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APN Multi State Reimbursement Alliance

Research Demonstrating the Impact of Advanced Practice Nurses on Patient Care Outcomes, Satisfaction and Cost Savings APN MULTI STATE REIMBURSEMENT ALLIANCE 2008. APN Multi State Reimbursement Alliance. Goals:

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APN Multi State Reimbursement Alliance

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  1. Research Demonstratingthe Impact of Advanced Practice Nurses on Patient Care Outcomes, Satisfaction and Cost Savings APN MULTI STATE REIMBURSEMENTALLIANCE 2008

  2. APN Multi State Reimbursement Alliance • Goals: • To utilize the legal, legislative and regulatory mechanisms needed to overcome the reimbursement barriers facing Advanced Practice Nurses (APNs) • To provide state and regional perspectives on the problems commercial payers create for APN providers due to inconsistencies in payment for services rendered • To assure that fair and equitable reimbursement is guaranteed to all APNs in the Multi State geographic area • To assure that patient access to APN services is not limited, restricted, or denied due to commercial payer rules and regulations

  3. Advanced Practice Nurses Advanced Practice Nurses (APNs) include: Certified Nurse Practitioner (CNP) Certified Nurse Midwife (CNM) Clinical Nurse Specialist (CNS) Certified Registered Nurse Anesthetist Master or Doctoral prepared registered nurses Board Certified in specialization

  4. Advanced Practice Nurses • Serve as PCPs (Primary Care Providers) • Prescribe Medication Schedule II-IV • Independently bill Medicare, Medicaid, Bureau of Workers Compensation, and most commercial payers. • Practice according to state law • Manage hospitalized patients and discharge patients with physicians • Provide preventive services and health counseling/education in clinical practice • Provide acute care and specialty services • Provide consult services

  5. Serve as Primary Care Provider (PCP)For Managed Care Plans • Assist with coordination of the member's overall care, as appropriate for the member • Serve as the ongoing source of primary and preventive care • Recommend referrals to specialists as needed • Triage to appropriate services • Participate in the development of case management treatment plans and • Case management referral and treatment planning.

  6. Access to Primary Careis an Ongoing Problem – Nurse Practitioners are Part of the Solution • US medical school graduates selecting primary care continues to decline steadily. • Nurse Practitioners provided a greater percentage of primary care services than any other practitioner or provider type including; Family Physicians, Internal Medicine, Pediatric Medicine and Physician Assistants (MEDPAC) • Data from MEDPAC (Medicare Payment Advisory Commission), which advises Congress on issues affecting Medicare, from an analysis of 2006 Medicare claims for 100% of Medicare beneficiaries

  7. Health Care delivered by APNs Results In: • High quality care • Cost effective care • High patient satisfaction • Value-added care

  8. EXCELLENT OUTCOMES & HIGH QUALITY

  9. Obstetrical Care and Certified Nurse Midwives (CNMs) Excellent Outcomes, Higher Quality of Care with CNMs • CNMs – have better outcomes than physicians, showing a 41% reduction in low weight births and very low weight births (Vistainer, Uman, Horgan, 2000) • CNMs – have better outcomes than physicians, (when analyzing all nurse midwife-delivered births in the US in 1991), In higher risk patients, showing a 19% lower infant death, 33% lower neonatal mortality, 31% decrease in number of Low Birth Weight babies (MacDorman 1998)

  10. Obstetrical Care and Certified Nurse Midwife (CNM) Excellent Outcomes, Higher Quality of Care • Pregnant women under the collaborative care of a CNM and an obstetrician were 15% more likely to have a normal vaginal delivery (less likely to receive interventions such as oxytocin induction, episiotomies and epidural anesthesia), and 28% more likely to be discharged within 24 hours compared to patients receiving care from physicians only (Jackson et al 2003) • Pregnant women under care of a CNM had fewer cesarean sections, decreased maternal and fetal complications, shorter hospital stays and decreased resource utilization (Rosenblatt RA, et al. 1997) • Because of the decreased time in the hospital and lower complication rates, CNMs are cost efficient, saving money for employees, employers and insurance companies.

