Public Sector Influence on NP Preceptorship (Week #7)

Value of Funding

Besides making rules and regulations, our government is an economic force in the business of healthcare, often referred to as the public sector. The laws our government enacts shape how our healthcare system functions or fails to function. How the government chooses to allocate it’s vast, though not unlimited, funds may shape the structure our healthcare system even more. Rules, programs, or care models that lack funding will not flourish and will most likely fail. The Centers for Medicare/Medicaid Services (CMS) is the largest payor of healthcare costs, and what CMS does, other payors tend to follow. In conjunction with The Affordable Care Act (ACA), CMS has changed provider payments from a volume-based, fee-for-service system to a system of value-based purchasing (VBP), which is simply saying payments are to be made based on demonstration of cost-effective, quality based outcomes in patient care (Aroh, Colella, Douglas, & Eddings, 2015).

Quality, Cost-effective Care

Nurse practitioners (NPs) have been demonstrating the quality and cost-effectiveness of their care for 50 years as they have fought for their place in the healthcare system. As early as 1979 the US Congress recognized the cost-effectiveness of NPs and recommended supporting the education and growth of NPs, as well as physician assistants (Congressional Budget Office). A 2015 systematic review comparing the outcomes and costs of NPs and physician continues to demonstrate that NPs provide healthcare that is at least equal to and in some cases superior to that provided by physicians (Swan, Ferguson, Chang, Larson, & Smaldone). The vulnerable populations that ACA and CMS are geared to protect, such as uninsured and underinsured, the working poor and immigrants are the very populations that NPs are known to have provided quality care for. These patients are at greater risk of overall poor health, disease complications, and serious illness; yet NPs have been able to develop innovate clinics and care models to reach these patients and reduce their healthcare problems and medical spending (Van Zandt, Sloand, & Wilkins, 2007). Many of the clinics that provide healthcare to the underserved populations also provide preceptors and training opportunities for NP students; thus meeting the needs of two groups and making the most efficient use of the public sector’s funding. Yet this fiscally sound contribution goes unrecognized and unfunded. The clinic may receive reimbursement for CMS qualified patients at 85% of the what a physician providing the same service would receive. The clinic’s potential income is further reduced since they are not training physicians, the clinic is not eligible to receive monies from Graduate Medical Education (GME) fund.

Education Funding is not Value Based

The same public sector that is demanding VBP from its providers, be they physician or NP, is not making that same demand in the training of providers. The BILLIONS of DOLLARS distributed through GME are done so on the volume and fee-for-service payment structure; the GME has no quality outcomes tied to the reimbursement of organizations and physicians providing training for the future medical providers. The distribution of these funds are also geographically biased to large metropolitan areas that have held the political clout to keep the payment system as is (Iglehart, 2015). It is time for those who have traditionally not spoken up for their needs and rights to step up and demand equitable funding for training based on outcomes and cost-effectiveness. The typically soft-spoken, quite nurse who is focused on serving the healthcare needs of patients may feel intimidated by those with political clout and experience, but there are mountains of evidence to support and shield those speaking up in favor of NP education and practice. Go fight the windmills Don Quixote and bring justice to the funding of our future healthcare providers.


Aroh, D., Colella, J., Douglas, C., & Eddings, A. (2015). An example of translating value-based purchasing into value-based care. Urologic Nursing, 35(2), 60-74.

Congress of the United States, Congressional Budget Office. (1979). Physician extenders: Their current and future role in medical care delivery. Retrieved from

Iglehart, J.K. (2015).  Institute of Medicine report on GME – A call for reform. The New England Journal of Medicine, 372, 376-381. doi: 10.1056/NEJM1413236

Swan, M., Ferguson, S., Chang, A., Larson, E., & Smaldone, A. (2015). Quality of primary care by advanced practice nurses: a systematic review. International Journal for Quality in Health Care, 27, 369-404. doi:10.1093.intqhc.mzv054

Van Zandt, S.E., Sloand, E., & Wilkins, A. (2007). Caring for vulnerable populations: Role of academic nurse-managed health centers in educating nurse practitioners. The Journal for Nurse Practitioners, 4, 126-131. doi:10.1016/j.nurpra.2007.09.017



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