Nurses Rap Payment Models Recommended by AMA

A recommendation from the American Medical Association calls for physicians to determine how care teams are paid. The American Association of Nurse Practitioners calls the AMA's link of reimbursements to physician-led teams "anti-competitive."

The American Medical Association House of Delegates this week adopted recommendations for creating payment structures for physician-led team care delivery models with physicians determining who gets paid and how much.

"The success rate of physician-led team-based models of care has been proven time and again by trusted industry leaders like the Mayo Clinic, Geisinger Health System, Intermountain Healthcare and Kaiser Permanente," AMA President Ardis D. Hoven, MD, said in prepared remarks.

"In the words of Dr. William Mayo, 'It has become necessary to develop medicine as a cooperative science: the clinician, the specialist, and the laboratory workers uniting for the good of the patient.' The AMA and the broader physician community firmly believe that this approach represents the future of health care delivery in America."

The AMA recommendations call for:

• Physicians who lead team-based care in their practices to receive payments for healthcare services provided by the team and to establish payment disbursement mechanisms that foster physician-led team-based care; 
• Physicians to make decisions about payment disbursement in consideration of team member contributions, including factors such as volume and intensity of the care provided, the profession, training and experience of each team member and the quality of care provided; 
• Payment systems for physician-led team-based care: to reflect the value provided by the team, with the savings accrued by this value shared by the team; to reflect the time, effort, intellectual capital provided by individual team members; to be adequate to attract team members with the appropriate skills and training to maximize the success of the team; and, to be sufficient to sustain the team over the time frame that is needed.

Not surprisingly, nurses associations are not embracing a list of recommendations that leaves physicians calling all the shots.

"We have supported integrated models of care moving towards reimbursement alignment for quality and outcomes over fee-for-service," says Tay Kopanos, DNP, FNP, vice president of state government affairs for the American Association of Nurse Practitioners.

"However the AMA's continual link of reimbursements to physician-led teams and outdated licensure approaches is not only anticompetitive, it limits patient choice and access to care. It fails to recognize not only the Institute of Medicine recommendation on team-based care, it also fails to recognize the national accreditation standards for team-based care and patients who are in medical homes that allow flexibility in team leadership."

The AMA's House of Delegates also passed a report that more specifically defines team-based roles and terms including "physician-led," "supervision," and "collaboration."

"Virginia recently adopted a law that supports and promotes physician-led healthcare teams as a collaborative, consultative approach to healthcare," Hoven said. "With an aging population and a surge of newly-insured patients entering the system, we encourage other states to consider adopting this innovative approach to helping facilitate the work of highly-functioning teams of medical professionals who can meet the growing demand for healthcare."

Kopanos says states' efforts to develop guidelines for physician-led team-based care have not worked well for nurse practitioners.

"In any state that has nurse practitioner practices owned and operated by nurses or nurse-managed health centers, their ability to participate in insurance and managed Medicaid is eroded when physician leadership is a requirement," she says.

"Many nurse-managed health centers see patients, diagnose them, treat them, manage them and write prescriptions without any involvement from physicians. If a reimbursement model requires physician leadership those nurse-managed health centers close and the patients who get their care at those sites can no longer get care."

Kopanos says it is well established that not all care regimens require a physician's input, which otherwise adds needless costs and wastes resources for an already short-staffed national healthcare workforce.

"Team-based care is centered on the needs of the patient and the providers who can best meet that care. We have a multitude of providers, nurse practitioners, pharmacists, physical therapists, behavioral health experts, who at certain times based on the needs of the patient may be the best ones to lead the team for what that patient needs," she says.

"When we artificially move the licensure or reimbursement to one particular profession we are shortchanging the patients' ability to get the provider they need and to utilize our workforce more efficiently to take care of patients."