Assessing the Patient Care Implications of "Concierge" and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians.

As physicians seek innovative practice models, one that is gaining ground is for practices to contract with patients to pay directly for some or all services-often called cash-only, retainer, boutique, concierge, or direct primary care or specialty care practices. Such descriptions do not reflect the variability found in practices. For the purposes of this paper, the American College of Physicians (ACP) defines a direct patient contracting practice (DPCP) as any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care. This definition encompasses the practice types previously described. The move to DPCPs is based on the premise that access and quality of care will be improved without third-party payers imposing themselves between the patient and the physician. Yet concerns have been raised that DPCPs may cause access issues for patients who cannot afford to pay directly for care. This ACP position paper, initiated and written by its Medical Practice and Quality Committee and approved by the Board of Regents on 25 July 2015, assesses the impact of DPCPs on access, cost, and quality; discusses principles from the ACP Ethics Manual, Sixth Edition, that should apply to all practice types; and makes recommendations to mitigate any adverse effect on underserved patients.

Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review.

BACKGROUND: One proposed strategy to expand primary care capacity is to use nurse practitioners (NPs) more effectively in health care delivery. However, the ability of NPs to provide care to the fullest extent of their education is moderated by state scope-of-practice (SOP) regulations. PURPOSE: The purpose of this study was to examine the impact of state SOP regulations on the following three key issues: (a) NP workforce, (b) access to care and health care utilization, and (c) health care costs. METHODS: Systematic review. RESULTS/DISCUSSION: States granting NPs greater SOP authority tend to exhibit an increase in the number and growth of NPs, greater care provision by NPs, and expanded health care utilization, especially among rural and vulnerable populations. Our review indicates that expanded NP practice regulation can impact health care delivery by increasing the number of NPs in combination with easing restrictions on their SOP. CONCLUSIONS: Findings show promise that removing restrictions on NP SOP regulations could be a viable and effective strategy to increase primary care capacity.

Modifying State Laws for Nurse Practitioners and Physician Assistants Can Reduce Cost Of Medical Services.

"Bending the cost curve" for health care services in the United States challenges policymakers. A cost analysis was undertaken based on what would occur if more physician assistants (PAs) and nurse practitioners (NPs) per capita were deployed over a 10-year period. The State of Alabama was used as a case study because it is one of a handful of U.S. states with restrictive legislation impacting the scope of practice of PAs and NPs. Changing PA and NP scope of practice legislation in Alabama to match states in the upper quartile of collaborative legislation such as Washington and Arizona would increase the employment and distribution of PAs and NPs. Even modest changes in legislation will result in a net savings of $729 million over the 10-year period. Underutilization of PAs and NPs by restrictive licensure inhibits the cost benefits of increasing the supply of PAs and NPs and reducing the reliance on a stagnant supply of primary care physicians in meeting the needs of its citizens.

Physicians, the Affordable Care Act, and primary care: disruptive change or business as usual?

The Patient Protection and Affordable Care Act 1 (ACA) presages disruptive change in primary care delivery. With expanded access to primary care for millions of new patients, physicians and policymakers face increased pressure to solve the perennial shortage of primary care practitioners. Despite the controversy surrounding its enactment, the ACA should motivate organized medicine to take the lead in shaping new strategies for meeting the nation's primary care needs. In this commentary, we argue that physicians should take the lead in developing policies to address the primary care shortage. First, physicians and medical professional organizations should abandon their long-standing opposition to non-physician practitioners (NPPs) as primary care providers. Second, physicians should re-imagine how primary care is delivered, including shifting routine care to NPPs while retaining responsibility for complex patients and oversight of the new primary care arrangements. Third, the ACA's focus on wellness and prevention creates opportunities for physicians to integrate population health into primary care practice.

Increased autonomy for nurse practitioners as a solution to the physician shortage.

