Institutions, People, & Regulations Roles in NP Preceptorship (Week #5)

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.

Next Steps

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.

 

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4 Comments Add yours

  1. I enjoyed reading your post and agree there are disparities among reimbursement for NPs who provide preceptorship to students. I have precepted many students over the years and have really done it out of my love for teaching not for any kind of reimbursement. I also am responsible for teaching residents and fellows who work in my unit but have never seen reimbursement for those efforts either despite the money that GME allots to the institution. Too me, it is just seen as an expectation in my role as a nurse practitioner. This underlying expectation and lack of reimbursement has lead to the shortage of good preceptors. Constant precepting without being rewarded for the time and effort it takes causes practitioners to become burnt out.
    As healthcare continues to evolve and change, APRNs are going to more vital to the healthcare system then they already are. With decreasing numbers of residents entering the medical field and residency hour restrictions (Varghese, Silvestri & Lopez, 2012), APRNs are going to be called upon to be the primary providers. Strong and knowledgable preceptors are going to be needed in order to get the new generation of APRNs where they need to be in order to care for the increasing complex patient populations that are present. Although they have attempted funding programs, like you eluded to, these programs were not robust enough to cause a significant impact. Programs like the current GME system are going to be required so that APRNs can have the same impact on future generations that medicine has had for its profession. APRNs are going to be important in forming healthcare policy to support future professional growth opportunities for future generations of APRNs.

    References:
    Varghese, J.R., Silvestri, A., & Lopez, P. (2012). Development of the emergency department nurse practitioner fellowship program. Pediatric Emergency Care, 28(1):6-7.

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    1. Deb says:

      Thanks for your thoughtful reply. And a huge THANKS! for all the precepting you have done. As an RN, I precepted many types of students and new graduates as well. A few organizations paid a little extra, most had the clinical ladder programs; both of which are nice rewards. However, like you, my motivation was my enjoyment of working with students and keeping my knowledge current, which is a benefit that stated by 95% of respondents in a study to determine barriers and incentives to preceptorship of the APRN (Wiseman, 2013). Sadly 97% of those same respondents stated they had never received financial compensation for their efforts (Wiseman, 2013).
      Also, thank you for pointing out an aspect I missed – that NPs and RNs do a lot of teaching for medical students (I’ve worked in a teaching hospital). I guess the institution just considers the funds they get as balancing the “expense” of a nurse, be it NP or RN.
      The GME program was meant to be a temporary measure until communities could figure out a better way to fund the training of healthcare providers (IOM, 2014). It was through the policies around GME that physicians were able to mandate the 3-year residency as part of the process of obtaining a medical license. In reading the history of the program, I can see how the physicians and hospitals used the program to establish expectations, income, and recognition. Sadly, they left out quality outcome measures of those receiving the funds. And now with such a different mix of healthcare providers, they left out a lot of people! I think NPs should take a lesson from history and take advantage of the restructuring of our current healthcare system to get adequate financial reimbursement for training. It is certainly necessary that our providers are strong, confident critical thinkers and that takes time with patients and a preceptor who can help connect the text to life.

      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

      Wiseman, R.F. (2013). Survey of advanced practice student clinical preceptors.
      Journal of Nursing Education, 52, 253-258. doi: 10.3928/0148434-20130319-03

      Liked by 1 person

  2. wspfan says:

    Graduate nursing education as a whole- whether it be for Nurse Practitioner’s, Nurse Midwives, Nurse Anesthetists, Nurse Educators or Nurse Specialists need to be financially supported. Currently there is an initiative to promote funding education called Nursing Workforce Development Programs that is within the Public Health Care act Title VIII funding. This funding provides monies to colleges and universities to help offset budget cuts. This type of funding helps authorize grants for nursing schools to increase both the number of nursing students but also increase the numbers of nursing faculty. The original Title VIII did not include initiatives for increasing nursing faculty, but in 2009, Sen. Richard Durbin (D-IL) promoted legislation to alter Title VIII to do just that [1]. Interestingly enough though, Title VIII are not permitted for community colleges. The original intention was to promote 4 year degrees and increase the professionalism of the nursing workforce based on a federal workforce policy panel suggestion. However, as more and more of the nursing workforce becomes specialized, there is a greater need for the reimbursement or aiding of funding the graduate education for nurses.
    The IOM has recommended since 1997 that mediare payments for training nurses and physicians depend on the same principles and use the same process [2]. It also went on to promote the idea of re-directing the funding from pre-licensure to that of the graduate nursing education. This idea is supported by the American Nurses Association and American Association of Colleges of Nursing. Possibly re-routing the Medicare funding to graduate nursing education could aid in the financial burden of attending graduate programs. I personally would like to see this happen in order to make all of the education and training fair and equitable for all advanced practice nurses.
    1.American Association of Colleges of Nursing (2013). 2012-2013 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: Author.
    Benner, P., Sutphen, M., Leonard, V. & Day, L. (2009). Educating Nurses: A Call for Radical Transformation. Carnegie Foundation for the Advancement of Teach. San Francisco: Jossey-Bass.
    2. Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press.

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  3. You couldn’t have written about a more important topic and I completely with you! Not only looking at it from the prospective of a nurse practitioner student wanting and looking for a good quality preceptor but also a job seeker I have seen this issue come up too many times. As a student, I have had great experiences with wonderful preceptors that I have learned a lot from but most were average and a few were awful. As a RN who frequently precepted student nurses I understand and can sympathize with how mentally exhausting it can be to work with a student, especially when you are working with students that clearly have no interest in hearing what you are trying to teach. Therefore, I can understand how some NP preceptors can get a “just get it done” type of attitude and do “just the minimum to get by” from the burn out. However, that just further proves the need for reimbursement and incentives for good, quality preceptors.

    Likewise, as a new job seeker I have been surprised at how many positions that as a NP part of my job requirements are to teach and mentor residents and fellows. No longer will it be an option as it was as a RN. So in places that receive reimbursement for residents and fellows, the precepting responsibility falls partly on the NP. But in institutions where there isn’t residents and/or fellows there isn’t any type of reimbursement offered and even in academic institutions that offer reimbursement, it doesn’t cover NP education.

    It is interesting that during the National Nursing Centers Consortium, the group conducted a study that found that after the 2014 Affordable Care Act was created, approximately 16 million newly insured people were starting to seek health care services. Furthermore, the study found that 74% of health care organizations were seeing NPs as the primary care provider however, over one fourth of HMO’s don’t recognize NPs as a primary care provider for reimbursement [1]. When an organization can’t even bill or justify services for a NP (although multiple studies have proven their worth), how can we even begin to battle NP education? With the NP shortage already and physician retirement numbers climbing, who will care for these 16 million newly insured people? I really love your topic and I hope to see more information coming. Thank you for your dedication to our field!!

    1. Hansen-Turton, T., Ware, J., Bond, L., Doria, N., Cunningham, P. (2013) Are managed care organizations in the United States impeding the delivery of primary care by nurse practitioners? A 2012 update on managed care organization credentialing and reimbursement practices. Population Health Management, (16)5, 306-309. doi: 10.1089/pop.2012.0107

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