The Future of Nursing 2020-2030 Charting a Path to Achieve Health Equity (2021) / Chapter Skim
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6 Paying for Equity in Health and Health Care
6 Paying for Equity in Health and Health Care
Pages 147-188
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From page 147... ...
Payment systems greatly impact whether and how health care systems use their resources, including nurses, to improve public health.1 Nurses' ability to address an individual's social needs and the social determinants of health (SDOH) in the community, as well as to perform roles and implement interventions that can advance health equity, can be supported or inhibited by the payment systems that reimburse organizations and individual clinicians for the 1 This chapter focuses on payment systems that pay health care organizations and clinicians for the care they provide to individuals and payment systems that support public health and school nursing.
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From page 148... ...
The feasibility and value of innovative reforms to improve the nation's health are highlighted by many of the temporary regulatory health care reforms enacted in response to COVID-19, such as increased flexibility and reimbursement for telehealth and expanded scopes of practice. Payment reform can help improve population health, address social needs and SDOH, and reduce health disparities, supporting the provision of effective, efficient, equitable, and accessible care for all across the care continuum instead of incentivizing the volume of care or lowvalue procedures and practices.
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. Payment models can support nurses' roles and functions to address SDOH and advance health equity in four key areas: care management and team-based care, expanded scope of practice, community nursing, and telehealth.
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. Thus, the growing APRN and RN workforces have the potential to improve rural health disparities.
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. Telehealth Use of telehealth is a fourth area in which nurses can be supported and incentivized through different payment models to help address SDOH and advance health equity concerns.
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For example, health care organizations often focus on the relatively few most resource-intensive, highest-cost patients (the "superutilizers") in their population health management programs instead of on the broader spectrum of patients who could benefit from such interventions.
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For example, some safety-net providers, small practices, and rural clinics may lack robust 3 For the purposes of this discussion, payment functionality is conceptualized as key operational issues for those mechanisms that pay for infrastructure (e.g., care management, care teams, nurse primary care functions, telehealth, workforce, and education) and those mechanisms that incentivize and reward specific processes of care and outcomes that advance health equity, such as those that address SDOH, improve population health, and reduce health disparities.
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? • How will it be possible to ensure that the long-term societal benefits of improving public health are reflected in the short-term incentives pro vided to health care organizations to create a business case for them to address SDOH and improve health equity?
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The committee suggests expanding the goal and purpose of payment systems beyond traditional health care and traditional government and private payers to explore how the public health and social sectors can support nurses in using their expertise to eliminate gaps and disparities in health and health care. This section is not meant to be an exhaustive exploration of the current payment system4 but to give examples of the general principles by which current and future payment systems can be tailored to use nurses more wisely and effectively to improve population health and advance health equity.
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From page 156... ...
Two members are required to be nonphysicians representing the CPT Health Care Professionals Advisory Committee, such as nurses.5 The existence of a CPT code and the definition of the code have a critical impact on whether a service is reimbursed. The valuation and ultimately relative prices paid for the CPT codes are based on the work of another AMA committee, the Relative Value Scale Update Committee (RUC)
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. Despite many weaknesses, it is possible to reform FFS payment to support key nursing roles -- specifically, to allow nurses and health care organizations to bill and receive reimbursement for services that address SDOH and advance health equity at a level sufficient to support these interventions and incentivize organizations to persist in initiating and sustaining this work.
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Attaching relative value to complex health care services is a challenging task. In the current system, the CPT codes and associated RVUs are a bottom-up estimate of cost, which is used by CMS and other insurers as measure of relative value in their payment of providers without reference to the overall societal value of the service, the availability/supply of the service, the evidence base for benefit from the service, the quality of the service delivered, and the outcome for the individual (Berenson and Lazaroff, 2019)
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. Currently, Medicare reimburses APRNs for pre- and postdischarge care as part of transitional care management under the FFS model using CPT codes 99495 and 99496 (Fels et al., 2015)
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. The CMS policy encompasses telehealth reimbursement for a wide range of clinicians, including "physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals, however, this is subject to state regulation of scope of practice" (CMS, 2020a)
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A common example is pay-for-performance, in which providers and health care organizations receive more payment if they meet preestablished clinical performance accountability metrics. In this context, it is important for performance metrics to incentivize nursing roles and functions that address SDOH and advance population health and health equity.
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From page 162... ...
