CEO BLOG:

What happens if the ACA subsidies expire at the end of the year?

Here are key facts about the subsidy change:

• Enhanced premium tax credits (PTCs) that reduced marketplace premiums for many enrollees are set to expire at the end of 2025.
• If they expire, the assistance for many marketplace enrollees will shrink or vanish — meaning subscriber premium contributions will go up.
• For example, estimates are that net premiums could increase by 75% or more on average for subsidized enrollees if the enhancements aren’t extended.
• Also: many enrollees whose incomes are above 400% of the federal poverty level (FPL) could lose eligibility for subsidies entirely, reversing the temporary expansion of subsidy eligibility above 400% FPL.
• Because of this, enrollment in ACA marketplace plans is projected to drop if subsidies expire.
• Premium rates (gross) may also rise because the risk pool could worsen (healthier individuals drop out) which insurers already are referencing in their rate filings.

What this means for your NP-owned practice

As a practice owner (especially if you serve self-employed individuals, freelancers, uninsured or under-insured populations, or rely somewhat on patients with marketplace coverage), here are some of the issues you might face:

Potential challenges

• Patient affordability and access: If marketplace premiums go up, some patients may drop or reduce their insurance coverage. That may lead to more uninsured or under-insured visits, increased uncompensated care, or no-shows because of cost concerns.
• Volume changes: If fewer people maintain marketplace coverage, your patient base might shift (fewer insured patients means higher risk for you of patients delaying care or avoiding visits).
• Mix of payer risk: A shift toward more uninsured patients or patients with less coverage may reduce your average payment per patient (if you provide care out-of‐pocket or sliding scale) or raise your administrative burden (billing difficulties, bad debt).
• Negotiation/contract pressure: Some insurers may increase premiums or reduce plan offerings. That may indirectly influence provider reimbursement dynamics or network access.
• Planning uncertainty: Without knowing whether subsidies will be extended, insurers and providers are in a uncertain environment which makes budgeting and forecasting harder for your practice.

Potential opportunities

• New patient growth: If premiums increase and people drop employer-coverage or marketplace coverage, they might seek lower-cost care alternatives (like NP-led practices) especially if you offer more affordable, flexible models.
• Value-based/cost-effective care positioning: Your practice can position itself as a lower‐cost alternative for routine / primary care, which becomes more attractive when insurance costs rise.
• Population health / outreach: You may find an opportunity to reach self-employed or independent workers whose marketplace coverage becomes more burdensome — you could offer self-pay packages or membership models.
• Strategic partnerships: With insurer changes ahead, you could explore alternative models (direct primary care, hybrid models) that appeal when coverage becomes less generous or more expensive for patients.

Operational & financial considerations

• Review payer mix: What portion of your patient base has marketplace‐insurance vs other coverage vs uninsured?
• Monitor trend in patient cancellations or changes in coverage termination: Supplemental ask your front-desk or billing team to flag when patients report higher premiums or dropping plans.
• Evaluate sliding scale/out-of-pocket pricing: If more patients shift to self‐pay, do you have a model for that pricing or membership model?
• Consider billing/collections risk: If patients lose subsidies and become uninsured or partially insured, collection risk goes up; evaluate your policy for uninsured patients.
• Consider marketing message: If affordability becomes a concern, you can emphasize cost transparency, affordable access, convenient care.
• Keep an eye on policy/insurer changes in your state: Subsidy impact varies by state (because some states have additional subsidies or Medicaid expansion differences). For example, in your state (Connecticut) the marketplace () reports many enrollees would lose subsidies.

What you should do now (and plan for)

• Stay informed: Track Congress’s action on extending subsidies (as of now, enhancements expire end of 2025).
• Scenario planning: Build financial models for your practice that assume: (a) subsidies stay (b) subsidies expire. What happens in each case re: patient volume, payer mix, bad debt?
• Engage patients/education: Have discussions with patients about their insurance coverage, premium burdens, possible changes next year — they may need to adjust their choices, and sooner you know, the better for your scheduling/planning.
• Review contracts: Especially if you participate with marketplace‐plans; see what the insurer is doing for 2026. Are they planning rates/benefits changes that will affect access to your practice?
• Consider alternative models: If you haven’t already, think about offering direct membership care, hybrid pricing, telehealth, or bundling to capture demand from cost-sensitive patients.
• Billing and collections readiness: Tighten policies for patients who may lose coverage; assess your allowance for sliding scale; possibly review charity care policy.
• Communicate with staff: Prepare your team about possible shifts in patient behavior (e.g., delayed care, insurance drop-outs) so scheduling, billing, and patient flow can adjust.

Specific relevance for NP-owned practice

Since your practice is NP-owned (likely smaller, more agile than large hospital systems), you have some advantages: you may be better able to pivot to more cost‐effective models and respond to patient affordability needs. But you also may have fewer resources to absorb sudden increases in uninsured visits or bad debt.

