Provider Practice Essentials registered nurse continuing education

Part 3: How do PA’s and RN’s fit into healthcare reform

And so the rest of this blog post comes to you – the biggest investment in healthcare.


Physicians, Physician Assistants, Nurse Practitioners – anyone who is considered a provider in healthcare, is now having their own quality measures applied to their care delivery.  As part of the permanent “Doc Fix” the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015. CHIP is the Children’s Health Insurance Plan that provides matching federal payments to state-funded children’s insurance programs.  MACRA is designed to shift the healthcare fee-for-service model of payments to the value-based payment (quality) payment model through Merit-based Incentive Programs (MIPs), which are designed to focus on quality measures at the provider level. Each specialty will have different requirements.  The intent of these quality measures is aimed at reducing cost, but their application to current medical standards is debatable.

A great example of such a measure is management of sinusitis, that requires a patient not receive any antibiotics for days 1-7 of symptoms, is given ONLY Amoxicillin for symptoms greater than 7 days, and a head CT for chronic headache is ordered only after the patient has a 1 month or more of symptoms.  Any deviation from this approved treatment plan will result in a non-payment to the provider, and a dent in his or her quality rating. Here’s the kicker – you may not know the patient has seen another provider who ordered something in another state, or the patient may tell you a different story, or (insert reason here).  The penalties are coming to healthcare providers, and the national goal for implementation of nationwide electronic health records is December 31, 2018. This is managed by the department of Health and Human Services (HHS) and the GAO. The economic penalties are passed directly to you and your ability to collect payment from medicare.  Fortunately, MIPS also provides an opportunity to earn increased reimbursement from CMS if your quality care compliance score is high.

If you thought that being graded on your performance stopped in graduate school, think again.  Each physician in the nation will be held to the MIPS requirements for their specialty AND be required to report their scores.   Remember the Ritz Hotel?  Consider yourself the person at the check-in desk who is now also part of the quality measures that are being reported.  Imagine how long the Ritz will want to keep you employed with them if you bring their score down! On the other hand, imagine how happy the hotel will be if you are consistently earning 9% annual bonuses because of your documentation and management! 

As a member of the healthcare team, your role as an APP has never been in greater need, and your need to be efficient, accurate, up to date, and have a strong knowledge base has never been more important.  The physician and groups that you work for will be completely dependent on every dollar they receive to survive, as costs continue to increase. If you are non-compliant with MIPS measures, or have a low compliance score, you will may a low quality rating, which will be available online for the world to see – including potential employers.  Your score will be composed of study utilization, unnecessary antibiotics, high lengths of stay, and a multitude of variable that you won’t be able to control. Perhaps most important to you is the potential impact you may have on the doctor you are currently working with. If they sign your charts or bill for your care, they will receive the bad marks on their quality reporting, and you will held accountable!  Regardless of your specialty, these measures will be your responsibility to know and be compliant with.

Private Insurers

Keep in mind, this post applies to patients who are covered by medicare and medicaid.  Private insurers (non-exchange products like Blue Cross/Blue shield, United Healthcare, etc)  reimburse providers at a much higher rate than Medicaid, but it may be only a matter of time before they drastically reduce payments due to similar measures.  Interestingly, they may come full circle and join the ranks of Medicare again – especially if we go to a single payer health care system. Notice, that none of these reimbursement issues have anything to do with practicing “bad” medicine.  Nor are they even remotely related to malpractice, which is an entirely different blog post.

The only ways you can navigate the waters ahead are by staying current with treatment guidelines, mastering your care plans, ordering the correct and necessary tests, being prompt and efficient with your care delivery, and continuing to do this throughout your career.  Improved documentation and knowing what to document when is critical to every type of practice.

The Provider Practice Essentials resource section will help you with this, and keep you off of the proverbial naughty list of APP’s who are deemed “too expensive” for the healthcare system!  We want to put you and your practice in the BONUS category, and give you the tools needed to be an exceptional provider and maximize your revenue and worth to any practice setting where you work.  For more information, consider joining our online member resource section or, better yet, attend one of our programs to get the most up to date information and clinical skills!  Membership resources are included in your registration for one year.

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