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Can Part C Plans Tackle PCP Shortages with CMS?

Updated: Feb 25

PART 2 IN OUR SERIES ON STRATEGIES FOR MEDICARE ADVANTAGE PLANS


Co-written by: Melinna Giannini, CEO of ABC Coding Solutions & Karen Avino, EDD, RN, AHN-BC, HWNC-BC



Medicare Advantage (MA) plans continue to rely on physicians to be primary care providers for the seniors in MA insurance plans. So, what’s the problem?


According to the National Institute on Aging, about 80 percent of older adults have at least one chronic disease and 68 percent have two or more.


In many areas of the country, the number of doctors needed to meet primary care needs for seniors will have to increase by over 60% right now.


Physician gaps are predicted to increase through 2030 according to the National Institute for Health which reports: “The physician shortage is increasing steadily throughout the nation and will influence the delivery of healthcare, thus affecting patient outcomes negatively.


So, how can Medicare Advantage plans overcome the physician shortage?


Nurse practitioners and physician assistants are already filling physician gaps and serving as primary care providers. However, a Kaiser Family Foundation study from Sept. 30, 2020 found that the demand for all PCPs is much greater than the supply in most states.


Strategies Medicare Advantage plans can adopt today to overcome PCP shortages and meet senior care needs for chronic care:

  1. Part C plans can apply to become a Centers for Medicare and Medicaid Services (CMS) Value-Based Insurance Design Model and, if accepted, test the impact of increasing access to a greater number of licensed non-physician providers without requiring a PCP referral.

  2. MA plans can identify providers - such as acupuncturists, behavioral health providers, chiropractors, massage therapists, naturopaths, nurses and other non-physician providers who are trained to treat chronic conditions.

  3. MA plans can adopt a business infrastructure needed to process claims, collect outcomes data and measure cost and efficacy data from those claims.

  4. MA plans can clearly define how claims will be reviewed in-house to assure new benefits for expanded care are not denied based on using older models of care review.


Holistic Nurses Can Help Fill Physician Gaps


MA plans can identify and use advanced practice nurses with holistic certifications to manage registered nurses with holistic certifications and avoid patients having to see a conventional physician before seeing an alternative medicine provider. Instead, patients with chronic conditions could first see a holistic nurse and go to the right holistic provider based on the care needed. Advanced practice holistic nurses can manage holistic nurse treatment plans and claims adjudication to avoid unnecessary staff training.


The American Nurses Association has recognized holistic nursing as a nursing specialty. The American Holistic Nurses Association defines holistic nurses as healing facilitators, consultants, collaborators, educators and guides. Because all holistic nurses are also RNs, holistic nurses can provide a unique communication bridge between conventional doctors, nurses, health plans and integrative medicine providers and help build solutions to care access as they arise.


Holistic nurse coaches, a subset of holistic nurses, hold additional national certifications in behavioral health and alternative medicine. Nurse coaches help patients overcome lifestyle issues that impact chronic conditions such as diabetes, hypertension, obesity, cardiovascular disease, anxiety disorder, depression, chronic pain and nicotine dependence.


MA organizations can establish direct patient access to nurse coaches for these conditions to expand care and also to save money. Nurse coaches only see patients for six visits or less while helping patients maximize health and well-being.


Holistic nurses spend quality time interacting with patients – which in turn fosters higher patient satisfaction and reduced dependence on medications. When critical care needs do arise, holistic nurses are able to quickly refer the patient to their PCP or direct them to an urgent care center or hospital.


All of the strategies listed above can help improve patient outcomes. Thus, there is a path forward for MA organizations to overcome physician shortages today and into the future.


How ABC Coding Solutions Can Help


ABC Coding Solutions specializes in contracting non-physician providers. Our patented technology validates scope of practice by provider and state as claims are filed. The company has developed over 4,500 ABC codes to supplement medical codes, accurately document care, file claims and process payments. We help organizations expand access to over 2 million qualified non-physician health professionals and compare their outcomes to conventional medicine.


To learn how to increase access to quality and cost-effective care, visit us at www.abccodes.com


ABOUT THE AUTHORS

Melinna Giannini has successfully worked with insurers to help establish reimbursement for integrative healthcare since 1999. As CEO of ABC Coding Solutions, she developed systems and methods to overcome barriers to reimbursement and also led in the development of an integrative healthcare coding system. Her experience includes healthcare legislation, medical billing, claims processing, legal variations in state scope of practice regulations and the impact of coding on U.S. healthcare policy and costs. She has testified before federal agencies, had multiple articles written about her work, been invited to speak to the National Press Club, helped develop comparative outcome studies and has long-standing relationships with integrative healthcare leaders and subject-matter experts. Before her career in integrative healthcare, Melinna designed, sold and monitored self-funded plan benefits for large employers.

Karen Avino is the Director of Education for the Integrative Nurse Coach Academy and the International Nurse Coach Association providing online and onsite continuing education programs for nurses. As a consultant, Karen helps healthcare organizations create optimal healing environments and integrate holistic nursing into practice. She taught Holistic Nursing and Integrative Health for 20 years in online and on campus classes at the University of Delaware. She received the Faculty Senate Excellence in Academic Advising and Mentoring Award and the Delaware Excellence in Nursing Practice Award as Nurse Educator. Karen has over 40 years of experience in Maternal-Child Health, Administration, Community Health, Holistic Nursing and Nurse Coach practice. She is board certified as both an Advanced Holistic Nurse and a Health & Wellness Nurse Coach. Karen is a Reiki Master, Stress Management Instructor, HeartMath, and Clinical Meditation and Imagery Practitioner. Karen is a Director-At-Large board member of the American Holistic Nurses Association and a founding leader of the Delaware Chapter (DEAHNA). She is an author and editor of Holistic Nursing: A Handbook for Practice (2016, 2021) and Core Curriculum for Holistic Nursing (2014). She is a Peer Reviewer for the Journal of Nursing Scholarship and Holistic Nursing Practice journals and is an international and national speaker on holistic and integrative topics.




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