid mental health and medical needs.28 The financial and policy barriers for APNs effectively deny equity in care to those most vulnerable and disadvantaged. Laws, rules, and regulations, along with funding policies, must change to accommodate the APN’s practice in optimal and varied settings and in settings of the APN’s choosing.27 Until then, APNs remain in a chokehold, prevented from fair payment for their services as a discipline. APNs are essentially shut out of providing financially reliable health care as a result of complex, ever-changing, and noninclusive regulations. Furthermore, patients, particularly those with comorbid mental health diagnoses or tenuous private health insurance, will experience more vulnerability because there is a lack of equity in healthcare delivery that stems from the limitations and barriers inherent in contemporary payer strategies. This being said, nothing short of policy promoting sweeping changes will effectively turn around the current practice challenges facing APNs in private practices, whether the practices are mental-health focused or otherwise. Hope seems to be dawning with recent healthcare reform initiatives inclusive of the broad interests of nurses, from education to practice equity. One comprehensive document is the Nursing Community Consensus Letter on Health Care Reform to Pelosi and Reed.24 Contained therein are the seeds to remediation of initial www.npjournal.org
practice cost defrayment through reduced overhead and discriminatory reimbursement, as well as broadly supportive policy changes. References 1. Tennessee Board of Nursing. Rules of the Tennessee Board of Nursing. 2009; 1st - 4th:Chapter 1000-1004-1001 to 1000-1004-1003. Available at http://tennessee.gov/sos/rules/1000/1000-04.20090625.pdf. Accessed September 4, 2009. 2. TN CODE 71-5-102. TennCare. 71-5-1022009. 3. Ozmibnkowsk R, Aizer A, Smith G. The value and use of the Qualified Medicare Beneficiary program: Early evidence from Tennessee. Health and Social Work. 1997;22(1):12-19. 4. Kaiser Family Foundation. Tennessee: Distribution of the nonelderly uninsured by federal poverty level (FPL), states (2006-2007), U.S. (2007) 2007. Available at http://www.statehealthfacts.org/profileind.jsp? ind=136&cat=3&rgn=44. Accessed September 4, 2009. 5. Mann C, Artiga S, Guyer J. Assessing the role of recent waivers in providing new coverage. 2003. Available at http://www.kff.org/medicaid/loader.cfm?url=/ commonspot/security/getfile.cfm&PageID=28336. Accessed August 27, 2009. 6. U.S. Congress. Medicare Prescription, Drug, Improvement and Modernization Act of 2003 Eligibilty, Enrollment and Provision. PL 108-173. 1 ed. Washington D.C.2003:1-6. http://www.medicare.gov/medicarereform/ 108s1013.htm 7. U.S. Congress. To amend title XXI of the Social Security Act to make technical corrections with respect to the definition of qualifying state, 108th Congress of the United States of America, 1st Session. Vol 2009. 108th Congress ed2003. 8. de la Cruz B, Wadhwani A, Paine A. Tenncare staredown. The Tennessean November 11, 2004. 9. Donaldson L. Health Coverage & Uninsured Nonelderly Uninsured Distribution by Federal Poverty Level 2003-2004. In: McCoy K, ed. Excel ed. Washington D.C.: Kaiser Family Foundation; 2009:1. 10. Buppert C. The primary care provider's guide to compensation and quality: How to get paid and not get sued. Sudberry, MD: Jones and Bartlett; 2005. 11. Buppert C. Nurse practitioner's business practice & legal guide. 2nd ed. Sudberry, MD: Jones and Bartlett; 2004. 12. Milbank Memorial Fund. Tracking state oversight of managed care. 1999. Available at http://www.milbank.org/reports/stateoversight/ 990918soihs.html#revision. Accessed August 27, 2009. 13. Mauer B. Background paper: Behavioral health/primary care integration models, competencies, and infrastructure. 2003. Available at http://www.machc.com/Documents/Reports/Intergrative%20Behavioral%2 0Health%20Care/Supplemental%20Tools/SectionI%20Intergrative%20Care .pdf. Accessed August 27, 2009. 14. Satcher D. Closing the gap: A national blueprint to improve the health of persons with mental retardation: Report of the Surgeon General's conference on health disparities and mental retardation in U.S. 2002. Available at http://www.surgeongeneral.gov/topics/ mentalretardation/ retardation.pdf. Accessed Sept. 4, 2009. 