New Hampshire Nurse Practitioners Take the Lead in Forming an Accountable Care Organization

What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis

Introduction

Accountable Care Organizations (ACOs), implemented in the United States (US), aim to reduce costs and integrate care by aligning incentives among providers and payers. Canadian governments are interested adopting such models to integrate care, though comparative studies assessing the applicability and transferability of ACOs in Canada are lacking. In this comparative study, we performed a narrative literature review to examine how Canadian health systems could support ACO models.

Methods

We reviewed empirical studies (published 2011-2020) that evaluated ACO impacts in the US. Thematic analysis and critical appraisal were performed to identify factors associated with positive ACO impacts. These factors were compared with the Canadian context to assess the applicability and transferability of ACO models within Canada.

Findings

Physician-led models, global budgets and financial incentives, and focus on collaborative care may optimize ACO impacts. While reforms towards alternative payments and team-based care are not unprecedented in Canada, significant further reforms to physician remuneration, intersectoral collaboration, and accountability for performance are required to support ACO-like models.

Conclusion

This comparative study uncovered several insights on the applicability and transferability of ACOs to the Canadian context. Further comparative research outside the US is needed to infer the essential components of successful ACO models.

Nurse practitioner-owned practices and value-based payment

BACKGROUND

The United States is steadily shifting away from volume-based payments toward value-based payment for health care. The nursing model's emphasis on high-value care, such as disease prevention and health maintenance, ideally positions nurse practitioner (NP) practice owners to contribute to the goals of value-based care. However, little is known about NP participation in value-based care.

PURPOSE

To better understand NP-owned practice participation in value-based care.

METHODOLOGY

Using convenience sampling, we developed a registry of NP owned practices, which we used to conduct a web-based survey from November 2019 to February 2020.

RESULTS

Of the 47 NP-owner respondents, 40 practice in primary or specialty care. Practices are relatively small with a mean clinical staff of 4 full-time equivalent (FTE; range: 1-17), mean total staff of 7 FTE (1-28.5), and with a mean of 325 patient visits annually. A third participate in value-based payment arrangements, whereas a half are considering and three quarters are knowledgeable about value-based payment arrangements. Over 70% of practice owners report lack of knowledge, lack of financial protections, and lack of payer partnership as barriers to participation in value-based payment models.

CONCLUSIONS

NP practice owners face many challenges to taking on risk, including insufficient patient volume.

IMPLICATIONS

Joining together may allow small NP practices to participate in and thrive under value-based payment. Reducing the barriers and regulation of all NPs will enable the health care system to capitalize on the nursing model to meet the goals of value-based care.

Impact of state scope-of-practice laws on nurse practitioner-provided home visits

Millions of older Americans receive nurse practitioner (NP)-provided home based primary care (HBPC). Little is known about how state scope-of- practice (SOP) laws may impact use of NP-home visits. Using 2017 Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File (PUF), we examined the impact of state SOP laws on the use of NP-home visits. The PUF file was merged with the 2017 American Community Survey to assess area-level median income. Over 4.4 million home visits were provided to 1.6 million Medicare beneficiaries. NPs represented the largest share of providers (47.5%). In states with restricted SOP laws, compared to NPs, physicians and physician assistants had higher odds of providing HBPC. In states with reduced SOP laws, compared to NPs, physicians and PAs had decreased odds of providing HBPC. Our study provides evidence that SOP restrictions are associated with decreased utilization of NP-provided HBPC.

Introduction to four reviews addressing critical topics identified by the 2015 Nurse Practitioner Research Agenda Roundtable: Priorities for policy, workforce, education, and practice

BACKGROUND AND PURPOSE

In 2015, an invitational think tank was convened by the Fellows of the American Association of Nurse Practitioners to update the 2010 Nurse Practitioner (NP) Research Agenda Roundtable. This effort was undertaken to provide guidance for future health care research. The purpose of this article is to introduce the process used for conducting four reviews that address critical topics related to specific research priorities emanating from the 2015 NP Research Agenda Roundtable. The four reviews are published in this issue of Journal of the American Association of Nurse Practitioners (JAANP) to address the state of current research relevant to NP policy, workforce, education, and practice.

METHODS

This introductory article provides an overview of the systematic process used to evaluate the four topical area. The type of review selected, the search strategy, critical appraisal, data extraction, and data synthesis will be further described in the four review articles.

CONCLUSIONS

Four reviews that examine literature regarding specific aims important to NPs will address strengths as well as gaps in the literature.

IMPLICATIONS FOR PRACTICE

The knowledge offered by the four reviews has the potential to inform future research, which will benefit NPs and other health care stakeholders.

Care Transformation Strategies and Approaches of Accountable Care Organizations

Although accountable care organizations (ACOs) proliferate, little is known about the activities and strategies ACOs are pursuing to meet goals of reducing costs and improving quality. We use semistructured interviews with executives at 16 ACOs to understand ACO approaches. We identified two overarching ACO approaches to changing clinical care: a practice-based transformation approach, working to overhaul care processes and teams from the inside out; and an overlay approach, where ACO activities were centralized and delivered external to physician practices. We additionally identified four methods ACOs were using to achieve their aims: using patient support roles; targeted clinics, events, programs, and interventions; clinical process standardization; and tracking and identifying patients on which to focus resources. We expect that ACOs using either of the major approaches can succeed under current ACO programs, but that as value-based payment programs mature, ACOs will need to undertake practice-based approaches to be successful in the long term.