• Your practice may benefit from emphasizing affordability: As marketplace premiums rise, patients may look for lower cost care alternatives — your NP-led model could appeal.
• You may consider membership or subscription models: Direct primary care (DPC) or hybrid models might become more attractive to patients facing higher premiums.
• You may also need to monitor payer reimbursement trends: If insurers raise premiums because of subsidy expiration, they may also try to negotiate provider rates differently; staying aware and actively managing contracts is key.

In short: The expiration of ACA marketplace subsidies is likely to increase cost pressures for patients, which in turn can impact your practice via changes in payer mix, uninsured volume, and patient behavior. But if you anticipate and adapt, your NP-owned practice may be well-positioned to respond to those changes.

Here are several reliable sources that discuss what the expiration of the enhanced Affordable Care Act (ACA) marketplace premium tax credits (subsidies) would mean:

• The Kaiser Family Foundation (KFF) Issue Brief: “Inflation Reduction Act Health Insurance Subsidies: What is Their Impact and What Would Happen if They Expire?” — shows that if the enhanced subsidies expire at the end of 2025, almost all Marketplace enrollees would face steep increases in premium payments starting in 2026. KFF+1
• KFF’s “About Half of Adults with ACA Marketplace Coverage…” — indicates that around 48% of adults under age 65 enrolled in the individual market are either self-employed or small business owners/small business employees, meaning this change affects a lot of people in your category (NP‐owned practice serving self­employed patients). KFF
• Analysis by the Health System Tracker (via KFF) “Early indications of the impact of the enhanced premium tax credit expiration…” — estimates that expiration will result in over a 75% average increase in enrollee premium payments, and that insurers anticipate a sicker risk pool. Health System Tracker+1
• Commonwealth Fund Issue Brief: “Expiring ACA Premium Tax Credits Could Lead to Nearly 340,000 Jobs Lost Across the U.S. in 2026” — emphasises broader economic and coverage implications if the subsidies expire. Commonwealth Fund
• KFF “Who Might Lose Eligibility for ACA Marketplace Subsidies …” — shows how eligibility for subsidies would change, particularly for incomes above 400% of the Federal Poverty Level (FPL). KFF
• KFF “How Much Would People Pay in Premiums if the ACA’s Enhanced Subsidies Expired?” – interactive/analysis tool showing large increases in premium payments if the subsidies expire. KFF+1

BE INFORMED AS A BUSINESS OWNER.

 

Across the country, Nurse Practitioners (NPs) are filling critical care gaps, especially in underserved communities. We’re driving value, improving outcomes, and offering cost-effective solutions in a strained system. But despite our impact, NP-led practices continue to face an uphill battle—one shaped not by clinical skill or patient demand, but by structural, policy-driven barriers that hold us back.

If we want a healthcare system that truly reflects the needs of patients and the realities of care delivery, we must start with the truth: the system was not built with NPs in mind. It’s time to name the problems, expose the inequities, and demand the reforms that will finally level the playing field.

Consolidation Is Undermining Community Health

Healthcare consolidation is often sold as a path to efficiency and streamlined care. But the reality on the ground tells a different story.

As NP practice owners, we’ve seen how corporate mergers prioritize shareholder returns over patient outcomes. Community voices are promised a seat at the table—but are quickly sidelined when governance is centralized and local accountability fades.

When decision-making is divorced from the people delivering and receiving care, equity becomes an afterthought. Health care cannot—and should not—be managed like a corporate portfolio. Our communities deserve better.

Value-Based Payment: Designed to Exclude?

NPs have long been at the forefront of providing patient-centered, preventive care—exactly what Value-Based Payment (VBP) models aim to reward. Yet we continue to face systemic exclusion.

Whether it’s being left out of ACO attribution models, grappling with outdated billing structures, or shouldering disproportionate risk as small practice owners, the barriers to VBP participation are clear. And they’re costing patients the benefits of NP-led care.

VBP programs must evolve to reflect how healthcare is actually delivered today. That begins by including all qualified providers—NPs included.

The “Full Panel” Lie: When Insurer Directories Mislead

Another quiet barrier lies in credentialing and network access. Time and again, NPs are denied entry to insurance panels under the pretense that they’re “full.” But those same panels often feature outdated directories filled with inactive providers.

This deceptive practice misleads patients and restricts access to high-quality, NP-led care. It’s more than an administrative oversight—it’s a form of gatekeeping that reinforces systemic inequity.

We must demand transparency, accuracy, and accountability from insurers. Patients deserve to know who’s actually available to care for them.

Credentialing Delays: A Hidden Threat to NP Practice Growth

When physicians onboard a new provider, they can bill during the credentialing period. But NP-owned practices? We’re left waiting—often for months—without support or reimbursement.

This delay doesn’t just hurt business viability; it blocks patient access and undermines our ability to grow the workforce. Equal care deserves equal process. Streamlining credentialing for NP practices is not a luxury—it’s a necessity.

