MovingtheDisparityNeedle
ResourcingCareDeliveryforThoseWithGreatest Needs
TeriAronowitz,PhD,APRN,FNP-BC,FAAN, KennethS.Peterson,PhD,APRN,FNP-BC, andNancyS.Morris,PhD,APRN,ANP-BC
Healthcarequalityisasigni fi cantpolicyconcern.TheUnitedStateshashigher hospitaladmissionratesthancomparabl ecountriesforchronicconditionssuchas congestiveheartfailureanddiabetes-relatedillnesses. 1 Effortspersisttobetterunderstandandmitigatefactorscontributingtohospitalizationsandreadmissionrates,particularlyforgroupsdisadvantagedbysocialandeconomiccircumstances.Peoplewho areduallyeligibleforMedicareandMedicaidinsurancerepresentadisproportionately higherrateofhospitaladmissionsandsigni fi cantsocialhealthcareneeds. 2 Nikpour etal ’s 3 publicationoffersanimportantcontributiontothisexpandingliterature.They examinedtheassociationofnursepractitioners(NPs)practiceenvironmentsonthecare ofduallyeligiblepatients.Theauthorsasso ciatedasupportiveNPpracticeenvironment withadecreaseinhospitaladmissionsamo ngduallyeligiblepatientswithchronic healthconditions.
Wecommendtheseresearchersforexaminingthisimportantdeliverysystem characteristicanditsinfluenceonpatientoutcomes.Whenattentionisdirectedatimprovingcarequality,patientoutcomesimprove.Wewouldliketoaccentuateseveral pointsmadebytheauthors.Furtherclarityisneededtodescribewhatqualifi essomeoneas duallyeligibleforMedicareandMedicaid,andtherecognitionthatsigni ficantresources andservicesarenecessaryinapracticeenvironmenttoprovidehigh-qualitypersoncenteredcaretoduallyeligibleindividuals.Additionallimitationsofassessingthework environmentforNPsinclude(1)noconsiderationofthedepthandbreadthofresourcesin apracticesettingnecessarytoprovidequalityperson-centeredcare,(2)thepotential relationshipofstate-regulatedscopeofpracticeonprovidingperson-centeredcare,and(3) theassociationofscopeofpracticestatelegislationtoNPsassessmentoftheirpractice environment.Wewilladdresseachindividuallybelow.
DUALELIGIBILITY
Duallyeligible referstoindividualswhoqualifyforandareenrolledinboth MedicareandMedicaid,the2majorgovernme nt-sponsoredhealth insuranceprograms intheUnitedStates.EligibilityforMedicaregenerallycomesfromage(65yearsor older)orcertaindisabilities,whileMedicai deligibilityisbasedonlowincomeandmay alsocoverspeci fi cgroupslikepregnantwomen,children,andpeoplewithdisabilities. 2 Pro fi lesofduallyeligibleindividualsrevealedthat87%ofenrolleesliveonanannual income < $20,000,and49%oftheenrolleeswerepeopleofcolorcomparedto20% wereMedicare-onlyenrollees.4 Duallyeligibleindividualsoftenfacecomplexhealth needsandmayrequireawiderangeofservices.In2019,duallyeligiblebene fi ciaries totaled19%oftheMedicarepopulationbutaccountedfor34%ofMedicarespending.
FromtheDepartmentofTanChingfenGraduateSchoolofNursing,UMassChanMedicalSchool,Worcester,MA. Theauthorsdeclarenoconflictofinterest.
Correspondenceto:TeriAronowitz,PhD,APRN,FNP-BC,FAAN,DepartmentofTanChingfenGraduateSchoolofNursing,UMassChanMedicalSchool,55 LakeStreetNorth,Worcester01655,MA.E-mail:terese.aronowitz@umassmed.edu.
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ISSN:0025-7079/24/6204-0213
MedicalCare Volume62,Number4,April2024www.lww-medicalcare.com
Copyright r 2024WoltersKluwerHealth,Inc.Allrightsreserved.
