PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS IN RURAL HEALTH
Who is providing healthcare to rural America and how are policies incentivising healthcare providers to serve these geographical areas. Physician assistants and nurse practitioners in rural medicine.
You are listening to ReachMD XM 157, the channel for medical professionals. Welcome to the clinician's roundtable.
HOST:
Lisa D'Andrea.
Ron Nelson, Physician Assistant and the President of Health Services Associates in Fremont, Michigan, a firm that specializes in rural health system development. Ron is the cofounder and First President of the National Association of Rural Health Clinic and the past President of The American Academy of Physician Assistants.
Dr. D'ANDREA:
Hi Ron. Welcome to ReachMD.
Dr. NELSON:
Hi Thank you for the opportunity here today.
Dr. D'ANDREA:
Ron, what is the Rural Health Clinic and what does it mean to be a certified Rural Health Clinic?
Dr. NELSON:
A federally certified Rural Health Clinic is an institute that has made a decision to go through a process of evaluation by state and federal government to establish first of all that is an underserved area based on certain criteria established by the Federal Government and secondly that it must be staffed 50% of the hours by a nurse practitioner or physician assistant.
Dr. D'ANDREA:
And what are the benefits of being certified as a Rural Health Clinic?
Dr. NELSON:
The initial impetus for the development of this program was during the current administration and recognition of lack of access in those rural areas as well as a lack of mechanism to pay for non-physician providers. So, 2 things happened in the program, 1 mechanism to incentivize via a cost based reimbursement method and secondly the ability to pay for PAs and nurse practitioners the same as paying for physicians for providing services to Medicare and Medicaid patients.
Dr. D'ANDREA:
What is the cost based reimbursement?
Dr. NELSON:
Cost based reimbursement is a method to look at the cost of an organization or a cost that an organization incurs and calculate a mechanism to pay for those services based upon the cost divided by the total visits, so rather than being paid on a fee schedule, which is traditionally used today in healthcare one is paid based upon the actual cost and determine on a pro-visit basis and then as <_____> each year.
Dr. D'ANDREA:
So Rural Health Clinic certification guarantees a better financial return?
Dr. NELSON:
In most cases, it does, while it has had less of an impact in recent years with changes in fee schedules under Medicare program on the Medicaid side. Most practices will realize, some were in the range of a 100% greater reimbursement or for example, a typical reimbursement people service was seen in Medicaid patient today in rural areas is about $30 to $40 and the typical reimbursement under the Rural Health Clinics program for that same patient would be about 72 dollars. So, essentially, almost double the reimbursement for seeing Medicaid patients.
Dr. D'ANDREA:
Can Rural Health Clinics offer services to cash paying or private payers?
Dr. NELSON:
Rural Health Clinics are actually like any office and often are the first point of service in many rural areas and in many communities are actually the only point of service and therefore they provide care to both private, commercial, self-pay Medicare and Medicaid. Statistically, the Rural Health Clinic will provide, about 60% of the service that they provide are going to be Medicare or Medicaid and the balance is distributed then between commercial and private payers and those with the self-pay as well.
Dr. D'ANDREA:
And what type of services do they provide?
Dr. NELSON:
A typical Rural Health Clinics will provide the basic kinds of primary care services. Some people use the definition in primary care or for example in family practice from birth to death but, often it's going to be the general types of primary care, preventive care that would be provided from the, you know, newborn life cycle if you go to the senior and elderly life cycle and in many cases, the difference between Rural Health Clinics, some may have additional ancillary services that it can be really differ based upon the community and the particular clinic.
Dr. D'ANDREA:
And how are hospitals associated with the Rural Health Clinics?
Dr. NELSON:
There are really 2 categories of Rural Health Clinics under the Federal <_____>, one is called provider based and one is called independent. The provider based is attached to hospital and as such has some other opportunities or incentives when attached to the hospital, specifically if the hospital is under 50 beds, there is no limitation on the amount of reimbursement per visit on the Medicare side and the Medicaid reimbursement is generally higher, for example in a provider based or hospital based Rural Health Clinic, the average medicaid reimbursement is closer to $100.
Dr. D'ANDREA:
Does a Rural Health Clinic have to be public or not for profit?
Dr. NELSON:
One of the unique situations about or any characteristics of the Rural Health Clinics program is that it offers any type of ownership opportunity. Interestingly, 3% of the Rural Health Clinics that are about depending on which number you look at, they are probably somewhere in the range of 3400 Rural Health Clinics today, 3% of those are owned by PAs and/or nurse practitioners. There are some that are owned by public such as health department and there are some that are owned by hospitals, nursing homes, private physicians, community groups that have gotten together and created not for profit to own and operate and provide that kind of care in their community. One of things that was part of the proposal when this program was created is to allow the flexibility it would offer any opportunity in a rural community. Having said that, I think it's also important to understand that this still subject to state laws as it relates to the ownership and <_____> practice as well.
Dr. D'ANDREA:
What are the restrictions on PA and NP ownership?