Education Funding: Invest Where the Workforce Is

As physician shortages dominate headlines, federal and state funding continues to pour into medical education pipelines. Meanwhile, NP training remains chronically underfunded.

We need a national loan program for NP students, administered through community-based Doctor of Nursing Practice (DNP) programs, with dedicated funding for preceptors and infrastructure. We cannot build a resilient healthcare workforce while ignoring the fastest-growing segment of it.

Supporting NP education is not just about fairness—it’s about future-proofing healthcare.

The Path Forward: Real Solutions, Right Now

Change is possible—and within reach. From payment reform to antitrust enforcement, here are just a few policy priorities that can make an immediate difference:

• End “incident to” billing that masks NP contributions
• Modernize VBP programs to include NP attribution
• Enforce insurer accountability on network accuracy
• Streamline NP credentialing to match physician credentialing standards
• Fund a national NP student loan program
• Protect independent NP practices from anti-competitive transactions
• Enforce existing healthcare anti-discrimination laws

We’re encouraged to see the Department of Justice’s Antitrust Division taking these issues seriously. But now we need action—not just analysis.

Conclusion: It’s Time to Be Heard

NPs are ready. We’re leading practices, educating students, filling care gaps, and building healthier communities. But we cannot do it alone—and we shouldn’t have to fight the system we serve.

It’s time for our voices to be heard in every room where decisions are made. Because when NPs are supported, patients thrive. And when policies reflect the real world of healthcare delivery, everyone wins.

Join the Conversation:

• How has consolidation impacted care in your area?
• What policy change would make the biggest difference for your practice?
• What does an equitable future for NPs look like to you?

Let’s build it—together.

May 10, 2025

Ladies and Gentlemen of the DOJ Antitrust Division:

My name is Dr. Lynn Rapsilber, APRN and I am the CEO of NNPEN, a national network of Nurse Practitioners (NPs) who are owners of, and employees within, nurse-led clinical practices.  These NPs are included within MACRA’s QPP definition of “eligible clinician” and CPC+’s definition of “practitioner”.

As a general statement, NNPEN believes that replacing a legislative/prescriptive definition of scope of practice with one that defers to the education and training of the designated practitioner’s license is a good thing.  Is it the educational preparation or the license that counts?

My comments relate to the effect of recent Executive Orders but also more broadly to how CMS, guided by healthy healthcare competition policy, can take the lead with other payers in the construction of infrastructure that facilitates the quickest uptake of, and access to, advanced practitioners into the Medicare provider network—increasing competitors and competition. 

Expecting that AANP and many other friends of NPs will also be responding, NNPEN restricts our comments to preparing NPs to be informed risk-takers in Value Based Payment risk programs that can sustain small, nimble group practices.

NP Scope of Practice [SOP] success is a pyrrhic victory and will not reduce harmful barriers to healthy competition without NP access to Value-Based Payment arrangements that we know can reliably reward the NP outcomes that flow from the Nursing Process.  Recent executive orders give this conversation—i.e., NP risk-taking skills required to succeed in Value Based Payment programs --new and significant urgency. 

Here are our comments detailing opportunities for the DOJ, partnering with CMS, to level the SOP playing field short and long term and create provider choices that the American consumer deserves:

#1—Preserve/extend the low cost and high quality benefits of the Nursing Process

• Uncontroverted literature of >100 peer-reviewed studies finds that NPs produce quality and cost outcomes as good or better than those of physician PCPs. Why? because of the integrated view of the patient that is the backbone of the Nursing Process. This patient-facing hard-wired Nursing Process also explains why nurses are consistently viewed as the most trusted profession, and the group most trusted to “fix” health care.
• Yet the Nursing Process is desecrated by the dominant medical model pressure to “see”25-30 patients per day, squeezing patient office visits into 15 -minute segments
• NP-owned practices are typically small and community based—by design.  They struggle to find SBA lenders that appreciate their creditworthiness. To preserve the benefits of nurse-led care, NP practices need many more sustainable independent practice options, that give consumers access to healthcare and preserve the benefits of the Nursing Process in all fifty States.  Recent Executive Orders do not do that;  CMMI has stood up only one model, the REACH ACO, as “NP friendly” because it recognizes the physician and NP PCP ‘s network eligibility and payment options as equivalent, while CMMI’s dominant Medicare Shared Savings ACO model does not.
• Even Original Medicare, which does not reflect the anti-NP bias of private insurers that’s been built into managed Medicare, punishes the NP PCP by paying NPs only 85% of the physician fee schedule for the same work, and adds insult to injury by perpetuating an “Incident to” billing policy  that recognizes the billing provider [deemed to be the physician in most institutional settings], not the treating provider who would be paid only 85% of the physician’s charges].  MedPac’s recommendation to abandon incident- to billing has not prevailed.
• Given these VBP program limitations, the SBA needs much more encouragement to create a robust lender safety net for NP practices who form the healthcare safety net in underserved communities.