In this paper, the author addresses decreased access to health care in underserved areas and the shortage of primary care physicians and how nurse practitioners (NPs) can fill this void. In order to make up for the lack of primary care doctors, NPs need to be politically involved in fighting for their autonomy; specifically, they must work toward removal of the statutory requirement that NPs practice in collaboration with a physician. NP associations need to increase membership, encourage members' political involvement, and move legislative agendas to bring about change. Although this paper focuses mainly on New York, it does highlight NP legislative agendas and how they were used to fight for autonomy in other states.

Towards national health insurance: Alignment of strategic human resources in South Africa.

BACKGROUND: South Africa is implementing national health insurance (NHI) and primary health care (PHC) re-engineering, and has concomitantly introduced the Human Resources for Health (HRH) Strategy. These policies are underpinned by the National Development Plan (NDP), which aims to address widespread inequality and inequity. AIM: The aim of this study was to analyse the alignment of national HRH-related policies to implement NHI and PHC re-engineering and determine knowledge gaps and research needs. METHOD: A narrative review of the NDP, PHC re-engineering, HRH and NHI strategies was carried out, supplemented by key HRH reports, data and articles. RESULTS: Current policies stress NHI and PHC re-engineering without effectively addressing shortages and maldistribution of HRH across the provincial and public-private divides. In line with PHC re-engineering, the HRH Strategy emphasised strengthening of community health workers (CHWs), professional nurses (PNs), mid-level workers (MLWs), medical practitioners (MPs) and clinical specialists (CSs). Four of these, CHWs, MLWs, MPs and CSs, are varyingly still in absolute shortfall, as well as being inequitably distributed across the provincial and public-private divides. The seeming adequacy in the absolute number of PNs may disguise provincial and public-private sector disparities. Although expedited HRH development and equitable deployment are crucial, it is also vital to resolve extant education and accreditation challenges delaying HRH policy implementation. CONCLUSION: The current lack of alignment of HRH policies does not portend well for the successful implementation of NHI and PHC re-engineering. Knowledge gaps include the need for further clarification of ideal multi-disciplinary team compositions and responsibilities.

Community and family nurse: Present keys, future challenges. / Enfermería Familiar y Comunitaria: claves de presente, retos de futuro.

It is the mission of the Community and Family Nurse through an integral and holistic approach to accompany people from cradle to death in developing their health potential, and promote different family, work and social environments to facilitate this development. Throughout history, various international, European and national organizations have regulated the figure of the Community and Family Nurse, and now their functions, powers and professional performance are fully regulated. The Community and Family Nurse can respond to the needs of a changing population and take on new responsibilities in management and research. Their extensive basic and advanced skills gathered under a rigorous training programme, benefit the health system, the nursing profession, citizenry and its communities. Many challenges remain for the Health Departments of each Autonomous Region to make it possible for this specialty to develop its full potential for improving care.

The Intersection of National Immigration and Healthcare Policy.

Immigration policy and health care policy remain principal undertakings of the federal government. The two have recently been pursued independently in the judicial and legislative arenas. Unbeknownst to many policymakers, however, national immigration policy and health care policy are linked in ways that, if unattended, could undermine the well-being of a significant portion of the US population, specifically medically underserved rural and urban populations. Using current data from a workforce report of the Association of American Colleges and the published literature, we demonstrate the significant impact that contemporary immigration policy directives may have on the number and distribution of international medical graduates who currently provide-and by the year 2025 will provide-a significant portion of primary health care in the United States, especially in underserved small urban and rural communities.

Influence of provider mix and regulation on primary care services supplied to US patients.

Access to medical care and how it differs for various patients remain key policy issues. While existing work has examined clinic structure's influence on productivity, less research has explored the link between provider mix and access for different patient types - which also correspond to different service prices. We exploit experimental data from a large field study spanning 10 US states where trained audit callers were randomly assigned an insurance status and then contacted primary care physician practices seeking new patient appointments. We find clinics with more non-physician clinicians are associated with better access for Medicaid patients and lower prices for office visits; however, these relationships are only found in states granting full practice autonomy to these providers. Substituting more non-physician labor in primary care settings may facilitate greater appointment availability for Medicaid patients, but this likely rests on a favorable policy environment. Relaxing regulations for non-physicians may be an important initiative as US health reforms continue and also relevant to other countries coping with greater demands for medical care and related financial strain.

