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College of Population Health Faculty Papers Jefferson College of Population Health
February 2007
Convenient care clinics: The future of accessiblehealth careTine Hansen-TurtonNational Nursing Centers Consortium, Philadelphia
Sandra RyanTake Care Health Systems, Conshohocken
Ken MillerAmerican Academy of Nurse Practitioners and Pennsylvania State University
Mona CountsAmerican Academy of Nurse Practitioners and Pennsylvania State University
David B. NashThomas Jefferson University, [email protected]
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Recommended CitationHansen-Turton, Tine; Ryan, Sandra; Miller, Ken; Counts, Mona; and Nash, David B., "Convenientcare clinics: The future of accessible health care" (2007). College of Population Health Faculty Papers.Paper 32.http://jdc.jefferson.edu/healthpolicyfaculty/32
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DISEASE MANAGEMENTVolume 10, Number 2, 2007© Mary Ann Liebert, Inc.DOI: 10.1089/dis.2006.636
Convenient Care Clinics: The Future of Accessible Health Care
TINE HANSEN-TURTON, M.G.A.,1 SANDRA RYAN, M.S.N., C.P.N.P.,2KEN MILLER, Ph.D., C.R.N.P., F.A.A.N.,3 MONA COUNTS, Ph.D., C.R.N.P.,4
and DAVID B. NASH, M.D., M.B.A.5
ABSTRACT
The need for accessible, affordable, quality health care in the United States has never beengreater. In response to this need, convenient care clinics (CCCs) are being launched acrossthe country to help provide care to meet the basic health needs of the public. In CCCs, highlyqualified health care providers diagnose and treat common health problems, triage patientsto the appropriate level of care, advocate for a medical home for all patients, and reduce un-necessary visits to emergency rooms and Urgent Care Clinics. CCCs have been called a “dis-ruptive innovation” because they are consumer driven. They serve as a response to many pa-tients who are unhappy with the current conventional health care delivery system—a systemthat is challenged to provide access to basic health care services when people need it the most.CCCs are based in retail stores and pharmacies. They are primarily staffed by nurse practi-tioners (NPs). Some CCCs are staffed by physician assistants (PAs) and physicians. The au-thors acknowledge the important roles of both PAs and physicians in CCCs; however, thispaper primarily provides education about the role of NPs in CCCs. CCCs have evolved at atime when our health care system is floundering, and the need for accessible, affordable healthcare is at its greatest. The CCC model provides an accessible, affordable entry point into thehealth care system for those who previously were restricted access. (Disease Management2007;10:61–73)
INTRODUCTION
THE NEED FOR ACCESSIBLE, affordable, qualityhealth care in the United States has never
been greater. In response to this need, conve-nient care clinics (CCCs) are being launched
across the country to help provide care to meetthe basic health needs of the public. Thesehealth care clinics, based in retail stores andpharmacies, are staffed primarily by nursepractitioners (NPs) and provide care for pa-tients with and without insurance. Physician
1National Nursing Centers Consortium, Philadelphia, Pennsylvania.2Take Care Health Systems, Conshohocken, Pennsylvania.3American College of Nurse Practitioners, and University of New Mexico College of Nursing, Albuquerque, New
Mexico.4American Academy of Nurse Practitioners, and Pennsylvania State University School of Nursing, University Park,
Pennsylvania.5Department of Health Policy, Jefferson Medical College, Philadelphia, Pennsylvania.
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HANSEN-TURTON ET AL.62
assistants (PAs) and physicians also staff CCCs;however, this paper primarily focuses on therole of NPs in CCCs. CCC providers are expe-rienced and highly educated health care pro-fessionals who deliver high-quality, patient-centered care. Health care driven by the needsof the patient is at the heart and soul of the Con-venient Care Industry (CCI).
Over the past year, the media has extensivelycovered the emergence of retail-based CCCs.Many have written about the expectation thatretail health clinics will “profoundly affecthealth care delivery by providing an alterna-tive site for basic medical needs.”1 CCCs havebeen called a “disruptive innovation” becausethey are consumer driven and they serve as aresponse to many health care patients who “arefrustrated with the conventional health care de-livery system,” which provides little access tobasic health care services when people need itthe most.2 While the CCI still has yet to fullyestablish itself, the clinics have shown tremen-dous potential in providing affordable, acces-sible, and quality health care to consumers whootherwise would have to wait hours, days, oreven weeks for the care they deserve. Other al-ternatives include seeking costly, time-con-suming emergency room care for illnesses thatcould have been prevented if basic health careservices had been accessible.