#2—Full Practice Authority (aka Independent Scope of Practice) will generate a much-needed NP primary care outcomes database that supports pricing based on competition

• As long as the NP is not the independent Primary Care Provider, no performance data is being separately attributed to the NP--- syphoning NP value off to benefit the billing physician and allowing payers to resist exploration of VBP with NPs for “lack of credible data”. CMS terminating the practice of incident- to billing would support collection of the longitudinal data that is essential to measuring and documenting the NP’s (and all other PCPs’) management of population health risk

• ·         The metaphor when Medicare sneezes everyone gets a cold is trite but true here. Think of this as the encore to our government’s funding technology development in early years by supplying the expensive hardware.

 

#3--Without NPs delivering primary care access across the nation, CMS will fail to meet its Quadruple Aim Goals

• We are losing primary care physicians at an unprecedented rate across the U.S., especially in rural areas where the needs are extremely high and opioid addiction/deaths are skyrocketing.  Many doctors are moving to "concierge" care models which leave out the poorest/sickest in the U.S.
• NPs are the fastest growing health care professional group by a lot. The American Association of Nurse Practitioners’ website reports there are 385,000 NPs in America in 2024. According to the Bureau of Labor Statistics, overall employment of physicians and surgeons is projected to grow 4 percent from 2023 to 2033 with 23,600 openings annually. https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm

Empowered by the current administration’s libertarian leanings, and reinforced [but never enforced] by ACA Section 2706 prohibiting insurer discrimination on the basis of license, DOJ and CMS have the power and gravitas with a top- of -license SOP vision to overcome the staunch payer resistance and physician stonewalling that still confounds SOP progress in more than half of our 50 states.  The marketplace and the workforce are ready for SOP change that is refreshingly bipartisan.  The time is now! 

We applaud President Trump for his recognition that advanced practice providers, specifically Nurse Practitioners that can practice independently, are the market disruptors his administration needs to break down the barriers to healthy primary care access. 

On behalf of our independent NP practice membership and an America filled with consumers without access to primary care, NNPEN thanks you for our opportunity to comment on barriers to healthy competition in health care today.

Sincerely,

/s/ Dr. Lynn Rapsilber, APRN

Computer Clicks” Tips on EHRs

by NNPEN partner OptiMantra

Building your business: Engaging patients with packages and recurring memberships

For nurse practitioners in independent practice, finding ways to improve patient retention can help drive financial stability. Packages and recurring memberships offer a sustainable way to enhance engagement, generate predictable revenue, and streamline service delivery. However, implementing these models effectively requires careful planning—from pricing and perks to compliance and tracking.

While these tools have traditionally been much more common in cash-pay NP practices with non-primary care specialties, they are also increasingly used in primary care and insurance-based practices.

Interested in actionable insights? If you're already offering memberships and packages or considering adding them to your practice, check out our recommendations.

Computer Clicks” Tips on EHRs

by NNPEN partner OptiMantra

Cyberattacks can target healthcare practices of any size, and protecting your patients' data should be a top priority. While it can seem daunting to start implementing security precautions, protecting your data happens one small and manageable step at a time.
For instance, password-sharing happens at most clinics -- if one account is compromised, your other accounts are at risk too -- and it's easy to address!

To get started, tackle the basics today: 
‍
‍1. First, Keep Computers and Applications Locked and Password-Protected
‍
‍One of the easiest and most effective ways to protect your patient data is by ensuring that all computers and applications are properly secured! Many breaches are attributable either to i) unauthorized device access in the office, or ii) compromised passwords. Here are a few key steps to enact across your key systems - like your email, EMR, CRM, and any other office systems 
Enforce strong passwords: Implement a robust password policy for all staff accessing your systems. Passwords should include a combination of uppercase and lowercase letters, numbers, and special characters.
‍Change your password regularly:  Regularly remind your team to update their passwords - ideally every couple of months. 
‍Avoid password sharing: Each staff member should have their own unique login credentials. Do not share passwords or leave them written near computers. Unique log-ins also ensure that you can monitor unauthorized access (more on that below).
‍Lock computers when unattended: Computers, particularly those in high-traffic areas like the front desk, should not be left unlocked or unattended - even if it’s just to check into the backroom. Make sure all your devices also have automatic time-outs, just in case you forget to close out before getting up.


‍3. Enable Two-Factor Authentication (2FA)
‍
‍Better monitoring of devices and strong passwords is a critical first step, but bad actors can use brute force to try to guess your password or, if they’ve secured access to your device, they may be able to log into your systems remotely. Two-factor authentication (2FA, also multi-factor authentication) is an effective way to further secure your access to your systems. By requiring not only a password but also a second form of identification (such as a text message code), you greatly reduce the risk of a security breach—if #1 was ineffective and your login credentials are compromised.
Set up 2FA for all users and all healthcare systems - Most systems have 2FA options. Set 2FA as a practice-level requirement where possible vs. waiting for your team to enable it themselves. This additional security layer is a must in today’s cyber threat environment.
In OptiMantra, you can easily add 2FA for all your providers and staff directly from Settings to ensure compliance. To reduce the log-in burden, you can also whitelabel/save secure IP addresses (like your office location) to avoid authenticating every time when you’re in a secure location.