  11. Prenatal Care and Advanced Practice Nurses Excellent Outcomes, Higher Quality of Care and Reduced Costs • One Half of 173 high risk prenatal patients received home care from advanced practice nurses resulting in 78% fewer infants deaths, 11 fewer preterm births, fewer prenatal and infant rehospitalizations (Brooten et.al 2001) • Health Care Savings in this group – included 750 hospital days saved for a total savings of $2,496,145. (Brooten et.al 2001) • Prenatal care provided to 80 women with high risk pregnancies by the APNs resulted in fewer hospital days and significant savings over the infants’ first year of life (Brooten et.al 2005)

  12. Psychiatric Clinical Nurse Specialists (CNSs)Provide Quality Care • United Behavioral Health – conducted a national survey on prescribing practices of psychiatric CNSs and found only minor differences between psychiatrists and CNSs. • Chart documentation: not different between the two groups: intervention, treatment plans and monitoring processes were excellent for all practitioners.

  13. Psychiatric Clinical Nurse Specialists (CNS) Provide Quality Care (cont.) • Clinical Management: No differences in dosing between psychiatrists and CNSs • Psychiatrists were more likely to augment and switch medications than the CNSs. • CNSs have less polypharmacy (patients on multiple drugs)- indicates that CNSs are cautious prescribers • Length of Therapy: same between CNSs and psychiatrists • HEDIS measures of Quality: were the same between CNSs and psychiatrists • Recommendations were to: Increase the number of psychiatric CNSs in the United Behavioral Health provider network (Feldman et al, 2003)

  14. Quality of Care is improved with Advanced Practice Nurses(cont). • Nurse Practitioners identified more physical abnormalities, they were as accurate as physicians in ordering and interpreting x-ray films, gave more information to patients, had more complete records and scored better on communication than did doctors.(Horrocks 2002) • Summary: NPs had better outcomes and lower costs than physicians when managing patients in the Medical Intensive Care Unit.(Hoffman, etal.2005)

  15. Quality of Care is improved with Advanced Practice Nurses (cont). • Nurse Practitioners provided a “total package of care that was equal to and better in some cases than the physician care in an emergency – urgent care setting.” • Waiting times were much lower and medical errors were significantly lower (13.2% vs. 9.6%) (Sakr, et al. 2003) • Preventive care services including screening and rates of health counseling provided in primary care practices for diet, HIV, STD, tobacco use, exercise etc., were significantly higher in visits involving a NP (Lin 2004; Hung 2006) Write Message

  16. Quality of Care is improved with APNs (cont) • Quality of care in nurse managed centers (NMCs) using HEDIS outcomes. Journal for Healthcare Quality (Barkauskas, Pohl 2005). • NMCs achieved or exceeded HEDIS outcomes in asthma, diabetes, hypertension, cervical and breast cancer screening. • Nurse Practitioners were more successful in managing hypercholesterolemia following coronary revascularization with 16% > drug compliance and greater decrease in LDL than those receiving physician care. (Paez 2006)

  17. LOWER COSTS

  18. Chronic Disease and Aging Population Fuel Health Care Costs • Americans are living longer • Chronic health problems have overtaken acute illnesses as the major determinant in health care costs. Retirees chronic health care costs have skyrocketed. • Patients with heart-failure typically have the highest rate of hospitalization at a cost exceeding $24 billion annually. Nearly 5 million US citizens require heart failure management and 500,000 cases are diagnosed each year. (National Institute of Health News, 5/12/04; American Heart Association 2004)

  19. CHRONIC ILLNESS – COST SAVINGS Hospitalized Congestive Heart Failure Patients • Adding independent NPs to the inpatient heart failure team reduced total hospital costs significantly and length of stay (Dahle 1998). • Hospitalized CHF patients managed by NPs had excellent outcomes, lower mortality, met quality indicators and had an overall decrease in the length of stay (Oakwood Hospital, Dearborn Michigan, 2005; Rasmusson 2005).