Ownership of CCCs varies; some are pri-vately held, and others are run by health sys-tems or non-profit organizations. Most have amedical director involved at the highest levelof the organization, and some have nursingleadership. Several of the leading CCCs have amedical and a NP officer who work collabora-tively to oversee the medical scope of practiceand quality care of the organization.
In addition to highly qualified PAs andphysicians, CCCs are usually staffed by Fam-ily Nurse Practitioners (FNPs), who providehigh-quality health care services for episodic,common family ailments. Services include di-agnosis and treatment of the most commonhealth problems experienced by patients, in-cluding sore throats, immunizations, and pre-ventive health care screenings. Evidence todate has shown that “clinics do not increaseoverall demand for medical services, an initialconcern expressed by the medical and insur-
ance community; rather, they offer an alter-native for consumers [at all socioeconomic levels] facing access problems within the con-ventional health care system.”2 To date, con-sumers have expressed high levels of satisfac-tion with the services provided by NPs, PAs,and physicians in CCCs, as well as the conve-nience of the CCC model.
The CCI plans to expand across the nation,establishing thousands of clinics over the nextfew years and ultimately increasing access forall Americans. CCI leaders are determined toensure that the convenient care movement isrecognized as one of high quality and integrity.Thus, in the summer of 2006, leaders and stake-holders of the new and emerging retail-basedCCI convened a Summit to shape the future ofthis new industry. At the Summit, participantspresented information about CCCs and NPs asproviders of care. The information, data, andinput from Summit participants have resultedin this paper, the purpose of which is to pro-vide background and historical information onthe industry, to explain the role that NPs playin CCCs, to describe the role of the new con-sumer-driven model of care, and to identify fu-ture directions for the CCI.
HISTORY AND BACKGROUND OF THECCC MODEL
While CCCs are a relative new provider typein the United States, the concept of highlytrained nurses as independent care providersdates as far back as the 1890s, when visionar-ies such as Lillian Wald founded the HenryStreet Settlement; later, Margaret Sangeropened the first birth control clinic. CCCs arefollowing in the footsteps of independentnurse-managed health centers, in which anurse occupies the chief management position,accountability and responsibility for client careand professional practice remain with nursingstaff, and NPs are the primary providers seenby clients.3 CCCs began in 2000, when the firstin-store clinics, operated by QuickMedx, ap-peared in Minneapolis–St. Paul. These first clinics initially saw a very limited number ofillnesses and accepted only cash for services.Today there are over a dozen companies across
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CONVENIENT CARE CLINICS 63
the country that provide health care services toindividuals and families for common illnesses.A 2005 Wall Street Journal Online InteractiveHealth-Care Poll showed that 83% (n � 2245)of those polled strongly or somewhat agree thatcompanies can provide on-site health servicesat retail stores, and that 78% (n � 2245) feltstrongly that retail-based clinics provide a con-venient way for people to receive basic med-ical services.4
There are an estimated 200 CCCs through-out the United States today. The clinics are con-veniently located in drug stores, food stores,and other retail settings with pharmacies, en-abling patient accessibility, and making it easyand convenient for patients to get their pre-scriptions filled on site. Therefore, it seemedsuitable to call this revolution in health care de-livery the “Convenient Care Industry.”
