Does NP Education Matter?
NPs are widely acknowledged as a viable solution to the physician shortage, which is predicted to worsen in the coming years (Forsberg, Swartwout, Murphy, Danko, & Delaney, 2015). Despite accomplishments, in the 52 years since Loretta Ford and Dr. Henry Silver started the first nurse practitioner (NP) program, NPs are still fighting for tangible, financial, and equitable recognition of their valuable and necessary position in the healthcare system, especially for those NPs who precept students in addition to their patient care roles. NPs are becoming the provider of choice for many primary care patients. Per the American Association of Nurse Practitioners (AANP) over 80% of NPs are in primary care setting, “with approximately 2/3 of Americans having seen an NP for their primary care needs” (2017, NP Awareness Campaign section, para 4). It is in the best interest of the public’s health to ensure that it’s health care providers are well-trained.
Medical Training is HIGHLY Reimbursed
While the Centers for Medicare and Medicaid Services (CMS) is beginning to equitably reimburse NPs, CMS is not yet placing a monetary value on education for the NP. In 1965, when the Graduate Medical Education (GME) program was established as part of the Medicare and Medicaid section of the Social Security Act, it was acknowledged that education activities improved the quality of care and the costs of that education should be covered in part, temporarily, by the insurance program (Institute of Medicine [IOM], 2014). Medicare and Medicaid contribute the most to the GME, but several other agencies, such as the Department of Defense, Department of Veterans Affairs, and the Health Resources and Services Administration, also make substantial contributions to the GME (Congressional Research Service, 2016). The GME provides organizations with funds related to the direct and indirect costs of training medical students through several means. Organizations can bill CMS at increased rate to cover the indirect costs involved with oversight of a student’s work. GME also provides funding for the student’s stipends (including benefits), the preceptor salaries, program administration costs, and educational space. Medical students’ and residents’ services are also considered billable services by CMS. Even if it is a physician precepting an NP student, these funds are unavailable to the physician or organization. The GME is criticized for having no quality or outcome measures associated with the disbursement of billions of dollars, as well as its 20-year old formula for determining the number of residency slots available (Institute of Medicine [IOM], 2014). Though far from perfect, it is a substantial recognition of the value of training medical students.
A Short Study on Funding NP Education
CMS recognized the inequity of reimbursing both physicians and NPs for patient care, holding both to the same standard of quality care; yet only supporting the education of physicians. In 2012, a section of the Affordable Care Act called for an investigation and demonstration of possible solutions to this issue. Of the 5,564 hospitals and 350 NP programs in the US, 5 hospitals were chosen to share $200 million dollars over the 4-year study period for the Graduate Nurse Education Demonstration program. Two hundred million dollars sounds like a sizeable amount, but in reality it is less than 1% of the single annual GME funding from Medicare & Medicaid alone (Institute of Medicine [IOM], 2014)!
Funds for General Nursing Programs
Other funding available to nursing is afforded via H.R. 2713 – Title VIII Nursing Workforce Reauthorization Act of 2016. This bill allocates just under $230 million for ALL programs of nursing from associate to doctoral education. These funds are used for loan repayment, scholarships for nurses, loans for nursing faculty, geriatric care education, workforce diversity and nurse retention (American Association of Colleges of Nursing, 2015). Though NPs and school faculty may receive some funding, again this far less than a single year’s GME allotment. Also, since this Act covers such a broad spectrum of nursing education, it lacks specifics to remunerate NP preceptors.
Non-governmental Funding Trial
Some organizations, aware of the inter-relationship between education and cost-effective, quality care have used incentive programs to reward physicians. The physician incentive programs are based on relative value units (RVUs) schedules and incorporate productivity, positive outcomes, patient satisfaction, and professional activities which includes teaching. Involvement in teaching is also an integral part of many nursing clinical ladders. Organizations have used clinical ladder programs to recruit and retain direct patient-care registered nurses (RNs). The clinical ladder keeps the RN in direct-patient care and usually provides both monetary and non-monetary forms of recognition for their increased knowledge and skills. However, neither of these programs are available to the NP. Some organizations have trialed combining the clinical ladder with the physicians’ RVUs to recruit, retain, and reward the NP (Rhodes, Bechtle, & McNett. 2015). Using RVUs as the basis for NP salaries allows the organization to see the income generated by the NP, as well as recognize the practitioner’s various contributions to the organization and the profession; instead of a simple expense column as nursing is often viewed in financial statements. While this monetary recognition of precepting is not direct, sufficient, or in widespread use it is a start.
Known shortcomings with the GME, expected governmental restructuring of the Affordable Care Act, and availability of research regarding NP patient outcomes and cost-effectiveness are creating the “perfect storm” for NPs to become involved with ensuring the equitable remuneration for their educational activities. Private organizations, as well as the government, are making small steps with the programs mentioned, but it will take NPs, their patients, and NP students voicing support to make this financial recognition more than a pittance.
American Association of Colleges of Nursing. (2015, May). AACN Policy Beat (Vol.7 Issue 5). Retrieved from http://www.aacn.nche.edu/government-affairs/June-2015.pdf
American Association of Nurse Practitioner. (2017). All about NPs. Retrieved from https://www.aanp.org/all-about-nps
Centers for Medicare & Medicaid Services. (2012, July 30). Fact sheet: Graduate nurse education demonstration. Retrieved from https://innovation.cms.gov/Files/fact-sheet/GNE-Fact-Sheet.pdf
Congressional Research Service. (2016, Feb. 12). Federal support for graduate medical education: An overview. CRS report R-44376. Retrieved from https://fas.org/sgp/crs/misc/R44376.pdf
Forsberg, I., Swartwout, K., Murphy, M., Danko, K., & Delaney, K.R. (2015). Nurse practitioner education: Greater demand, reduced training opportunities. Journal of the American Association of Nurse Practitioners, 27, 66-71. doi: 10.1002/2327-6924.12175
IOM (Institute of Medicine). 2014. Graduate medical education that meets the nation’s health needs. The National Academies Press. Retrieved from: https://www.nap.edu/catalog/18754/graduate-medical-education-that-meets-the-nations-health-needs
Rhodes, C., Bechtle, M., McNett, M. (2015). An incentive pay plan for Advanced Practice Registered Nurses: Impact on provider and organizational outcomes. Nursing Economics, 33, 125-132.