Inaddition,duallyeligiblebene fi ciariescomprised14%of allMedicaidrecipientsbutaccountedfor30%ofMedicaid spending. 5
Medicarecoverscertainhospitalandhealthcareservices,whileMedicaidmaycoveradditionalbenefitssuchas long-termcare,dentalservices,prescriptiondrugs,andother health-relatedservicesnotcoveredbyMedicare.Managing thecareofduallyeligibleindividualscanbecomplexand challengingduetothedifferentcoveragestructuresofMedicareandMedicaid,thehigheroccurrenceratesofchronic illnessandlong-termcareneeds,andincreasedsocialrisk. Thesecomplexconcernscanleadtothefragmentationof healthcare.6 Variousprogramsandinitiativesaimatimprovingquality,communication,andcoordinationofcareto ensuretheseindividualsreceivecomprehensiveandappropriatehealthcareservices.7 TheNikpouretal’s3 studyfocusedontheclinicalpracticeenvironmentforNPs.This researchdirectsattentiontocontextualdeliverysystemattributesconsideredessentialinunderstandingandaddressing thepoorqualityresultingfromfragmentation.6
NPshavebeenmeetingthedemandsforprimarycare servicesbyprovidinghigh-qualityprimarycareservicesand decreasingtheconcernsoffragmentedhealthcare.8 NPshave beencaringforduallyeligibleindividualswithcomplex healthconcernswithcomparableoutcomestophysicians.9 However,ifclinicalsitesdonothavesupportforNPstoassist duallyeligibleindividualstoovercomesocialdeterminant barrierstocare(ie,coverageissues,transportationassistance), itismorechallengingforNPstoprovideperson-centered care.6 Practiceswithgreaterresourcesandsupportfacilitate NP’seffortstopracticetothefullextentoftheirlicense.As shownbyNikpouretal,3 hospitalizationratesamongdually eligibleindividualsaresignifi cantlylowerwhenNPsreported morefavorablescoresoftheirorganizationalclimate.Hospitalizationratesmayalsobeassociatedwithstatelegislative supportforNPstopracticewithintheirNPmodelofcareand atthefullextentoftheirlicensure.
NPPRACTICEMODEL
Nikpouretal3 statethatthatNPmodelofcareisaperson-centeredapproach.Person-centeredcareisholisticand inclusiveoffamily,significantothers,andsocialdeterminants ofhealth.10 ThismodelofcareiscongruentwiththeInstituteof Medicine’srecommendationmorethan20yearsagotoshift toapatient-centeredmodel.11 Patient-centeredcareincludes providerqualitiesofcompassion,empathy,respect,and responsivenesstotheneedsandvaluesoftheindividual patient.11 NPsplayacrucialroleinassessing,treating,and educatingpatientsabouthealthmaintenance,diseaseprevention,andtreatmentoptions.12 Theyoftenengagein counselingandsupportofpatientsandtheirfamilies.They collaboratewithotherhealthcareprofessionalsmakingreferralstospecialistswhenneeded.NPsareexpectedtoengage inongoingeducationandstayupdatedonadvancementsin healthcaretoprovidehigh-qualitycare.Person-centeredcareis criticalwhenmanagingduallyeligibleindividualswithcomplexhealthconcerns.However,whenNPsareemployedin practiceenvironmentslackingcomprehensiveandnecessary
depthofsupportandpatientresources,theymaynotbeableto providehigh-qualityperson-centeredcaretoalltheirpatients. ThismaybeaccentuatedinstatesthatlimitNPscopeof practice.
ASSESSMENTOFPRACTICESETTING
TheNursePractitionerPrimaryCareOrganizational ClimateQuestionnaire(NP-PCOCQ)ratesapracticeonNP visibility,NP/Administrationrelationships,NP/Physicianrelationships,andavailabilityofresourcesandsupportforNPs topracticeindependently.13 WhileNPsmayrankapractice environmentashavinghighsupport,theabilitytoprovide person-centeredcarealsorequiresthesettingtohavecomprehensiveservicesforpatientsandtheirfamilies,collaborativepatientcareteams,adequateresourcesforclinical decisionsupport,andqualitycarecoordinationamong providers.2 Theseattributes,notspeci ficallymeasuredwith theNP-PCOCQassessment,wouldgreatlybenefitrecipients onMedicaidasitmayaddresssomeoftheirneedsbeyondthe offi cesettingsuchashousing,foodinsecurity,andtransportationallsocialdeterminantsofhealth.
SCOPEOFPRACTICE
ThescopeofpracticeforNPsvariesbystateandhealth caresettingduetodifferencesinregulations,laws,andpolicies.However,therearecommonelementsthatdefinethe scopeofpracticeforNPs.NPsareadvancedpracticeregisterednurseswithadvancededucationbeyondthatrequired forregisterednurses.NPsareeducatedtoconductcomprehensiveassessments,diagnoseriskforandactualhealth conditions,orderandinterpretdiagnostictests,anddevelop treatmentplans.NPsprovideawiderangeofprimaryand specialtyhealthcareservices,includingprescribingmedications,performingprocedures,andmanagingchronic conditions14 inadditiontoprovidingeducationandassistance withbehaviorchange.
DuringtheCOVID-19pandemic,therewasanincreasedneedforprimarycareprovidersinhealthprofessional shortageareas(HPSAs)wherethehighestpercentageofduallyeligibleindividualsareserved.TheCentersforMedicare andMedicaidServices(CMS)easedrestrictionsonNP practiceinHPSAs,andmanystateschangedthelegislationto increasefullpracticeauthority.15 ThisincreasedtheNPswho weremorelikelytopracticeinthoseareas,16 potentiallyincreasingsustainableperson-centeredcareforduallyeligible individuals.