CCCs range in size from one exam room tomultiple exam rooms with sinks and exam ta-bles. The clinics generally occupy 200–500square feet and are outfitted with all the ne-cessities of an outpatient health care office. Fed-eral laws require that owners and operators ofthe clinics rent retail space at fair market value.The NPs who staff CCCs work for the clinic op-erators and have a collegial relationship withthe pharmacy staff of the retail setting. The av-erage cost to set up a clinic is approximately$75,000, excluding payroll and corporate over-head costs. Most of the clinics are open sevendays a week—twelve hours a day during theworkweek and eight hours on Saturday andSunday. These hours are generally more con-venient than those of a traditional doctor or pri-mary care provider (PCP) office. The clinics areusually busier on the weekends, in the evening,and at lunchtime, reflecting their convenienceand consumer focus. Most of the clinics see pa-tients 18 months of age and older, and visits gen-erally take 15–25 minutes for diagnosis andtreatment. CCCs believe strongly in the trans-parency of medical costs; thus, the clinics postthe health care services offered, treatment costs,and information on NPs as providers of care.The basic cash cost for a visit to a CCC rangesfrom $40 to $70. Additional charges may be as-sessed for diagnostic screenings and immuniza-tions. Many insurance plans cover visits toCCCs, allowing the patient to pay only a co-pay.
The clinics are staffed by NPs, and in somecases PAs or physicians affiliated with a cor-porate entity. The NPs and/or PAs (and insome instances physicians) provide all medicalcare and also handle some administrative func-tions. Some CCCs also have medical assistantswho aid the NPs or physicians and help withpatient flow. Most care clinics use proprietarysoftware systems, electronic health records(EHRs), and technology to enhance the patientexperience and continuity of care within themedical community. In general, CCCs havewritten guidelines and established protocolsthat providers use to assist with their decision-making process and to ensure the highest levelof patient care and satisfaction. For example,when patients arrive at a clinic, they sign in andprovide basic demographic information andthe reason for their visit, sometimes using atouch-screen computer terminal (similar to anairline self-check-in kiosk). This sign-in processis the beginning of the patient’s EHR. In somecases, this information is then immediatelytransmitted to a computer terminal inside thetreatment room, where a NP is notified that apatient is waiting to be seen. Once the patientis escorted to the exam room, the NP validatesthe information provided by the patient at sign-in and enters additional medical informationabout the patient’s symptoms and conditions,as well as any pertinent medical history.
NPs perform Clinical Laboratory Improve-ment Amendments (CLIA)–waived lab tests,write prescriptions if needed, and transmit pre-scriptions to the store pharmacy or any phar-macy that accepts electronic scripts. Or, if thepatient prefers, a printed script can be providedat the conclusion of the visit for fulfillment atany pharmacy. To ensure continuity of care, pa-tients are given copies of their health recordsat the end of the visit, which they then are ableto share with their primary health careprovider or any other member of the healthcare team. In many cases, CCC operators sim-ply make the patients’ Personal Health Recordsavailable to their PCPs, referral physicians, orhospitals, pending patient request and ap-proval. This information also can be faxed toany provider that the patient designates to fur-ther enhance the continuity of care process. Atthis time, records cannot be e-mailed due to the
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unsecured method of transmission. However,the longer-term goal is to exchange the pa-tient’s EHR with the provider the patient au-thorizes. As CCCs continue to work withphysicians and other health care providers, andas relationships and technologies develop, safeand secure electronic sharing of records will be-come more standard and common. In turn, pa-tients will be able to access their health recordsonline.
Many physicians across the nation have part-nered with CCCs in providing a collaborationand referral network system for patients whocome to the clinics. Many of these physicianswelcome CCCs as an alternative for their pa-tients. However, some medical groups op-posed the formation of CCCs, basing their ob-jection on the fear that patients would notreceive quality care or get integrated healthcare, and that NPs were not qualified or suitedto work in an independent setting. However,others believed that the creation of CCCs wasspurred by patients’ desire for more conve-nient, affordable health care, and that CCCsrepresent a needed alternative for access tohealth care for patients.
To date, the American Academy of FamilyPhysicians, the American Medical Association,and the American Academy of Pediatrics haveresponded to the formation of the CCI by call-ing for increased regulation of the practice andindustry. They have published principles andguidelines in an attempt to regulate CCI oper-ations and to address the quality of care deliv-ered.5 The American College of Nurse Practi-tioners, meanwhile, has adopted a resolution insupport of the CCI and its role in improvingaccess to care. The CCI welcomes the input ofsuch organizations and will work in collabora-tion with them to foster quality of care and ac-cessibility within the delivery system. SeveralCCCs have reached out to the greater medicaland nursing community to encourage their par-ticipation in a meeting on access, integration,and most importantly, how they can unite toserve the needs of patients. The demand for thisnew model of care arises from an urgent issuerecognized by many across the entire spectrumof healthcare providers—that of access to care.There is a critical need for continued dialoguebetween the CCI and the medical/nursing
community. The CCI looks forward to workingwith medical and nursing organizations andthe local communities in which they operate toensure integrated patient care and the deliveryof a quality patient healthcare experience.