15. Hoge M, Paris M, Hoover A, et al. Workforce competencies in behavioral health: An overview Administration and Policy in Mental Health and Mental Health Services Research. 2005;32(5-6):593-631. 16. Hoge M, Morris A, Daniels A, Stuart G, Huey L, Adams N. An action plan for behavioral health workforce development: A framework for discussion. 2007; 347. Available at http://208.106.217.45/pages/images/ WorkforceActionPlan.pdf. Accessed September 4, 2009. 17. Mental Health Commission. President’s New Freedom Commission on Mental Health. President's New Freedom Commission on Mental Health. 2007. Available at http://www.mentalhealthcommission.gov/. Accessed October 23, 2009. 18. Druss B, Goldman H. New freedom commission report: Introduction to the special section on the President's New Freedom Commission Report 2003. Available at http://psychservices.psychiatryonline.org/cgi/reprint/ 54/11/1465.pdf. Accessed September 3, 2009. 19. Whitcomb M. The shortage of physicians and the future role of nurses. Acad Med. 2006;81(9):779-780. 20. Kaiser Daily Health Policy Report. New York Times Examines Declining Fees for Mental Health Therapists Coverage and Access 2006. Available at http://www.kaisernetwork.org/daily_reports/ print_report.cfm?DR_ID= 36242&dr_cat=3 Accessed September 17, 2009. 21. Aron L, Honberg R, Duckworth K, et al. Grading the states 2009: Overview: A report on America’s health care system for adults with serious mental illness. 2009. Available at http://nami.org/Content/
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NavigationMenu/Grading_the_States_2009/Overview1/Overview.htm. Accessed August 26, 2009. Centers for Medicare &Medicaid Services. The Mental Health Parity Act. 2008. Available at http://www.cms.hhs.gov/healthinsreformforconsume/ 04_thementalhealthparityact.asp. Accessed March 20, 2009. Centers for Medicare & Medicaid Services. Medicare Part B Physician Assistant, Nurse Practitioner & Clinical Nurse Specialist Billing Guide 2004. 2004. Available at http://www.acnpweb.org/files/public/ Medicare_PartB_PA_NP_CNS_Billing_Guide_Sept04.pdf. Accessed September 4, 2009. AANAC, Academy of Medical-Surgical Nurses, American Academy of Nurse Practitioners, et al. Nursing Community Consensus Letter on HCR Conference. Washington D.C.: Nursing Community; January 6, 2010. Weiss CH. Evaluation: Methods for studying programs and policies. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 1998. Policastro D. Hearing on health reform in the 21st century: Proposals to reform the health sysytem. Committee on Ways and Means. 6 ed. Washington D.C.: American Nurses Association; 2009:5. Longest B. Health policymaking in the United States 3rd ed. Washington, DC: Association of University Programs in Health Administration; 2002. Committee on the Future of Rural Health Care: Board on Health Care Services. Improving the quality of health care for mind and substanceuse conditions: Quality Chasm Series. Washington, DC: National Academies Press; 2005.
Kathleen McCoy, DNSc, APRN, PMHNP-BC, PMHCNS-BC, FNP-BC, is an assistant professor in the Department of Primary Care & Public Health Graduate Program at the University of Tennessee Health Science Center College of Nursing in Memphis. She is triple ANCC certified as a family psychiatric mental health nurse practitioner, a clinical nurse specialist in adult psychiatric and mental health nursing, and as a family nurse practitioner. She can be reached at [email protected]. Michael Carter, DNSc, DNP, APN, FNP-BC, FAAN, is a University Distinguished Professor in the College of Nursing. Patricia D. Cunningham, DNSc, APN, PMHNP/CNS-BC, FNP-BC, is an associate professor and coordinator of the family psychiatric DNP option in the college. Patricia M. Speck, DNSc, APN, FNP-BC, SANE-A/P, DF-IAFN, FAAFS, FAAN, is an assistant professor in the family psychiatric DNP option at the college. Cynthia Rector, MD, is the medical director of Lifecare Family Services in Nashville, TN. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Acknowledgment The authors would like to thank and acknowledge Ms. Gail Spake for her invaluable contribution and editorial revisions to this manuscript. 1555-4155//$ see front matter © 2010 American College of Nurse Practitioners doi:10.1016/j.nurpra.2010.02.025
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