‍2. Monitor and Install Regular Software Updates and Patches

‍Outdated software is one of the most common entry points for cyberattacks. Keep your systems up to date with the latest security patches to minimize your vulnerability. This doesn’t need to take long!
‍Regular updates: Ensure that all operating systems, browsers, and applications are updated frequently. For example, if you're using Chrome, you’ll often see reminders for updates in the top right corner of the browser. Don’t ignore these notifications!
‍Automate patches where possible: Set your systems to automatically download and install security updates, so you don’t miss critical fixes.


‍4. Talk to Your Team About Cybersecurity Awareness

‍Regularly educate staff on best practices to avoid falling victim to phishing attacks, social engineering, and other common online scams.
‍Stay vigilant against phishing: Most practices get tons of patient and vendor emails. Encourage patients to use HIPAA-compliant methods of communication (outside email) to connect with you to avoid getting emailed attachments. Remind your team to never open unexpected emails or attachments from unknown senders. If anything seems suspicious, encourage your team to double-check before clicking on links or downloading files.Bad actors can change the To address to look like it’s coming from a valid source, so that’s a good place to check first.
‍Run simulated phishing exercises: Consider testing your team’s response to phishing attempts by running mock phishing campaigns. The basics of this are easy - ask someone you know to send a sketchy email, and see how many folks in the office flag it! There are also online platform you can use to run a professional phishing exercise.

‍6. Use HIPAA-Compliant Communication Tools with Data Encryption

‍We touched on this in #5, but it bears repeating! To safeguard sensitive patient data, use communication channels that comply with HIPAA regulations and provide encryption for both data in transit and at rest.
‍HIPAA-compliant email and text: Use an email provider that offers encryption and HIPAA compliance when communicating with patients and other healthcare providers. This ensures patient information is protected from unauthorized access.
Remember that while your email may be HIPAA-compliant, your patients’ probably aren’t using HIPAA-compliant email! Make sure your consent forms include a consent for email and text reminders and communications.
‍Patient portal: Consider using a patient portal to centralize patient communications and avoid sharing sensitive medical information via email.


‍5. Strengthen Network Security
‍
‍Your network infrastructure should be designed with security in mind, especially when handling sensitive patient data.
‍Use a firewall: A robust firewall can help prevent unauthorized access to your practice’s network. Make sure your firewall is properly configured and updated regularly.
‍Update antivirus and anti-malware software: Keep your antivirus and anti-malware programs up to date to ensure your systems are protected from the latest threats.
‍Restrict access: Limit access to your systems to authorized personnel only. If your practice allows remote access, consider using a virtual private network (VPN) for secure communication.


‍8. Get Cybersecurity Insurance
‍
Consider purchasing your cybersecurity insurance to further protect your practice.

Tackling even just one item on this list today will help you enhance the security of your practice data! Staying proactive with regular updates, educating your team, and utilizing security measures like 2FA and encrypted communication will help you stay ahead of potential threats. Cybersecurity is an ongoing process — what you do today helps protect your practice for the future.

IS THERE MORE TO BUYING NP MED MAL INSURANCE THAN PRICE?

YES!!!!

Imagine a licensing board appearance for which you have no insurance policy that pays for license defense—this is not only threatening your license, but also your LIVELIHOOD.  Or you have a cash hustle in aesthetics that you plan to expand, until you discover that your incumbent insurance co excludes an aesthetics practice that makes up more than 25% of the practice?  Or surcharges a practice whose telehealth activity is >50%--suggesting that the practice is not seeing all patients for an in-person assessment—dashing your ideal 100% telehealth psychiatric NP practice vision?

Are you interested in what I’d look for in reviewing the NP’s medical malpractice policy?  Here are some questions on my top 10 list that will help you customize the standard med mal policy to your situation:

• 1.      Any rate increases imminent?
• 2.      Do they curate/publish NP claim info, and specifically for NPs who are practice owners/self-employed?
• 3.      Add to NP policy the NP’s’ Vicarious Liability [VL] for collaborator acts?  Additional premium or no charge?
• 4.      License defense endorsement
• a.      Ability to select counsel [remember, this is your livelihood] who is a nurse-attorney
• b.      Consent to settle with or without a hammer?
• c.      Covered only if complaint arises out of underlying medical incident or a broader professional services trigger?
• 5.      Telehealth—any constraints e.g. max percent of practice that can be telehealth?
• 6.      Cybersecurity—where is HIPAA protection—for defense and notification expenses.  Do I really need separate stand-alone cybersecurity policy or will the med mal policy cover my defense expenses and any fines? Is the $25,000 limit adequate?
• 7.      Do I need cover for just me, or also for employees/ medical directors?
• 8.      Any cover for criminal allegations of unlicensed telehealth practice outside state of license?
• 9.      Shop around—insurer underwriter hot buttons vary
• 10.   Price—ask about premium increases that will affect next year’s renewal. Significantly lower premium is not necessarily troublesome: a new entrant into the marketplace may not have paid many losses yet and is buying your business. So long as the company carries an A.M. Best rating of A or above, your risk that the company will not be able to pay your claims is low. 