HISTORY, SCOPE OF PRACTICE, ANDROLE OF NPs IN THE UNITED STATES
In a recent Pennsylvania policy paper, advo-cates argued that a highly trained cadre ofhealth care professionals, advanced practicenurses (APNs), is positioned to significantly ex-pand the capacity of the health care deliverysystem.6 APNs work in a variety of settings (eg,urban and rural, private and public) and aremore likely than PCPs to work in underservedareas.7 Within the profession of nursing, thereare four advanced practice providers: CertifiedRegistered Nurse Practitioner, Certified Nurse-Midwife, Clinical Nurse Specialist, and Certi-fied Registered Nurse Anesthetist. Unlike thetraditional hospital nurse who works under or-ders of a physician, APNs work relatively in-dependently in accordance with state laws. Tounderstand the business model of the CCI, it isnecessary to also understand the history andscope of practice of its main health careprovider, the NP.
Independent nursing practice initially devel-oped in areas where physicians had not yet es-tablished their field, such as nurse-midwiferyand anesthesia, and usually outside main-stream settings, such as in rural areas.8 The evo-lution in nursing education and, ultimately, ad-vanced nursing practice took off after theSecond World War. Nurses who had practicedin the war left the service with officer rank and,through the G.I. Bill, used federal funding toattend college to obtain basic and advancedpractice nursing degrees.8 Around the sametime, visiting and public health nurses ex-panded their reach in communities and beganto manage clinics, school-based care, and homecare.8 Further, in the 1960s, nurse and physi-cian collaborative teams began to practice inplaces such as Colorado and Rochester, NewYork.8 The passage of the 1965 Medicare andMedicaid legislation created a new demand forhealth care services. There was an inadequate
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CONVENIENT CARE CLINICS 65
supply of physicians to meet the demand,which gave nurses an opportunity to go intoprimary care and develop a new provider type,the NP.8
Simultaneously, organized consumer groups,women, and civil rights activists demanded anew level of more accessible and affordablehealth care. Nursing claimed that it had the his-tory, education, organization, and knowledge tomeet the growing primary care demands of thesegroups.8 Thus, NPs evolved from nursing’s po-tential, society’s needs, and a PCP shortage.8
Loretta Ford, a nursing professor, and HenrySilver, a pediatrician, established the first NPprogram at the University of Colorado in 1965.8The program was based on a “nursing modelfocused on the promotion of health in daily liv-ing, growth and the development for childrenin families as well as the prevention of diseaseand disability.”9 In the late 1960s, other schoolsof nursing followed suit and started NP pro-grams. Because the idea of NPs came at a timein history when there was a concern about con-sumer accessibility and affordable care, it wonoverall support from the general community,although less support from the professionalmedical community.8 In 1984, the Institute ofMedicine’s Committee on the Future of Pri-mary Care defined primary care as “the provi-sion of integrated, accessible health care serviceby clinicians who are accountable for address-ing a large majority of personal health careneeds, developing a sustained partnership withpatients, and practicing in the context of fam-ily and community.”10 This definition broad-ened the scope of primary care and supportedthe continued educational growth of NPs.
“NPs may perform any service authorized bya state practice act.”11 Generally, NPs can ob-tain medical histories; perform physical exam-inations; diagnose and treat health problems;order and interpret laboratory tests and x-rays;prescribe medications and treatments; provideprenatal care and family planning services,well-child care and immunizations, and gyne-cological examinations and pap smears; pro-vide education about health risks, health promotion, illness prevention and health main-tenance; and provide case management and co-ordination of service. It is the combination ofskills of physician and nurse that seems to con-
fuse people about the role of NPs,12 “yet it isthat combination of skills that makes an NPunique” and attractive to the new CCI groups.*The expansive duties and responsibilities ofthese health care providers is evidence of thediverse and comprehensive competencies ofNPs, and illustrates why NPs have becomepopular providers for physicians, who hirethem in their practices to supplement their care;for hospitals; for freestanding nurse-managedhealth centers; and now for CCIs that recognizetheir value in providing accessible health care.