Basic principles to consider when opening a nurse practitioner-owned practice in Texas.

PURPOSE: Advanced Practice Registered Nurse (APRN)-owned clinics in Texas are becoming more common and because of the success of these early clinics, more APRNs are considering opening their own practice; but Texas remains one of the most restrictive states for APRN practice and many questions remain. What are the regulations about physician delegation? Will you get reimbursed from insurance companies and at what rates? Can you be a primary care provider (PCP)? DATA SOURCES: Changes enacted after the adoption of Senate Bill 406 improved the opportunities for APRNs in Texas yet several requirements must be met and early consultation with a lawyer and accountant can facilitate the initial business setup. The Prescriptive Authority Agreement simplified the delegation requirements and allows the APRN increased flexibility in obtaining and consulting with a delegating physician. Becoming credentialed as a PCP with private insurance companies is often complicated; however, utilizing the Council for Affordable Quality Healthcare's Universal Provider Data source for initial credentialing can facilitate this. CONCLUSIONS AND IMPLICATION FOR PRACTICE: Although this article does not discuss the financial implications of opening a practice, it does cover many aspects including legislative and regulatory requirements for practice, credentialing process and challenges, business structure, and tax implications.

List of designated primary medical care health professional shortage areas (HPSAs); list of withdrawals from primary medical care HPSA designation--HRSA. Notice.

This notice provides two lists. The first is a list of all areas, population groups, or facilities designated as primary medical care health professional shortage areas (HPSAs) as of June 30, 1992. Second is a list of previously-designated primary medical care HPSAs that have been found to no longer meet the HPSA criteria and therefore are being withdrawn from the HPSA list. HPSAs are designated or withdrawn by the Secretary of Health and Human Services (HHS) under the authority of section 332 of the Public Health Service Act.

List of designated primary medical care health professional shortage areas (HPSAs); list of withdrawals from primary medical care HPSA designation--HHS. Notice.

This notice provides two lists. The first is a list of all areas, population groups, or facilities designated as primary medical care health professional shortage areas (HPSAs) as of August 31, 1993. Second is a list of previously designated primary medical care HPSAs that have been found to no longer meet the HPSA criteria and therefore are being withdrawn from the HPSA list. HPSAs are designated or withdrawn by the Secretary of Health and Human Services (HHS) under the authority of section 332 of the Public Health Service Act.

The role of legislation in health services development (with particular reference to China and Australia).

The World Health Organization has supported initiatives in many countries including China to improve the effectiveness and quality of legislation as a form of technical support to help achieve and consolidate the global strategy of health for all by the year 2000. These initiatives are reviewed. Traditionally China did not rely much on legislation as a technique to underpin and implement the organization and delivery of health services, but it appears that more use will be made of it in the future for a number of reasons, including the implementation of the momentous decision of the National People's Congress in October 1992 to move towards a 'socialist market economy'.

The impact of healthcare reform proposals on radiology practice.

Current healthcare reform proposals (especially the Clinton administration's Health Security Act) are daunting in their detail, scope and possible effect on radiology--daunting, but crucial for understanding the immediate future of the profession. Ms. Cahill reveals some of the most important proposed changes, the context within which they are framed and their implications.

Health care reform in Minnesota. Implications for the rural physician.

Minnesota's health care reform plan (by any name) is a cost-containment bill with provisions to provide health insurance for some uninsured people, to examine quality of care, to increase support for rural provider education and migration to rural practice, and to develop state and regional health planning procedures. It is an ambitious bill with very tight time frames, vague language, and heavy reliance on regional commissions and volunteer groups that are just now being established. Will it have an impact on rural health care? Undoubtedly, it will. But somewhere between what the bill says and the desired outcome is a void that physicians can help fill with constructive work and criticism. If physicians do not take the lead, someone else will fill that void--nonphysician providers, legislators, bureaucrats, or consumers. Or the structure could implode, taking all of us with it.