NNPEN is here to help you ask the right questions.  Your Insurance Advisor can answer them.

Members can use their free hour of consulting with a Founder to better understand what’s important to them in their policy choices.  Together we can view your insurance policies as the important asset they are.

SB

Here we go again.  Planning for NNPEN’s April 2024 conference is already underway and we are asking ourselves this question: will NP leaders feel that the healthcare delivery system, and NPs as a profession, are better off now than 12 months ago?  Are we any closer to quantifying NP value? And if not, does it still matter?

From the outside, it is hard to “hear” movement from “silence to voice,” as authors Buresh and Gordon labeled nursing’s challenge in 2013 -- ten years ago.  A few years later, here is what we thought NP disruptors would sound and look like, based on eight-year-old keynote slides from NNPEN’s Inaugural Boston conference in 2017:

 Attributes of an NP Market Disruptor

•         Understands what is driving change in health care, especially in primary care access.
•         Sees NP FPA struggle in broader regulatory & economic markets context: classic competition battle. History is on our side!
•         Identifies business models available to NPs and the skillsets needed to survive.
•         Develops confidence in the business case for NPs as independent practitioners.

Can we declare “mission accomplished!”?  Yes, and no…

I would argue that inside the NP community there is an unmistakable restlessness for change being channeled by NP entrepreneurs in increasing numbers. NP entrepreneurs take the road less travelled, color outside the lines, and make good trouble, in a nutshell are market disruptors.  We will open our 2024 conference with case studies of NP entrepreneurs who are showing us disruption first-hand:

1] “call me doctor” litigation brought by 3 NPs against the CA Board of Nursing

2] a fact check challenge to the AMA’s disturbing put-down of NPs as primary care equals

3] an academic proposal to move nursing out from under the bed rate to financial accountability as a free-standing revenue center, be it in a corporate setting or health system or nurse-led clinics.

This year, NNPEN aims to open NP eyes to the possibility that NP practice transition to a growth mode and risk readiness is already underway.  Indeed, we can find evidence of NPs as disruptors in two of our 2017 disruptor attributes list:  [Understands what is driving change in health care? Check! Identifies business models available to NPs and the skillsets needed to survive? Check!

Do NPs see the FPA struggle as a classical competition struggle that history tells us NPs will win?  Maybe. 

Do NPs feel confident in the business case for NPs as independent practitioners? No.

Have we translated the impact of the nursing model, our patient-centered north star, into dollars as well as clinical value? 

Not yet.  There is clearly work to do.

Market disruption is not the only growth tale to unfold on April 13 at our conference. Two of our favorite NP-literate attorneys Justin Marti and Dena Castricone will share their views on how growth uncertainties can be managed even as we encourage NP entrepreneurs to color outside the lines.  To top off the day, in-person attendees will sign up for consecutive breakout sessions that explore the everyday challenges to, and collaboration proposals for, making NP entrepreneurship sustainable by joining forces—not practice absorption but practice networking to make 2+2=5.  Ponder one very encouraging data point from our 2023 survey of 1200 independent NPs in Connecticut: 65% of the NP respondents indicated interest in “collaborating with other nurse-led practices to access the benefits of value-based reimbursement.

Change comes when entrepreneurs and intrapreneurs become disruptors who color outside the lines TOGETHER.  Bring an NP entrepreneur buddy with you so that your aspiration to “be the boss of me” does not die at the end of the day.  We will supply the crayons! 

Be there: April 13, 2024, at the Hartford CT airport’s convenient and safe Sheraton Hotel venue. 

SB

Making Care Primary (MCP) Model

On June 8, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary primary care model –improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health-related social needs (HRSNs) such as housing and nutrition. CMS is working with State Medicaid Agencies in the eight states to engage in full care transformation across payers, with plans to engage private payers in the coming months. CMS will begin accepting applications for the model in late summer 2023.  https://innovation.cms.gov/innovation-models/making-care-primary

Making Care Primary [MCP], like REACH, targets Medicare FFS beneficiaries in underserved areas.  MCP seems to focus on growing small independent primary care practice infrastructure sustainably,  with an eligibility minimum of 125 attributed lives per practice, while ACO REACH focuses on the ACO  as an aggregating vehicle to incentivize providers and measure outcomes of his/her panel minimum of 5,000 attributed lives. MCP is a 10-year beta beginning July 2025 in eight preselected states; ACO REACH is a 5-year beta that began January 1 2023 in all 50 states.  It sounds promising for NPs to have two value- based payment models to compare and contrast, but we have very little detail until the MCP RFA [Request for Application] is released this summer.  NNPEN tried to get an early answer confirming NP eligibility, attribution to NPs and the minimum # of attributed patients for MCP eligibility.  We got back this partial answer the next day:
“Small, independent primary care practices that meet eligibility requirements listed in the RFA may participate in the model. Applicants must have a minimum of 125 attributed Medicare FFS beneficiaries in order to be eligible for MCP. This eligibility criteria will be assessed at the applicant level. The applicant will submit a list of primary care clinicians as part of the application which will assist CMMI in conducting this eligibility check. The RFA will be published later this summer.”