In 2004, there were 196,279 APNs; 141,000 ofthis number were NPs.13 While advanced prac-tice nursing was not initially at the master’s de-
*In a typical primary care setting (such as a nurse-man-aged health center and not a convenient care center), aNP conducts comprehensive medical and social historiesof individuals, including healthy patients and those withacute illnesses and chronic diseases; conducts physical ex-amination of individuals; orders, performs, and interpretslaboratory tests for screening and diagnosing; prescribesmedications; performs therapeutic or corrective mea-sures, including urgent care; refers patients to specialists;makes independent decisions in relation to managementand treatment of identified medical problems; performsvarious clinical procedures such as suturing, biopsy ofskin lesions, and endometrial biopsy, usually with a writ-ten agreement with a collaborating physician; prescribesappropriate diet; provides information and counseling onhealth promotion, maintenance, illness prevention, socialproblems, and medication usage; evaluates the effective-ness of instruction and counseling; initiates and partici-pates in research projects and studies; teaches groups ofpatients about health-related topics; provides outreachhealth education services in the community; serves as pre-ceptor for nursing, nurse practitioner, medical, and physi-cian assistant students; accepts after-hours calls and han-dles problems; participates in the development ofpertinent health education and development of clinicalpractice guidelines; initiates and maintains follow-up onnoncompliant patients (in nurse-managed health clinics,this function is usually performed by community out-reach workers); makes patient home visits as necessary;makes hospital visits to patients and consults with otherproviders about patients who have been admitted to hos-pitals, home care, rehabilitation, or nursing homes; cor-responds with insurers; manages patient care and devel-ops treatment plans; assesses social and economic factorsfor each patient, tailoring care to those factors; tracks out-comes of interventions and alters them to achieve opti-mum results; obtains informed consent from patients;maintains familiarity with community resources and con-nects patients with appropriate resources; supervises andteaches registered nurses and non-licensed health careworkers; participates in community programs, healthfairs, schools and workplace programs; and represents thepractice and profession at local, state, and federal gov-ernment bodies and agencies.
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gree level, it is today.12 Requirements for NPsvary widely by state. Forty-two states requireNPs to pass a national certification exam by acertifying agency such as the American NursesCredentialing Center, the American Academyof Nurse Practitioners, and the National Certi-fication Board of Pediatric Nurse Practitionersand Nurses. These three agencies require amaster’s degree, whereas the National Certifi-cation Corporation, which certifies Ob-Gynand neonatal NPs, does not.12 It is perhaps thevarious state regulatory differences and the factthat not all NPs are prepared at the master’slevel that makes NPs vulnerable to criticismfrom some physicians.
In 2005, 346 colleges and universities offeredNP master’s degrees. The number has in-creased from 1998, when only 274 colleges anduniversities offered it. The increase in numberof schools offering NP degrees reflects the lo-cal and national demand for NPs.12 In fact, it isestimated that the CCI will need to hire a min-imum of 10,000 NPs in the next few years togrow and expand the model of care. Recently,and not without debate within nursing, the ma-jor national nurse education associations havesupported the implementation of a practicedoctorate in nursing by the year 2015.14 Nurseswith practice doctorates would be preparedand credentialed as independent practitionersjust as other professional disciplines credentialtheir providers: doctors of pharmacy, doctorsof clinical psychology, and doctors of medicine.Nurses with practice doctorates would be fullyaccountable for their own practices and wouldcollaborate with specialists of all kinds.
The average NP is female (95%), 47 years old,has been in practice for 8.6 years, is a FNP(35.1%), and is involved in direct care (85.1%).15
Currently, NPs are in such high demand thatmost of them are employed upon graduation.The NP degree offers specialization within cer-tain practice areas. The FNP degree is the mostpopular program, followed in prevalence byadult primary care, adult acute care/criticalcare, pediatrics, geriatrics, women’s healthcare, psychiatric/mental health, and neonatalcare.8 NPs with a family primary health carebackground are the most sought after by theCCI, because they are credentialed and licensedto care for patients of all ages.