  20. HOSPITALIZED PATIENTS – COST SAVINGSINPATIENT CARE FOR GENERAL MEDICINE PATIENTS • Nurse Practitioners and Physician teams significantly reduced the inpatient costs per patient during the initial hospital stay and the post discharge service use. • 1,207 patients were randomized to the intervention NP/physician team versus the usual care physician provider only, in an academic medical center. The net cost savings was $978 per patient, health outcomes were similar between the two groups (Ettner SL, 2006).

  21. HOSPITALIZED PATIENTS – COST SAVINGSHospitalist/Physician & Advanced Practice Nurses Nurse Practitioner/Hospitalist teams had significantly shorter hospital Length of Stay (LOS) than physician only teams. • Quasi experimental design 1,207 general medicine patients assigned to NP/Hospitalist team resulted in shorter LOS: • Lower costs; • No increase in readmission rate or mortality rate; • Hospital profit: $1,591/day/patient; and • Enhanced continuity, expedited discharge, and assessment after discharge (Cowan 2006)

  22. HOSPITALIZED PATIENTS – COST SAVINGS Hospitalized Elderly • Elderly patients co-managed by a Nurse Practitioner and an attending physician had 2.78 fewer hospital days in the 20 most common diagnostic categories (Miller 1997). Hospitalized Newborn • Neonatal NPs (NNPs) were more cost effective than medical house staff in providing care to newborns. Cost of care by the NNP group was $18,240 less per infant (Bissinger 1997). • NNPs were comparable to pediatric residents in measured outcomes such as survival (Karlowicz MG 2000).

  23. HOSPITALIZED PATIENTS – COST SAVINGS Preoperative Anesthesia Savings • Nurse Practitioners (instead of anesthesiologists) provided preoperative anesthesia assessments on outpatient surgery cases. • Quality Indicators • Respiratory complications – no change • Patient preoperative preparation time - improved • Parent and Staff Satisfaction greater with NPs • Cost Benefits • Contribution Margin (net revenue – direct operating expenses) for both the hospital and the department. Hospital contribution margin was $5.7 million after one year. Department of anesthesia contribution margin was $618,265 professional fee revenue captured. • This includes the expense of adding 6 FT NPs to the preoperative clinic and the expenses associated with opening 2 additional ORs (Varughese 2006).

  24. HOSPITALIZED PATIENTS – COST SAVINGS Acute Care Nurse Practitioners (ACNP)– Evaluation of in-patient interventional cardiology ACNP service • The ACNP decreased the total hospital costs and Length of Stay (LOS) for patients transferred from outlying hospitals for cardiac catheterization or PCI. • ACNP managed patients were more likely to receive appropriate discharge medications including beta-blockers, ASA, ACE inhibitors and lipid–lowering agents, than patients on the physician house-staff service. • Follow-up appointments and patient education were documented more often on patients on the ACNP interventional cardiac service than on the physician house staff service (Reigle, 2006).

  25. HOSPITALIZED PATIENTS – COST SAVINGS Cardiovascular Surgeons and Acute Care Nurse Practitioners • Examined patient and economic outcomes between 2 groups of adult patients with postoperative cardiovascular care directed by surgeons alone or surgeons in collaboration with an Acute Care Nurse Practitioner. • Findings: Length of Stay was 1.91 days less and total cost decreased $5,039 per patient in the team of surgeon and the Acute Care Nurse Practitioner (Meyer SC, 2005).

  26. HOSPITALIZED PATIENTS – COST SAVINGS Nurse Practitioner intervention model for community acquired pneumonia (CAP) and chronic obstructive Pulmonary disease (COPD) • Academic medical center NPs provided care for CAP and COPD based on Center for Medicaid and Medicare Services performance measures. • NP intervention model for patients with CAP and COPD resulted in 90% compliance with all CMS measures and significant reductions in length of stay (LOS) and cost savings (LOS decreased by 1.34 days; $2,576 profit per case). • Cost savings occurred without increase in pneumonia readmissions. • COPD – preliminary results show comparable outcomes (Gross 2004).