Model Overview

The Making Care Primary (MCP) Model is a 10.5-year multi-payer model with three participation tracks that build upon previous primary care models, such as the Comprehensive Primary Care (CPC), CPC+, and Primary Care First (PCF) models, as well as the Maryland Primary Care Program (MDPCP). MCP aims to improve care for beneficiaries by supporting the delivery of advanced primary care services, which are foundational for a high-performing health system. The MCP Model will provide a pathway for primary care clinicians with varying levels of experience in value-based care to gradually adopt prospective, population-based payments while building infrastructure to improve behavioral health and specialty integration and drive equitable access to care. State Medicaid agencies will commit to designing Medicaid programs to align with MCP in key areas. This model will attempt to strengthen coordination between patients’ primary care clinicians, specialists, social service providers, and behavioral health clinicians, ultimately leading to chronic disease prevention, fewer emergency room visits, and better health outcomes. 

NNPEN’s conclusion: the VBP cauldron is bubbling; stay engaged and bring your colleagues with you!  Curious NP PCPs in these eight states should evaluate the number of Medicare FFS patients they serve in aggregate as the threshold for application for this model—NOT whether they currently possess value-based payment experience:  Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina, and Washington. 

REACH FOR IT!

March 2023 Blog

What a Difference a Year Makes

Last year when NNPEN polled NP Value Summit attendees, they didn’t see Value Based Payment [VBP] at their doors for 10 years: Not a surprise. No payers were offering VBP contracts to NPs, and NPs felt a very low sense of urgency to leave FFS, the devil they knew.  But 12 months later, as of January 1, there are >100 payers willing to contract with NPs on VBP terms—a payer or two in most states. 

Q: Who are these payers?  A: REACH ACOs

REACH ACOs are the new Medicare payers for NPs, a five year pilot of CMMI focused on delivery of primary care services that create health equity and extend the reach of primary care into underserved populations—an NP sweet spot. [ REACH stands for Realizing Equity, Access and Community Health.]

And they are the NP friendliest of the CMS ACO models thus far—for one threshold reason [aside from NP’s love affair with seniors, especially high needs homebound beneficiaries]: REACH ACOs level the playing field for all eligible PCPs, docs and NPs alike—with a claims-based assignment system called Attribution also known as Alignment].  Attribution means eligibility for any auto-assigned revenue stream associated with traditional Medicare patients for the NP and any ACO s/he is part of.  By recognizing the NP in larger numbers through claim-based auto assignment [in addition to current voluntary assignment] as both the treating and billing provider, REACH creates visibility for NP PCPs and data to quantify NP value.

We already have that with our traditional Medicare patients that we see in our nurse-led practices…right?  Not really.  NPs are still stuck in a FFS payment system that is fiscally unfair, not patient-centered and affords little opportunity to grow into a practice big enough—visible enough—to leverage payers into reimbursement contracts that value NP quality and cost outcomes.

Like other ACOs, REACH creates critical mass leverage by aggregating—but not owning—small practices, creating a powerful Double AA battery of Attribution and Aggregation.  And with CMS as overseer and financial reconciler, REACH offers transparency and training wheels to accepting both risk and reward for your panel’s health . 

How does REACH support the NP’s shift to value?

• o   You keep your non-REACH patients and bill them as usual, direct to Medicare
• o   Monthly care management payments
• o   Monthly payment advances to support cash flow [“capitation”]
• o   Value-based payer contracting and population health program management
• o   Downside risk protection
• o   Access to shared savings
• o   Opportunity to erase the 15% differential with the Medicare physician rate schedule

There are 3 types of ACO REACH but all abide by same CMS/CMMI rules.   How do I tell these REACH ACOs apart? 