For example, metrics for care coordination and teambased care could incentivize investment in nurse-led care management programs that can reduce health disparities. Chronic diseases and ambulatory care–sensitive conditions -- including asthma, diabetes, heart failure, hypertension, and depression -- that are prevalent in POC and underserved populations and display disparities in outcomes compared with more advantaged populations often are well suited to nurse care management/team-based care programs (Davis et al., 2007; Lasater et al., 2016; Mose and Jones, 2018; Peek et al., 2007)
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strongly supported value-based care through funding measures or initiatives that develop nurse competencies (NACNEP, 2019) ; incentivize nurse care management and team-based care; and include population health measures, measures of the extent to which SDOH are identified and addressed, and measures to reward reductions in health disparities (NASEM, 2020b)
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. Flexible funding allows health care organizations to adapt services that address SDOH and advance health equity to suit local contexts and beneficiaries (Thomas et al., 2019)
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SUPPORTING SCHOOL AND PUBLIC HEALTH NURSES TO ADDRESS SOCIAL DETERMINANTS OF HEALTH AND ADVANCE HEALTH EQUITY School and public health nurses play crucial roles in improving the health of school-age children and their families, as well as the health of community members who are more likely to receive preventive care or treatment through community resources (APHN, 2016; Bogaert et al., 2020; NACCHO, 2020; NASN, 2016)
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School and public health nurses are therefore valuable resources for addressing population health and health equity; however, they are underfunded (IOM, 2011; Sessions, 2012)
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Schools may need to take advantage of multiple funding sources to support robust school health programs and school nurses. For example, Grand Rapids Public Schools in Michigan partnered with Spectrum Health to improve student health outcomes and used for that purpose funds from the school district budget, Spectrum Health, the local intermediate school district, and the state department
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. In a survey of 377 state and local health departments, most public health nurses reported finding strengths in their departments.
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. ROLE OF THE HEALTH AND SOCIAL SECTORS IN SUPPORTING NURSES TO ADDRESS SOCIAL DETERMINANTS OF HEALTH AND ADVANCE HEALTH EQUITY Historically, the health and social sectors (e.g., housing, transportation, food insecurity, employment, education, criminal justice)
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using braided funds from local, state, and federal sources. Eleven HEZ zones were established statewide, each focused on local priority issues and services, including providing psychological first aid, screening patients for depression and identifying patients at risk of suicide, developing safer roadways, banning smoking and vaping in town parks to ensure smoke-free areas, improving vacant or abandoned properties and addressing housing as a social determinant, building community linkages through the use of community health workers, and creating a community drop-in clinic for adults with substance abuse disorders (RIDOH, 2018)
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and education (see Chapter 10) are required to support the nursing profession in markedly expanding and strengthening roles and functions needed to address SDOH and advance health equity.
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Educating the Nursing Workforce About Social Determinants of Health and Health Equity As noted in Chapter 10, RNs in public or community health or school health surveyed in the 2018 National Sample Survey of Registered Nurses said their performance in their roles would have benefited from more training in SDOH. For example, in addition to training in effective communication, shared decision making, and cultural humility when working with diverse populations (Foronda, 2020)
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. Training programs within HRSA could be adapted to further incentivize diversification of the nursing workforce and improve training in addressing SDOH and advancing health equity (Strickland et al., 2014)
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One of the major factors limiting enrollment in advanced practice programs is the lack of preceptors, which is related to the paucity of federal funding for advanced nursing education relative to medical education. The GNE demonstration13 project authorized CMS to fund five hospitals to partner with clinical education sites, schools of nursing, and community-based care settings (CCSs)
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CONCLUSIONS Improving the health of the nation's diverse population needs to be the primary goal of health care and its payment systems. Thus, payment systems need to be intentionally designed to support key nursing roles, including care management and team-based care, expanded scope of practice, community nursing, and telehealth, as well as diversification of the workforce and improved training in addressing SDOH and advancing health equity.
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The current health care system does not value addressing social determinants of health. School and public health nurses are valuable segments of the nursing workforce with great potential to help improve population health and health equity by intervening at early ages, focusing on prevention, and connecting with the community to understand and address social needs and SDOH.
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Conclusion 6-3: Payment mechanisms need to be designed to support the nursing workforce and nursing education in addressing social needs and social determinants of health in order to improve population health and advance health equity. The United States spends a very large and growing amount of money on health care (CMS, 2020c)
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A position paper of the Association of Public Health Nurses. https://www.phnurse.org/assets/APHN-PHN%20Value-Position%20Paper%205%2030%20 2016.pdf (accessed April 6, 2021)
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National Academy for State Health Policy. https://nashp.org/wp-content/uploads/2016/02/Jean1.pdf (accessed April 6, 2021)
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https://www.cms.gov/Medicare Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid Coordination-Office/Downloads/MMCO_Factsheet.pdf (accessed April 6, 2021)
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org/wp-content/uploads/2017/01/FA3P4_Billing-Restrictions_Full-Report.pdf (accessed April 6, 2021)
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https://www. minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf (accessed April 6, 2021)
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. https://www.kff.org/health-reform/fact-sheet/explaining-health-care-reform-medical-loss-ratio mlr (accessed April 6, 2021)
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https://archives.lib.state.ma.us/bitstream/handle/2452/684841/ocn984131182-2012.pdf (accessed April 6, 2021)
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https://www.naccho.org/uploads/downloadable-resources/05-08-Public Health-Nurses.pdf (accessed April 6, 2021)
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acf.hhs.gov/ohs/funding (accessed April 6, 2021)
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Fact Sheet. https://www.scdhhs.gov/sites/ default/files/2-16-16-SC-NFP-PFS-Fact-Sheet_3.pdf (accessed April 6, 2021)
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Ann Arbor, MI: University of Michigan School of Public Health. http://www.behavioralhealth workforce.org/wp-content/uploads/2019/01/Y3-FA2-P1-Rural-Pop_Full-Report.pdf (accessed April 6, 2021)
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