DifferencesBetweenStates
Scopeofpracticelawsspecifythedegreeofpractice independenceforNPs.Someregulatorybarriersatstateand federallevelspreventNPsfrompracticingtothefullextentof theirlicense.17 Infact,whenthescopeofpracticelawpreventsNPsfrompracticingtotheextentoftheirlicensure, resourcesarenoteffi cientlyutilized,increasingcosts,and decreasingthequalityofcare.15 Thereare2typesofrestrictionsthatstateslegislateonNPscopeofpractice:practice authorityandprescriptionauthority.
Practiceauthorityisfurtherdefi nedinto3types:restricted,reduced,andfullauthority.RestrictedpracticerequiresNPstoworkunderasupervisingphysicianfortheir scopeofpractice.Stateswithreducedpracticeauthority determinewhatanNPcanandcannotdoindependently.In somestates,thismeansNPscanprescribecertainmedications,butnotordertestsordiagnosehealthconditions. PhysiciansupervisionofNPpracticeisusuallyrequiredin stateswithreducedpracticeauthority.Instateswithfull practiceauthority,NPscanperformthefullscopeofpractice withoutasupervisingorcollaboratingphysician.18 Prescriptionauthorityalsodiffersdependingonthescopeof practicelawsineachstate.
NPautonomyvariesfromstatetostate,dependingon theregulationsofthestate.ThescopeofNPpracticehas evolvedovertimewithchangesinregulations,advancementsinhealthcare,andtherecognitionofthevaluablerole theyplayinthehealthcaresystem.InNikpouretal’ s3 study,noneofthestatesinwhichtheyrecruitedhadfull practiceauthoritylegislation.Itwouldbeinterestingtosee iftheir fi ndingswouldbesimilarinstateswithfullpractice authority.
DifferencesWithinPractices
Thepracticeenvironmenthasbeenfoundtobethemost influentialfactorimpactingnurseoutcomesandperceptions ofqualityofcareandpatientsafety.19 ThismaybetrueinNP primarycarepracticesaswell,andsince2013theNPPCOCQhasbeentheonlymeasuretospeci ficallyassessNP organizationalclimate.13 TheNP-PCOCQwaspsychometricallytestedandfoundtodiscriminateNP’sself-reportsof differentlevelsoforganizationalclimatefromfavorableto unfavorable.20
NPshavereportedthatautonomyandpositiverelations withphysiciansandadministrationcontributetoamorefavorablepracticeclimate.21 Nikpouretal3 usedtheNPPCOCQtomeasuretheorganizationalclimateoftheNP participantsprovidingprimarycareinavarietyofoutpatient settings.PracticesthatNPsreportedaslessfavorablehad higherratesofhospitalizationsforduallyeligibleindividuals. Nikpouretal’s3 studysamplewasfromstateswithoutfull practiceauthorityleadingtoanunansweredquestionabout anyassociationbetweenlimitedscopeofpracticeandunfavorablepracticeclimatesforNPs.
DifferencesBetweenInsurers
Nikpouetal’s3 studyshowedthatindividualson Medicarebutnotduallyeligiblehadlowerratesofhospitalizationsascomparedtoindividualswhowereduallyeligible. IndividualswhohaveMedicarealoneorwithanothertypeof insurancehavethe financialmeanstopayforcoverageand mostlikelyhavesupportsthatduallyeligibleindividualsdo nothave.Thisdifferenceinhospitalizationratesmaynotbe duetothepracticeenvironmentalone.Lackofsupportforthe socialdeterminantsofhealth(ie,housing,food,socialsupport,literacy,transportation)forduallyeligibleindividualsis common.5 WhatwasnotaddressedintheNikpouretal3 study waswhetherpracticeswithmorefavorableNP-PCOCQ resultsalsohavegreaterdepthandbreadthofsupportand
resourcestoaddresssocialdeterminantsofhealthfactorsthat mayimpacthospitalizationrates.
CONCLUSIONS
Althoughduallyeligibleindividualshavehigherrates ofhospitalizationcomparedtoMedicare-onlyindividualsin thisstudy,afavorablepracticeenvironmentasmeasuredby theNP-PCOCQwasassociatedwithdecreasedratesofhospitalizationsinduallyeligibleindividuals.3 Whetheritisthe practiceenvironmentthatisdrivingthisassociationorother practicecharacteristicsthataremorelikelypresentinfavorablepracticeenvironmentsisnotclear.Whileduallyeligible individualshavemorebarrierssecondarytosocialdeterminantsofhealth,5 examiningotheraspectsoftheNPpractice sitemayfurtherilluminatetheriskofhospitalizationsand readmissions.Futureresearchcouldalsoincludeexamining thisassociationinstateswhereNPshavefullpracticeauthority.
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