NP SCOPE OF PRACTICE, PRESCRIPTIVE AUTHORITY, AND
PHYSICIAN RELATIONS
NPs are APNs. They are sometimes calledphysician extenders and mid-level practition-ers, which hinders the understanding of the NProle and CCCs.12 Physician extender is usuallythe term used by physician associations andmedical publications when referring collec-tively to APNs. Some states, physician groups,and the federal Drug Enforcement Adminis-tration (DEA) use the term “mid-level practi-tioner.”12 The DEA defines a mid-level practi-tioner “as an individual practitioner other thana physician, dentist, veterinarian, or podiatrist,who is licensed and registered, or otherwisepermitted by the United States or the jurisdic-tion in which he/she practices to dispense con-trolled dangerous substances in the course ofprofessional practice.”16 Thus, the DEA con-siders NPs, nurse-midwives, nurse anes-thetists, clinical nurse specialists, and PAs whoare authorized to dispense controlled sub-stances by the state in which they practice tobe mid-level practitioners.
There has been some confusion as to the dif-ference between a NP and a PA. PAs are edu-cated in the medical model and their trainingis designed to complement physicians.12 PAspractice under the supervision of or in collab-oration with a physician.17 In contrast, “NPspractice under their own license” and provideholistic care based on the nursing model.12
Since the early 1990s, many states have less-ened or exempted the collaboration and/or su-pervisory relationship between NPs and physi-cians. Currently, there are 23 states (inclusiveof the District of Columbia) that have no re-quirement for physician involvement, fourstates that require physician involvement butno requirement for written documentation ofthe relationship, and 24 states that require writ-ten documentation of physician involvement.18
States vary as to how they define scope of prac-tice for NPs. In some states, the scope is enactedby the state legislature; in other states, boardsof nursing have the authority to define thescope of practice.12
While NPs’ permitted scope of practice andworking relationship with the physician vary
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CONVENIENT CARE CLINICS 67
somewhat from state-to-state, NPs in generalare capable and legally authorized to provideprimary care to a patient that is comparable tothat of a PCP. More than a decade ago, re-searchers determined that NPs were able tomanage 80%–90% of the care provided to theirpatients without physician referral or consul-tation.19 Carolyn Buppert, a nurse-attorney,has argued that there is a need for clarity in thescope of practice for NPs.12 For example, thePennsylvania wording of its scope of practicelaw: “while functioning in the expanded roleas Registered Nurse, performs acts of medicaldiagnosis or prescription of medical therapeu-tics or corrective measures” gives NPs author-ity to diagnose and treat medical conditionsand to write prescriptions.12 Carolyn Buppertargues that the “succinct Pennsylvania law pro-vides more professional safety, than Oklahomascope of practice law, for example, where ‘a NPshall be eligible to obtain recognition as autho-rized by the Board to prescribe, as defined byrules and subject to the medical direction of asupervising physician.’”12
The lack of uniformity in the state definitionsmakes NPs vulnerable.1 The terms “indepen-dent,” “collaboration,” and “supervision” varywidely in interpretation and regulatory defini-tion.20 The Joint Commission on Accreditationof Healthcare Organizations (JCAHO) definesa Licensed Independent Provider, as “any in-dividual permitted by law and by the organi-zation to provide care and services, without di-rection or supervision, within the scope of theindividual’s license and consistent with indi-vidually granted clinical privileges.” Recent ac-knowledgement by JCAHO of NPs “offers sup-port for hospital privileges based upon the NPsindividual credentials, training, competency,and scope, rather than using the proxy of su-pervision as the primary eligibility require-ment.”20
NPs now practice independently or in re-mote collaboration with physicians in 43 states,whereas only seven states require physiciansupervision.12 In all states, NPs have some levelof independent authority to prescribe drugs.21
NPs are eligible for direct Medicaid reim-bursement in every state and direct reim-bursement for Medicare Part B services as partof the 1997 Balanced Budget Act.22
CCC PROVIDERS
While many CCCs employ physicians andPAs as providers, this paper primarily focuseson CCCs staffed by NPs. There are approxi-mately 141,000 NPs in the country, and almosthalf of the general public has seen a NP. Thosewho have been seen or treated by a NP reportvery high opinions of the quality of care theyprovided and their approach to providing thatcare. NPs, possessing advanced clinical skillsand a strong desire to expand access to care,are identified as the ideal provider to deliverthese needed services in this setting. Easily ac-cessible and affordable, this health care modelprovides an entry point into the health carearena where NPs have the potential to triagepatients to the needed level of care, advocatefor a medical home for all patients, and reduceunnecessary visits to emergency rooms and Ur-gent Care Centers, in addition to diagnosingand treating common health problems.