• o   High needs beneficiaries only: typically HCC >4.0; minimum ACO size=500 attributed lives
• o   Standard: established Medicare expertise; 5000 attributed lives
• o   New Entrant: New as Medicare providers; 3000 attributed lives with growth timeline

REACH ACO Nurse Practitioner Services Benefit Enhancement New in 2023

Wait—one more NP friendly change!  One of NNPEN’s members points to another way REACH ACOs will impact both the NP and the beneficiary, and in a much more immediate way.  Through the Nurse Practitioner Services Benefit Enhancement 2023 the NP can certify the need for hospice, diabetic shoes,  cardiac rehabilitation and several other therapies WHICH STILL REQUIRE PHYSICIAN CERTIFICATION FOR MEDICARE BENEFICIARIES NOT ALIGNED WITH AN ACO REACH.  This is a benefit the REACH ACO can elect to offer in an effort to streamline both quality and cost for seniors.  This benefit enhancement works for the patient [diabetic shoes today!] and also supports ongoing collection of quality and cost data starting this program year, and we know that data is what we need to change policy more broadly!  See page 75 in this link for a complete list of enhancement services: https://innovation.cms.gov/media/document/aco-reach-rfa

If you’ve railed against the barriers created by the physician certification of need requirements, recognize the REACH Nurse Practitioner Services Benefit Enhancement effective  2023 as another opportunity to create  the visibility NPs need to lay the foundation for quantifying NP Value.

Best ways to learn more about REACH ACOs

• 1.      Interviews with ones in your state; are they NP -friendly? Do they understand your questions? Have they shown willingness to negotiate a cap on downside risk? Have they elected to offer the NP Services Enhancement Benefits?
• 2.      Understand their timelines and match against yours
• 3.      Follow NNPEN’s REACH reporting and strategy to build a critical mass of like-minded NP practices
• 4.      Remember One and Done: Primary care providers cannot participate in >1 REACH at a time, but can withdraw
• 5.       Join us April 1, 2023 in person or virtually for our spring conference: [In]Visible* to Value, which will focus on creating NP visibility as a precondition to NP success in VBP, and hear how peers assess the downside risk of this migration.  Here’s the link to the NNPEN 2023conference landing page: https://mailchi.mp/2ed382004d0e/je04wxx0yw 

See you April 1 [no fooling!]

SB

POST 2022 SUMMIT BLOG

NP VBP: IS THE JUICE WORTH THE SQUEEZE?

NNPEN hosted its first Value-based Payment Summit on February 11^th and 12^th with attendance of 30+ like-minded professionals, all focused on NPs getting paid for the nursing model’s value add . Together the Summit ROCKED on content, every session recorded to reach a much larger audience.  NNPEN experts agreed that a fee-for-service model is unsustainable for nurse-led practices and NPs need to understand the benefits associated with an at- risk payment strategy.  With a focus on health promotion and disease prevention under a nursing model of health care delivery, the NP can survive and benefit from a value-based payment arrangement. Our narratives built one on another and made sense together: how often does that happen? We think this summit marks the beginning of a ground-up mapping to critical mass numbers! Many, many thanks to our subject matter expert speakers: researchers, payers, practice owners and educators.

We owe equal gratitude to the robust support NNPEN received from first-time sponsors, topped off with exhibits by the Emory Nursing Experience, a professional development initiative for nursing and Medical Advantage, a practice management company supporting NPs. These sponsors see the value of NPs in this space, even while we recognize NPs lag behind for many reasons revealed during the Summit sessions: lack of knowledge, small panel size and lack of incentives, to name a few.

The Summit concluded with these questions: How can we do this? How will we raise the value-based payment participation rate of nurse-led practices—and in turn, give NP practices agency over how they deliver the services their patients need, create sustainability both financially and clinically for their practices, and act with urgency?  NPs as a workforce cannot waste this opportunity to leverage the pandemic’s access crisis in each of the 50 states!

We have several takeaways to hold close as we push to construct the roadmaps to NP VBP model participation:

1.  NP attendance at the Summit tells us there’s more work to be done to move the value- based payment needle for NPs – not in 10 years’ time [the most common chat response on timing of VBP’s arrival for nurse-led practices] but starting now.  Policy wonks, including CMS, peg the transition timeline closer to 3-5 years.

2.  VBP covers services that are patient-centered, not volume driven, and aligns with the patient-centered nursing model.  Sharing values with payers bodes well for patient-centered partnerships—not so much with FFS payers that reward volume

3.  Our biggest risk is NOT down-side risk, but NP failure to plan for a transition to VBP that will be here, championed by Medicare and employers, in the frequently cited timeline of 3-5 years.

4.  We know that nurses are bottom-up problem solvers [because there has always been resource constraint in conflict with what our patients need?].  So, we need to get local NP organizations talking with each other, with a common agenda, to ultimately answer this one meta question: IS THE JUICE [THE TRANISITION TO VBP] WORTH THE SQUEEZE?  WHO DECIDES? Remember if we are not at the table, we are on the menu!

How will this happen?  NNPEN will edit the recorded Summit sessions, summarize a bit, and then invite partners on a local level to draft a consensus vision for NP VBP and to propose next steps, including sources of funding, that fit the region and that will lead to region-specific answers to our meta question, “Is the VBP Juice worth the Squeeze?”. 

We are also looking for other stakeholders who see the need for action to join us.  Is this too much to ask?  We don’t think so.!!

Sandy Berkowitz, Lynn Rapsilber, and Lorraine Bock

NNPEN