School District Health Plan Seen as a Blow to Independent Nurse Practitioners
A local microcosm of national issues at play regarding health care
The Lake Pend Oreille School District’s new contract for health care through the North Idaho Health Network does not cover services from independent nurse practitioners or the ambulatory surgery center—the Pend Oreille Surgery Center—in Ponderay.
Nurse practitioners are Registered Nurses with advanced training who provide primary care, diagnose and treat medical illnesses, write prescriptions, order labs and radiology tests, and provide referrals when necessary. Legislation in Idaho allows nurse practitioners to operate independently (without a physician on site). They are credentialed by almost all insurance companies. The school district’s previous Blue Cross policy covered independent Nurse Practitioners. The NIHN network includes nurse practitioners operating within doctors’ offices, but not independent ones.
There are several reasons why many people prefer NPs to doctors. Some women prefer to see women practitioners (there is only one full-time, female, primary-care doctor in Bonner County); many patients have established histories of care with NP providers, some for decades; and NPs often see entire families.
Up until 2005, Idaho required all nurse practitioners to have a “supervising doctor;” a requirement many said was driven by medical doctors seeking to protect their turf. Even today, the position of the American Academy of Family Practitioners (an association of physicians) states, “The nurse practitioner should not function as an independent health practitioner. The AAFP position is that the nurse practitioner should only function in an integrated practice arrangement under the direction and responsible supervision of a practicing, licensed physician.”
The demand for independent nurse practitioners has grown throughout the nation in response to declining access to family physicians. In many cases, services from independent nurse practitioners are less expensive than the same services from a medical doctor. A number of studies have documented the cost-effectiveness of nurse practitioners.
Based in Coeur d’Alene, North Idaho Health Network is not an insurance program itself; it’s a consortium of health care providers developed by doctors and hospitals in the five northern counties of Idaho who pay a membership fee to belong; this group of professionals are the exclusive providers under the Blue Cross plan selected by the school district. Under the plan, NIHN makes decisions about which providers are covered, that is, which ones are allowed to join the network. Independent nurse practitioners, and ambulatory care centers such as the Pend Oreille Surgery Center, are not currently allowed to join.
That could change in the future. Rick McMaster, the executive director of NIHN, said they have hired a consultant to evaluate current operations beginning this winter. One of the items to be evaluated is coverage of independent NPs. “We are really sincere about wanting to improve our services,” he said. “We have been around for 17 years and have worked hard to improve care in our communities while controlling the cost of that care. We want to address the future.” McMaster admits that NIHN’s belief is that the best care for patients is integrated care, and that the group is most comfortable with NPs who work in partnership with a managing physician. Nonetheless, he says they are investing “considerable financial resources” to determine whether adding independent NPs will meet their goals of improving care and containing costs.
Some local NPs fear this is a stall which may devastate their practices, as they are also losing patients from another NIHN product: Medicare Advantage. One local independent NP said her practice turns away about two patients per week because her practice is not established with NIHN.
But the independent NPs may take heart from learning they are receiving support from the school district itself. “We are aware of the issue regarding independent nurse practitioners,” LPOSD Superintendent Dick Cvitanich said. “We view their services as important to our community and staff. We have asked the NIHN to consider the inclusion of independent NPs. We began this process late last spring and through the summer. We have a desire to have them included for our employees.”
While many people prefer utilizing an NP for basic medical care over a traditional medical doctor, the majority of patients must choose their health care based on the services that insurance will cover. And when buying that insurance, supporting local independent nurse practitioners is not generally a prime motivation. Cvitanich says that while the district’s change in providers was given much thought, the process was driven by cost. “As the costs of health care rise, it reduces the amount of money that can be driven into the classroom for instructional purposes. With the reduction in finances from the state, and as a matter of procedure, the district examines all ways to reduce costs. This past year we more carefully examined health care costs,” he said.
The decision to contract for a Blue Cross plan that utilizes the North Idaho Health Network as a type of HMO was made in concert with staff through the collective bargaining group, headed up by President Brian Smith. “Doing our research together we learned of the benefits of the North Idaho Health Network,” said Cvitanich. “We determined to learn more and began consideration of proposing a change to the employees of the school district. We held a series of meetings for employees; all held outside of working hours so they could attend. We reviewed the information in the plan, showed the designated providers, and answered questions. Employees voted on the plan, and over 90 percent voted to move forward with the change. They appreciated the reduction in deductibles, flexibility of the plan, opportunity for orthodontia, and other provisions. Ninety percent is a compelling number.”
It’s possible that some employees may not have realized that independent nurse practitioners who do not work under a supervising doctor would not be covered under the plan. The list of NIHN providers given to the school district staff by the broker was misleading: some providers on the list are not taking new patients and several have limited or closed practices. McMaster said the list has been corrected, but there are still non-practicing and non-accessible providers listed on the NIHN website; Brad Schwartz to name just one.
According to Cvitanich five northern school districts contract with NIHN because of reduced costs and customer satisfaction. “Feedback we have received regarding the new plan from employees has been very positive,” Cvitanich said. “They appreciate the changes, reduced deductible costs, and the flexibility. In addition, it has reduced district costs. This is important to us and the community as school resources become scarce. We believe we are doing due diligence in monitoring the use of the public’s dollar.
“No health plan meets every employee’s need,” he added. “Our number one priority is to provide a health care plan that meets the needs of the greatest number of our employees. In some cases, health care providers covered under the prior plan were not part of the Network. Some chose to join since the district is now a part of the Network, and some have declined.” NIHN does not currently allow independent NPs to join, and they would if they could.