NPs are nurses with advanced education andtraining whose scope of practice qualifies themto diagnose and treat medical conditions thatare beyond the scope of the CCCs. NPs work-ings in this new innovative setting are morethan qualified to handle the common condi-tions that are treated in these clinics. The foun-dation of the NP model of care is based on col-laboration and patient advocacy. NPs in theCCC setting are in a position to reach patientswho might not have sought traditional healthcare and direct them back into the health caresystem, to advocate for a medical home, and towork with the local health care provider com-munity to ensure access to care.
In a CCC, the NP provides a limited scopeof services. The NP in this setting focuses ontaking care of everyday family illnesses such asstrep throat, mononucleosis, ear infections, andrashes, while also providing patient education,health promotion and prevention services, andreferring patients to an appropriate level ofhealth care if necessary. Many clinics providevaccinations, health screenings, and physicals.If a patient has a condition that falls outside ofthe provider’s scope of practice and or thescope of the CCCs, the patient is referred backto his or her PCP or given direction as to whereto get appropriate services for the illness. If a
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patient does not have a PCP, the CCI is com-mitted to providing him or her with a referrallist and advocating to the patient the need fora “PCP” and a “medical home.” Most clinicshave relationships with local physician groups,NPs, nurse-managed centers/practices, com-munity clinics, and hospitals. Using these rela-tionships, NPs can consult and refer patientswho need immediate care and treatment re-gardless of their socioeconomic and health in-surance status.
As this nascent industry begins its journeydown the consumer-driven health care pathway,providers and consumers are raising pertinentquestions. Providers want to know whether theirscope of practice will be more restrictive than inother settings. Industry and nursing leaders con-clude that they will not. States are tasked withdetermining scope of practice and that is not af-fected by where the provider works. Just as hos-pitals and clinics can modify policies to meettheir needs, so too can the CCI. This latter grouphas decided that rather than offer a full scope ofpractice services, they will focus on the mostcommon ailments that occur in family practice,while still providing quality education and in-novative health promotion instructions. Practi-tioners will still be using their full armamentar-ium of skills, but rather than treat all illnesses,those that fall outside the advertised conditionswill be referred to other appropriate health careproviders.
Consumers, on the other hand, ask differentquestions. They want to know whether theirhealth record can be shared with their PCP andwhether they can use the CCC on a regular ba-sis. The answer to both questions is “yes.” Mostclinics will eventually be able to share elec-tronic records with the patient’s PCP. How-ever, until that time, a printed record can begiven to the patient to share with their PCP.Continuity of care will be maintained in thebest interest of the patient. It is possible for apatient to use the CCC on a regular basis if theillness falls within the scope of the clinic’s ad-vertised conditions and is not symptomatic ofa serious condition. If so, they will be treatedappropriately, and if not, they will be referredto a specialist. Either way, the industry pro-vides both choice as well as access to qualitycare in a timely, cost-effective manner.
