How Nurse Practitioners Can Help Save MassHealth, and Its Patients

As the national spotlight on health care costs continues to intensify, soaring expenditures are the focus of heated debate at the Massachusetts State House. Seen as a leader in health care reform, Massachusetts has pioneered medical technologies, hospital system integration and insurance coverage.

But the state also has some of the highest per person health care spending in the nation—31 percent higher than the national average, according to a 2017 report from the Commonwealth of Massachusetts Health Policy Commission. In an effort to control rising Medicaid and health care spending, Republican Governor Charlie Baker responded with a proposal earlier this year to generate $314 million in savings or new revenue next fiscal year for MassHealth, Massachusetts’ Medicaid program.

Widening Gap in Care, Coverage

Part of the reason for the sky-high MassHealth costs is that, like the rest of the country, Massachusetts has a shortage of primary care physicians (PCPs), a problem that is predicted to worsen as America’s population continues to grow and age. These shortages exacerbate the demand for access to primary care physicians. Boston has the highest number of physicians per capita, and yet, wait times for new patients seeking a routine primary care appointment in Boston has been documented at 109 days.

“The untoward consequence of health reform is that we have created access to health insurance without true access to health care,” said Dr. Stephanie Ahmed, past president and legislative co-chair for the Massachusetts Coalition of Nurse Practitioners. Complicating the issue is that primary care physicians bill at a higher rate than other health care providers, especially for emergency room visits for symptoms that could be managed in a lower-cost primary care setting.

Many of these expenditures depend on relationships between federal and state budgets and their associated lobbying organizations. MassHealth, for instance, has been growing substantially with a significant portion dependent on federal dollars.

“Massachusetts is an expensive state in terms of the commercial health market,” said attorney Barbara Anthony, a senior fellow in healthcare policy at the Pioneer Institute, a Boston-based public policy think tank. “Most of the health care is delivered by downtown Boston academic medical centers, which are very high cost providers. While the state sets Medicaid rates paid to providers, there are no constraints on what providers can charge in the commercial market.”

So who does decide the fees charged by commercial health care markets? According to Anthony, such rates are the result of payer-insurer negotiations. “Large, powerful provider systems have an upper hand in such negotiations,” said Anthony, which can place legislators like Gov. Baker at odds with special interest groups.

Anthony pointed to CVS, which in addition to being an accessible pharmacy, also sometimes provides a limited service clinic (LSC), or mini-clinic, staffed by a Nurse Practitioner (NP) who is trained in “80 different services, gives copies of medical records and offers a list of PCPs to patients without a primary care provider.” Despite their efficacy, such mini-clinics are continually blocked by the city of Boston, undermining patient preference for LSC’s flexible hours, range of services and clear cost labeling.

According the Anthony, patients in need of immediate medical assistance must go to an ER or one of the four urgent care centers that are affiliated with a major hospital, adding that such “frequent ER visits are driving up costs and the wait time to see a PCP in Boston are some of the highest in the country."

Advanced practice registered nurses such as Nurse Practitioners help decrease wait times and as a result, are an affordable alternative to expensive emergency room visits at high-cost hospitals. With the ability to prescribe medications, NPs are trained to perform many of the services offered by primary care physicians, treating patients with preventive care before symptoms get so bad they require hospitalization. Studies suggest there is very little difference between the care offered by Nurse Practitioners versus physicians, since most primary care treatment is of low-to-moderate complexity.

Practice Expansion and the Primary Care Provider

The rates of NPs entering primary care have steadily increased over the past few years, while the number of medical students entering the field has declined. According to a 2015 report from the Health Policy Commission, the number of NPs in the United States is expected to double between 2010 and 2025. These NPs can be trained faster than physicians and at a much lower cost, which could help taper the ballooning expenses imposed by the MassHealth program.

Though all Nurse Practitioners are educated in the administration of primary care, the level and scope at which NPs may practice differs from state-to-state. Some states allow NPs to provide care and write prescriptions without physician oversight while others have more restrictive legislation limiting the kind of care NPs are allowed to provide. The result is that there are great variations in the activities Nurse Practitioners are permitted to perform across the county––a difference in practice related more to state political decisions than to clinician competency and training.

Multiple studies have shown that NPs deliver care that is as good as or better than physicians. One found that geriatric patients co-managed by NPs receive better care than when managed by physicians alone. Other findings show that NPs are better than their physician colleagues at screening, assessment and counseling, and that their patients have higher satisfaction rate.

Evidence also suggests that NPs offer care at lower rates than physicians and are more likely to treat Medicaid patients and practice in rural areas.

Though some physician organizations argue against expanding NPs scope of practice citing safety concerns, unique clinical knowledge and technical skills, there are not any studies that suggest care is better in states that have more restrictive policies for NPs versus those that do not.

A Way Forward

Massachusetts is one of only 12 states that places significant restrictions on practice, requiring NPs to be supervised by a physician to develop treatment plans and prescribe medications.

“Massachusetts is a state that leads the nation with respect to health care, innovation, technology and health reform,” Ahmed said, “but it has failed to position nurses as professionals who are able to work to the full extent of their education and training to alleviate contemporary health care challenges the state is facing.”

However, the state is making strides toward expanding the role of Nurse Practitioners, particularly in an effort to curb the growth of MassHealth spending, which accounted for two-thirds of statewide expenditures between 2013 and 2014 according to the 2015 Health Policy Commission report.

Last November, Baker and the Centers for Medicare and Medicaid Services approved a waiver to restructure the MassHealth program, to move from a fee-based model to an integrated system of outcomes-based care. In July of 2017, Baker introduced a bill to remove restrictions on Nurse Practitioners and allow them to treat patients and write prescriptions without a doctor’s supervision. The governor paired the bill with other MassHealth reforms including new provider disclosures and changes to tiered insurance plans. Lawmakers are currently debating the bill and a decision on expanding the scope of practice for NPs is expected this fall.

Looking to the future, Ahmed said, “the health care challenges we face will require the efforts and goodwill of all providers to work together to meet the needs of patients.”

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