Where we are now
As we have been discussing in this blog, the current push for improved healthcare outcomes, cost efficiency, and evidence-based decisions has many private and public sectors examining how we provide healthcare, who provides healthcare, and how we educate those providers. It is crucial that solutions proposed are equitable among providers as well as financial feasible and sustainable. The US spent $3.4 TRILLION on healthcare in 2016 alone; yet is far from the healthiest nation (Keehan et al., 2017). The Graduate Medical Education (GME) fund provided nearly $14 BILLION in education financing in 2012; yet physicians and NPs alike are exiting their training programs with 6-figure personal educational debt (Delisle, Phillips, & van der Linde, 2014). Despite all this spending, we are still not meeting the educational needs of our future providers as well as continuing to face a severe shortage of providers, especially those in primary care. A better utilization of all those dollars must be found.
At one time training of physicians and nurses occurred in hospital-based programs, where healthcare was delivered. As the understanding of bio-physiology deepened and healthcare became more complex, training moved from the hospital to academia; separating education and practice (Institute of Medicine, 2011). The partnership between hospitals, outpatient clinics, and academia must be renewed and cultivated. One partnership that has shown promise is the dedicated educational unit (DEU), in which one unit within the hospital focuses on one school, providing nearly all clinical experiences. Nurses desiring to precept are sponsored by the university and supported in that role as adjunct faculty. The hospital gains a direct contribution to program design needs and access to potential new employees (Institute of Medicine, 2011). It has been continually reiterated since the implementation of Medicare in 1965 that institutions and persons involved with educational activities improve the quality of care and advance the profession and the field of healthcare (Association of American Medical Colleges, 2015).
Funding should not only be sourced from the healthcare organizations. Universities and colleges derive revenue from tuitions, donations, interest, and federal funding. All the various programs offered by the university battle for their share of the budget, which is often focused on campus needs. Nursing faculty must help financial administrators reformulate budgeting to account for educational experiences that occur outside of the boundaries of the university (Horns & Turner, 2006).
Programs that combine educational clinical experience and new employee orientation have provided a smoother transition from the academic world to the work world of the undergraduate nurse. These programs have cost-saving benefits for the hospital and the college, while providing consistent education to the student (Trepainer, Mainous, Africa, & Shinners, 2017). Adapting these for the NP could be developed with minimal investment. Another possibility is combining precepting of undergraduate nurses in order to obtain credits during the pursuit of graduate degrees; similar to the offering of continuing education to licensed NPs for precepting NP students.
Some organizations are offering loan repayment as an employee benefit. This helps to ease the loan burden on providers, is an attractive benefit for many, and offers the organization tax benefits. If tied to precepting students, such as increasing percentage reimbursed based on work with students, it could be one means of indirectly funding NP clinical experiences.
There are many calls for accountability within and revision of the General Medical Education (GME) fund (Eden, Berwick, & Wilensky, 2014). The billions of dollars distributed by this program needs to reflect the balance of healthcare providers and provide evidence of quality outcomes. Current caps on numbers are geographically imbalanced and based on acute-care hospital statistics. To improve healthcare outcomes and reduce costs, the focus of healthcare is moving from the acute setting to prevention within the community; funding must be redirected to cover care provided in these areas.
Another solution is the provision of tax credits to licensed providers for training students. This is one means of offering providers reimbursement for potentially reduced income or increased cost associated with training new providers. Currently, Arizona has a bill (HB 2137) that has initially passed a house committee, but it only offers this incentive to physicians who precept students of medical schools. As this bill is not yet fully implemented, modification to include NPs and NP students should be considered.
Sustainable but responsive
Ensuring that NPs have quality preceptorships in order to become strong, efficient providers requires investments of time and money. Whichever solutions are utilized must be responsive to changes in the healthcare landscape. The current practices have resulted in arbitrary rules and regulations that do not increase the number of NPs or MDs, encourage cost-effectiveness, or promote quality outcomes. The Institute of Medicine’s committee that analyzed the current state and proposed guidelines of the GME stated that future funding should be both operational and transformational; recognizing the need to fund innovative educational models for physicians and other health professionals (emphasis mine) “toward achievement of the “triple aim,” that is, improving the individual experience of care, improving the health of populations, and reducing the per-capita costs of care” (Eden, Berwick, & Wilensky, 2014, p. 14). Policies and plans must be designed to be flexible to address the changing provider mix and educational models of the future.
Association of American Medical Colleges. (2015). Medicare’s graduate medical education policy: Its inception and congress’s clear and persistent commitment. Retrieved from https://www.aamc.org/download/449774/data/medicaresgraduatemedicaleducationpolicyitsinceptionandcongresss.pdf
Delisle, J., Phillips, O., & van der Linde, R. (2014). The graduate student debt review. (Policy Brief). Retrieved from New American Education Policy Program webpage: https://static.newamerica.org/attachments/750-the-graduate-student-debt-review/GradStudentDebtReview-Delisle-Final.pdf
Eden, J., Berwick, D. & Wilensky, G. (Eds.). (2014). Graduate medical education that meets the Nation’s health needs. Institute of Medicine of The National Academies. Retrieved from https://www.nap.edu/catalog/18754/graduate-medical-education-that-meets-the-nations-health-needs
Horns, P.N., & Turner, P. (2006). Funding in higher education: Where does nursing fit? Journal of Professional Nursing, 22, 221-225. doi: 10.1016/j.profnurs.2006.03.0014
Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (2011). Transforming education. In The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK209885/
Keehan, S.P., Stone, D.A., Poisal, J.A., Cuckler, G.A., Sisko, A.M., Smith, S.D.,…Lizontiz, J.M. (2017). National health expenditure projections, 2016-2015: Price increases, aging push sector to 20 percent of economy. Health Affairs, 36, 553-563. doi: 10.1377/hlthaff.2016.1627
Trepanier, S., Mainous, R. Africa, L., & Shinners, J. (2017). Nursing academic-practice partnership: The effectiveness of implantation of an early residency program for nursing students. Nurse Leader, 15, 35-39. doi: 10.1016/j-mnl.2016.07.010