Health plan networks slowly embrace nurse practitioners


There is a trend in the medical community where third-year residents are turning away from primary care medicine in favor of more lucrative specialties.

THERE IS A TREND in the medical community where third-year residents are turning away from primary care medicine in favor of more lucrative specialties.

That trend is being countered by another trend-the growing number of nurse practitioners, which has risen from 30,000 in 1990 to 115,000 today, according to the American Academy of Nurse Practitioners (AANP).

"The increase is related to the demand that has been generated for nurse practitioners," says Jan Towers, PhD, director of health policy for AANP. "They provide high-quality care. Their patients are satisfied with the service, so other people want them to be their provider. As a result, they have become more prevalent."

Towers describes nurse practitioners as a hybrid that combines both the medical and nursing components of treating patients. Nurse practitioners go to school almost as long as physicians, but the training is different. They can prescribe under their own signature in every state. (In four states, they cannot prescribe controlled substances and narcotics, however.)

They operate their own practices or nurse-managed primary care centers, and some practice in health clinics that can be found in major pharmacy and retail chains.

Not everyone supports the idea of nurse practitioners as primary care providers. The American Medical Assn. opposes giving full autonomy to nurse practitioners, saying that physicians should supervise nurse practitioners at all times and in all settings.


As a result of their growing popularity with the general public, nurse practitioners are becoming more widely accepted by health plans, many of which have added them to their basic member coverage, Towers says. She cautions, however, that there is still reluctance on the part of some health plans to accept nurse practitioners.

"Acceptance by health plans varies across the country," she points out. "Some are fully onboard in certain parts of the country. But in other sections, health plans are still hesitant and require strings that we believe are unnecessary.

"Then there are cases where you work very well with a company, but there is a merger with a company that hasn't worked with nurse practitioners," Towers adds. "You have to start all over again."

Medical Mutual of Ohio began contracting with nurse practitioners in January 2004. Those nurse practitioners must be affiliated with a network provider, says Jerelyn Pinkham, director of Professional Contracting & Network Management (Southern Division) for the Cleveland-based health plan.

"Although we recognize that nurse practitioners play an important role in the primary care field, we are only allowing physicians to act as the primary care giver in our point-of-service and HMO products," she says.

Pinkham says Medical Mutual recognizes that its members enjoy the convenience and accessibility of nurse practitioners.

A popular venue for nurse practitioners is retail-based health clinics. CVS, Wal-Mart, Target and Rite Aid are among the outlets that have opened these clinics during the past several years. The clinics offer patients fast access to routine medical services, typically charge between $25 and $65 per visit, don't require an appointment and are open during pharmacy hours, including nights and weekends.

One such clinic is Minneapolis-based MinuteClinic, which operates nearly 200 facilities in 12 states. MinuteClinic is a provider for more than 30 health plans, including Blue Cross Blue Shield (BCBS) Minnesota.

Some Blue Cross and Blue Shield of Minnesota (Blue Cross) clients have chosen to waive copays for their employees if those employees choose to visit a MinuteClinic rather than a physician, says Jan Hennings, a spokeswoman for the health plan.

An analysis conducted by BCBS Minnesota between June 2004 and May 2005 showed a MinuteClinic visit costs about half of a primary care physician office visit ($43 compared with $87) and less than half for other related costs, such as laboratory services. BCBS Minnesota paid MinuteClinic $1.13 million for 22,956 visits during that period.

According to the analysis, people who chose MinuteClinic were twice as likely to be a member of a consumer-directed health plan (CDHP).

"With the growth of CDHPs, members are becoming more savvy with their healthcare dollars," Hennings says. "There is value for members who use MinuteClinic. There is also savings for the [healthcare] system."


Towers says it is hard to determine just what role nurse practitioners play in the effort to lower the overall cost of healthcare in the United States. She maintains, however, that they do contribute to cost savings.

For example, Medicare reimburses nurse practitioners at 85% of the rate of physicians.

"How much of that trickles down to the patient is questionable," Towers says. "But it saves money for the Medicare program. That certainly helps. The program can last longer and people can continue to take advantage of it."

Nurse practitioners advocate prevention and health promotion. As a result, there are multiple studies that show lower rates of emergency room visits and a lower number of hospital days by patients, Towers says.

"That's a good reason why health plans would like nurse practitioners, because nurse practitioners as primary care providers can reduce the number of people who have to go to the emergency room," she says. "People are getting sicker because they can't get into a physician's office in a timely manner. You create a sicker population that will cost everybody money."

There also is increased attention to the continuity of care and an increase in the number of follow-up visits with nurse practitioners, Towers says. "The more you follow up with a patient, the better chance you have to see good results," she points out.

In some cases, it's only a matter of educating purchasers to the level of service provided by nurse practitioners, Towers says.

"If purchasers aren't aware of what a nurse practitioner can provide, they may not request it and, therefore, you don't get into the system," she says. "If enough members demand that nurse practitioners be added to their coverage, health plans will have little choice but to comply.

"It's an area we're still working on," she notes. "We are accepted in the public sector. As health plans begin to see what can be done by nurse practitioners, they will accept us."

Ken Krizner is a frequent contributor to MANAGED HEALTHCARE EXECUTIVE . He is based in Cleveland.

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