  27. SURGICAL RESIDENTS AND NURSE PRACTITIONERS CARING FOR HOSPITALIZED PATIENTS Reduction of resident work hours to 80 hour work week has created pressure on academic health-care systems to find “replacements”. • NPs have been effective in coverage of inpatient surgical services. • 91% of surgery residents in a large academic center believed that the addition of these non-physician practitioners to the teams was positive overall (Resnick A, 2006).

  28. Adding NPs to Trauma Services Benefits Hospital Services • Utilizing NPs (Mid level providers) as substitutes for trauma residents will address the hospitals’ Level I trauma accreditation requirement for continuous availability of trauma providers. Staff and patients at a major medical center were very positive about NPs and PAs as trauma house staff (Nyberg, 2007). • Adding NPs to trauma team discharge rounds resulted in the provision of high quality services, equal to that provided by senior house staff and continued efficiency of the discharge process with a reduced Length of Stay (Haan, 2007)

  29. CHRONIC ILLNESS – COST SAVINGS Chronic Disease – Outpatient Congestive Heart Failure Patients • Advanced Practice Nurses coordinated the care of high risk patients with heart failure, both inpatient and outpatient. These patients had fewer hospital readmissions –saving $4,845 per patient, with improved Quality of Life. APN care resulted in 38% savings in Medicare Costs. Six Philadelphia academic and community hospitals participated in this study. (National Institute of Health: Naylor, 2004)

  30. Long Term Care – Cost Savings LONG TERM CARE FACILITIES: Burl (1998) examined revenues and costs for 1077 HMO enrollees residing in 45 long-term care facilities. Data included: cost, revenues, ER transfers, hospital and sub acute days. • Result: Geriatric Nurse Practitioner(GNP)/MD teams utilized fewer services and total expenditures were significantly less for these residents with lower costs in the ER, hospital & skilled nursing. • Cost/Benefit: GNP/MD team able to manage costs for the HMO to earn $72.93/resident/month, compared with resident/month/loss of $197 in MD-only group which equals a final cost benefit $270/month/resident.

  31. PRIMARY CARE – COST SAVINGS Outpatient Care • Nurse Practitioner managed practice had fewer emergency department visits and fewer inpatient days. Total cost per managed care member was 50% less than the physician cost (Jenkins& Torrisi, 1995). • Nurse Practitioners delivered health care at 23% below the average cost of other primary care providers and had a 21% reduction in hospital inpatient rates (Spitzer 1997).

  32. PRIMARY CARE – COST SAVINGS • Evaluated 26 capitated adult and pediatric primary care practices of a group model Managed Care Organization. • Health Care Provider labor costs per visit and total labor costs per visit were lower among practices with greater use of Nurse Practitioners (Roblin DW, 2004). • Adults with hypercholesterolemia, and Coronary Heart Disease, post surgery, were randomly assigned post hospitalization to receive lipid management and lifestyle modification/pharmacologic intervention from a Nurse Practitioner for one year (Paez, 2006). • The cost-effectiveness ratio using the % change in LDL(cholesterol) indicated that the cost-effectiveness of the Nurse Practitioner case management was significant. (Paez, 2006). Outpatient Care-Managed Care Organization

  33. SAVINGS WITH A WORKSITE NURSE PRACTITIONER Worksite Nurse Practitioners and Health Care Costs • Study assessed the impact of an on-site nurse practitioner initiative on the health care costs (HCC) among 4,284 employees and their dependents. • Method: The first analysis compared actual costs for first 6 months of the start up year to projected costs based on claims paid in previous 2 years without a nurse practitioner. • The benefit of the NP program was then defined as the difference between the actual and the projected costs of the NP program (very significant benefit ratio). • Second analysis: Health Care Costs were calculated using the paid claims for major diagnostic categories for the year previous to NP and compared with the claims calculated for same time period the NP provided health care. • Both methods of analysis demonstrated a very substantial reduction in HCC that was at a minimum benefit-to-cost ratio of 2.4 to 1 (Chenoweth D, 2005).