To those not impacted by the district’s change in health care this may seem to be an academically interesting look at medical turf wars. Yet without access to independent nurse practitioners, there are inadequate numbers of providers to care for people in Bonner County, where there is only one physician per 1,220 people. The U.S. as a whole has 2.67 doctors per 1,000 people. (We’re right up there between Uzbekistan and the Republic of Moldova. Cuba has 80 per 1,000)
There are simply not enough primary care providers in this area There are 33 NPs in North Idaho. You can’t swing a cat without hitting one. But female MDs? We don’t have any cats with long enough tails. In the real world a lot of non-physician providers do a lot of care in a lot of places. They are a huge help in areas that don’t have enough providers, like here.
NIHN also does not currently allow coverage for procedures done at the Pend Oreille Surgery Center. The Surgery Center is a certified ambulatory surgery center, with board certified physicians, a qualified staff of nurses and nurse anesthetists. It offers a comfortable, non-hospital environment for outpatient procedures like colonoscopies. The only other option for ambulatory procedures in Bonner County is Bonner General Hospital, one of five hospitals that, along with 320 physicians, is a member/owner of NIHN.
Mark Savarise, a local surgeon who is a part owner of the surgery center in Pend Oreille, as well as being a member of NIHN, says, “I’ve had patients call to schedule a colonoscopy at the Pend Oreille Surgery Center, only to be told that they have to schedule at Bonner General. I’ve never been told by an insurance company before how or where to practice... and it costs more to have these procedures done at Bonner General; colonoscopies and hernia operations cost at least twice as much, gallbladder three times. And I can tell you this: it’s exactly the same operation.” Savarise also has privileges at Bonner General Hospital, so can treat his patients at either facility.
According to McMaster, one reason for the difference in cost is that the hospital is required to treat indigent patients, while the ASC is not. He pointed out that surgeons who use the ASC can use BGH. McMaster, however, is uncomfortable with discussing costs for procedures, characterizing it as a violation anti-trust laws. In addition, health care costs are complex: many people are surprised to learn that there is no set cost for a given procedure; instead, costs are determined based on who is paying: there are different charges for each insurance company, as well as different charges for non-insured patients.
Yet knowing the cost of health care is important for any reform efforts. A report in the New England Journal of Medicine in March of this year, “Increased Price Transparency in Health Care: Challenges and Potential Effects,” points to the growing demand for transparency in health care costs and opines, “It is difficult to defend the obscuring of health care prices.” Information on comparative Medicare reimbursement rates of surgery at hospitals and at Ambulatory Surgery Centers is available online at www.justice.gov.
Similar to the controversy between medical doctors and independent nurse practitioners is the controversy between traditional hospitals and ambulatory surgery centers at play in this local debate. A research paper from Archives of Surgery (a publication of the American Medical Association) on the NIHN website concludes that “financial incentives linked to ownership of either specialty hospitals or ambulatory surgery centers influence physicians’ practice patterns.” These results are disputed by research cited on the ASC Coalition website.
The complexity of the issue is highlighted on the U.S. Justice Department website, where various sources write that ASCs are “a common-sense, intelligent response to a mature health care delivery system and industry gripped by inefficiencies and to health care spending being out of control... offer patients more convenient locations, shorter wait times, and lower coinsurance than a hospital department...” but at the same time, ASCs are “eroding the outpatient market share of hospitals that hospitals depend upon, that ASCs do not care for Medicaid beneficiaries,” they “skim and cherry-pick on the front end regarding the finances of the patient,” and that ASCs “only enter areas where business is profitable.”
According to Savarise, “Although NIHN was formed to keep health care in North Idaho, it has resulted in managed care— controlling where people go to get their care—and that’s based more on protecting the turf of the doctors and hospitals that are on NIHN’s board. That might not be so bad, except that in many cases managed patients don’t have as good outcomes, and they are excluding some of our best people—nurse practitioners—from the list of covered providers. They are behaving like HMOs used to behave in the ‘90s.”
Of the nurse practitioners, Savarise went on, “They are as good as any doctor in town. I refer my patients to them for primary care all the time. They are being excluded and there isn’t any reason for it.”
NIHN’s mission is to provide quality, affordable care in North Idaho. Under the current system, however, there is available quality care via independent nurse practitioners which is not included. Should it be? It has been established for 25 years that NPs provide quality care at lower costs.
According to the American Association of College Nursing, “... in 1986, the congressional Office of Technology Assessment concluded that nurse practitioners can deliver as much as 80 percent of the health services, and up to 90 percent of the pediatric care provided by primary care physicians, at equal to or better quality and at less cost. In 12 studies, OTA found that the quality of care by NPs—including communication with patients, preventive actions, and reductions in the number of patient symptom—was higher than that for physicians.”
Protecting turf is understandable. That’s what happens in free market health care: everybody is forced to defend their own financial interest. The current concerns raised not just by the school district’s change in health care plans, but in the changes to coverage for county employees as well, are a microcosm of the debate ongoing at the national level regarding the ways in which people can afford medical care.
On both sides there is agreement that our health care system isn’t working. The details are choking us. The expense will kill us. Our provincial skirmish is just the rash on the toe of a patient with bubonic plague.
The first part of any cure is information, and the second part is action. From local medical providers to local insurance purchasers to those who simply want to be able to get medical help when they need it without breaking the bank, we all have a vested interest in debating these issues.
If you are a school district employee who would like full access to care in the Sandpoint area, contact teacher union representative Brian Smith, the school board, Blue Cross, and NIHN. If you are concerned about privacy, call or email me at 304-9066 or firstname.lastname@example.org and I’ll make sure your concerns are shared.