Dr. NELSON:
Really in Rural Health Clinics there are none in the Rural Health Clinic, it sounds like it can be owned and operated by Rural Health Clinics or by PAs and nurse practitioners unless there is a restriction in the state in terms of ownership as a practice. There is no restriction in terms of their ownership, in difference and traditional medicare in this case, PA and nurse practitioner can own the practice in its entirety and obtain numbers and then contract with the physician for providing the direction and supervision which is often the model that is seen in many rural communities where a physician may be in a separate community, travel periodically to the clinic and is contracted to provide the medical direction and the direction of the care in that clinic.
Dr. D'ANDREA:
What about the supervision requirements by a physician? How does that work?
Dr. NELSON:
All medicare beneficiaries are required in the Medicare program to be under the general direction of the physician, but its clearly an opportunity for physicians in terms of extending care to these rural communities to serve as a contracted service or they provide the medical direction that requires that they are involved in the development of the policies and procedures which govern the operation of the clinic including safety, patient care policies, and that they must be as a minimum in the clinic at least once every two weeks for a sufficient period of time to ensure quality of care and to also see patients if necessary, unless the state law requires something more rigid that is the absolute minimum requirement to the RHC program requires and in most of the rural states, that is an acceptable standard, the physician then have to be available by some formal radio or telephone communication generally, but literally physically is able to travel to the clinic periodicity schedule determined by the clinic and its staff or by state regulation.
Dr. D'ANDREA:
If you are just joining us, you are listening to the clinician's roundtable on ReachMD XM 157, the channel for medical professionals. I am Lisa D'Andrea and I am speaking with Ron Nelson, Physician Assistant and President, CEO of Health Services Associates in Fremont, Michigan. We are discussing physician assistants and nurse practitioners in rural health.
Ron, let's talk about the daily work in a Rural Health Clinic. Do the providers feel isolated and how do they grow professionally without the professional interaction?
Dr. NELSON:
Well, one of the issues we face currently is the same problem with nurse practitioners and PAs that physicians face which is going to the rural communities, being alone and having both the social and professional isolation and so in order to recruit people to these communities, there is a couple of areas that you can focus on, one trying to create professional relationships in neighboring communities between the PA, nurse practitioner and/or other colleagues and physicians that they don't feel the professionalized relation and the feeling of being all alone. The second area, I think in the social aspects are somewhat more problematic and that we see the changing demographics of the graduates coming out of nurse practitioner and PA training program are predominantly female and often in many cases are single females that are at this point in their career now deciding about issues of starting family and relationships and that social isolation is a difficult one. One of the things that we recommend to clinics is to look at ways to provide some respite for the provider to get away from the clinic to, you know, more urban areas if that is their desire, building relationships that making clear to the end of <_____>, you know, the need for them there and why you want them there, but also be supportive in any ways to ensure that as much as we can we take away some of the social isolation barriers that preclude people from choosing that as an option to their practice.
Dr. D'ANDREA:
What about the new practitioners? How can they provide competing care when they have so little experience and they are alone?
Dr. NELSON:
Well, all Rural Health Clinics are not staffed independently and alone by NPs and PAs, and I would tell you that probably its only 5% or less of the typical PA, nurse practitioner graduates that are really at a level that can function independently and alone in a practice such as the Rural Health Clinic, so it really depends on the individual, their previous healthcare experience, and where their level of skill is at. It usually takes couple of years of experience for one is comfortable going out in a more independent setting where they are delegated autonomy from the physician who may be 30 to 40 miles away, as such is the case I practice in where my supervising physician who resides about 40 miles away from where I am are practicing.
Dr. D'ANDREA:
With increased cost of education and following the physicians and the money and especially practice, how do you recruit a PA or an NP to a Rural Health Center?
Dr. NELSON:
Well, I think that presents one of the most unique and difficult challenges that we face in rural healthcare today, which is how we will recruit and retain those individuals and I think one of the ways we do that is we try and as much as we can train and socialize these individuals during their training that it is okay to be in rural areas, which means developing rural training opportunities, further exposed to practice situations in rural areas so they can understand some of the positives of being in that kind of environment and not that just hear about it and kind of develop a fear that <_____> I go out there and be myself. The second area for communities to develop models or programs to really encourage people to come to their community whether its bonuses as a sign-on or mechanisms to ensure that there is going to be a true respect via some kind of local <_____> for ways to really get them away from the practice if you will and the opportunity to enjoy being in the rural area, but to not feel necessarily socially and professionally isolated. There are lots of strategies that are out there, that are written about trying to help rural communities in many state offices of rural health can really help with that approach.
Dr. D'ANDREA:
All physician assistants and nurse practitioners have been know to fill medical needs. Tell our audience about the impact that the Rural Health Clinics have had on access to care on these areas.
Dr. NELSON:
Well, first of all, the Rural Health Clinics program is the single largest program in the country today providing care to the rural underserved communities and interestingly, it is staffed 50% of the time that these clinics are staffed and must be staffed by PAs and nurse practitioners, so they are making huge impact on
ENDS ABRUPTLY.