  34. Utilization of Nurse Practitioners as Attending Providers for a State Workers’ Compensation System • Study, 3 year pilot program, compared the NP and physician PCPs in the role of attending provider for Washington State Worker’s Compensation System. • Method: Comparison was based on medical costs and disability outcomes of injured workers in their care. 29,949 injured workers billing and claim data was reviewed. • Results: NPs were more likely than PCPs to be located in rural areas and counties with high unemployment. Injury type and severity were similar across both provider types. • The likelihood of any time loss from work was lower for NP claims. • The duration of lost work time and medical costs did not differ by provider type (Sears, 2007) • Authorizing NPs as attending providers, may be a cost-effective approach to address access barriers.

  35. HIGH PATIENT SATISFACTION

  36. Advanced Practice Nurses Provide High Quality Health Care and Patients are More Satisfied • Research supports that patients are more satisfied or very satisfied with health care provided by APNs than by physicians ( Horrocks, 2002; Shum et.al 2000; Kinnersley et.al, 2000; Venning et.al 2000;Sakr et.al 1999). • Patients reported receiving more information about their illness from APNs than from physicians (Kinnersley, et al. 2000; Hooker, 2001).

  37. Advanced Practice Nurses Provide High Quality Care and Patients are More Satisfied Cipher’s random survey of 146, 880 Medicare beneficiaries • Older patients were very satisfied with Nurse Practitioner care and no difference in satisfaction between nurse practitioners who were the designated PCP (primary care provider) and physicians who were the PCP (Cipher 2006). • NPs cared for more dual eligibles than other provider groups – serving a greater percentage of Medicare/Medicaid recipients i.e., caring for the underserved and poor (Cipher 2006). Advanced Practice Nurses care for vulnerable populations- HPSAs • NPs and CNMs served significant % of the underserved in rural and urban settings and in health professional shortage areas (HPSAs)(Stange 2003).

  38. Advanced Practice Nurses Provide High Quality Care and Patients are More Satisfied LONG TERM CARE FACILITIES (LTC): • Survey of Medical Directors of LTC facilities to determine the national practice patterns of NPs providing care in LTC facilities. Reviewed types of LTC facilities that use NPs, NP activities, employment arrangements and effectiveness of NP care (Rosenfield, 2004). Response: 63% used NPs in care of residents. NPs provided sick/urgent care (96%), preventive care to residents (88%), hospice care (80%) and wound care (78%). Effectiveness: Large majority of medical directors rated the NPs as highly effective, 90% of medical directors reported physician satisfaction with the NP, 87% reported resident satisfaction with the NP and 85% reported family satisfaction with the NP (Rosenfield, 2004).

  39. NPs Provide High Quality Care and Patients are More Satisfied LONG TERM CARE FACILITIES-Rosenfeld(cont.) • Conclusion: “The substantial number and types of services provided by these Nurse Practitioners, coupled with high resident, family and physician satisfaction with their services, suggests the need for education, policy, and reimbursement strategies to encourage the further involvement of Nurse Practitioners in the care of Long-Term Care residents”.

  40. Health care delivered by Advanced Practice Nurses Results In: • High quality care • Cost-effective care • High patient satisfaction • VALUE-ADDED CARE: Customer satisfaction>Optimized health>Efficient utilization of health-care dollars

  41. APN MULTI STATE REIMBURSEMENT ALLIANCE AND THE OHIO ASSOCIATION OF ADVANCED PRACTICE NURSES • For more information, please contact: Christine Williams, RN, MSN, CNP masada2@earthlink.net 216-536-3670

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