HEALTH PROVIDER WORKFORCESHORTAGE AND
PROVIDER CHALLENGES
Nursing’s focus on people, its blend of med-ical, social science, and behavioral expertise, andits commitment to caring, counseling, teaching,and supporting patients are the characteristicsthat make nurses very qualified to provide pri-mary care.8 Over the past three decades, stateshave adopted laws that authorize NPs to pre-scribe and provide primary care. The Instituteof Medicine’s broad definition of primary careis inclusive and not restrictive with regard towhich profession can provide primary care. Thedefinition was developed by a consensus groupof providers, which included nurses, NPs, andphysicians, and thus was not subject to bias fromany one professional group.12 Most NPs workin collaboration with physicians, “but efforts tochange licensing regulations to allow more in-dependent practice have produced interprofes-sional clashes.”23
By 2010, the United States will experience ashortage of 50,000 physicians; this shortage isexpected to rise to 200,000 physicians by 2020.To meet the primary care needs of the US pop-ulation, the American Academy of FamilyPhysicians (AAFP) has estimated that resi-dency programs need to graduate 3,700–4,100family physicians per year. However, only2,782 family physicians graduated in 2005, andthe number continues to decline. Currently,only 20% of third-year internal medicine resi-dents are choosing careers as generalists.24 Thisdecline in PCPs is partly due to increasing pro-fessional and educational emphasis on special-ization.25 The decline is reinforced by the fund-ing structure of Graduate Medical Education,which does not necessarily place funding in ar-eas of need. Regardless of attempts to attractmedical students into primary care, the declinein family physicians cannot be ignored, andthus supports the expansion of the CCC model.
Studies show that the proportion of patientsseeing non-physician providers is growing, andthe CCI is helping this trend.26 While states mayhave used physician shortages in underservedareas as a way to expand the scope of practicefor NPs, recent studies have shown that patientstreated by non-physician providers were more
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similar to than different from patients treatedby physicians.26 Furthermore, there has been asignificant “increase in the proportion of pa-tients obtaining preventive services from non-physician” providers.26 According to the Bu-reau of Labor Statistics, the annual number ofnew PA graduates is projected to fall 25% by2020. While the number of NPs graduates is alsodeclining, the rate is only by 4.5% every year.Approximately 80% of NPs practice in primarycare, whereas only 44% of PAs currently prac-tice in primary care.23 According to the AAFP,both NPs and PAs “remain important contrib-utors to the primary care workforce and shouldnot be neglected in workforce projections or inthe designing of effective interdisciplinaryteams.”27 PA and NP workforces have ex-ploded during the past 15 years, and the AAFP,representing 94,000 family physicians, reportthat there are now, collectively, more NPs andPAs providing primary care than there are fam-ily physicians.28 Between 1987 and 1997, theproportion of patients who saw a non-physicianprovider rose from 30.6% to 36.1%.26
NP QUALITY CARE
In 1986, a case study was released by the Of-fice of Technology Assessment (OTA) in re-sponse to a request from the Senate Commit-tee on Appropriations.29 The study assessedthe contributions of NPs, nurse-midwives, andPAs in meeting the nation’s health care needs.OTA concluded that the quality of care pro-vided by NPs and physicians was equivalent.29
OTA concluded that potential heightened com-petition may decrease physicians’ acceptanceof NPs.29 While OTA and other studies con-ducted during the past two decades suggest theprimary care delivered by NPs is equal to thatof physicians, none of these studies have di-rectly compared NPs and physicians in pri-mary care health center practices that were sim-ilar both in terms of responsibilities and patientpanels.21 Thus, a federally funded randomizedtrial was conducted by nurse and physician re-searchers at Columbia University between Au-gust 1995 and October 1997, “with patient in-terviews at 6 months after initial appointmentand health services utilization data recorded at
6 months and 1 year after initial appoint-ment.”21 The study was designed to comparepatient outcomes for NPs and physicians func-tioning equally as PCPs, within a conventionalmedical care framework in the same medicalcenter, where all other elements of care wereidentical. The study concluded that of 1,316primary care patients randomly assigned to ei-ther NPs or physicians in an ambulatory caresituation, and where NPs had the same au-thority, responsibilities, productivity, adminis-trative requirements, and patient population asPCPs, patients’ outcomes were comparable.21
The results of the randomized controlled study“strongly supports the hypothesis that, usingthe traditional medical model of primary care,patient outcomes for NP and physician deliv-ery of primary care do not differ.”21
While Mundinger concluded that the care ofNPs and physicians functioning within themedical model is similar, no randomized trialhas yet been conducted in nurse-managed cen-ters, where NPs practice independently withina nursing model of primary care. Therefore, “toaddress the dearth of data and literature de-scribing the full scope of services provided bynurse-managed health centers, the 2002 budgetappropriation language for the Centers forMedicare and Medicaid Services (CMS) and theaccompanying conference committee report in-cluded . . . a demonstration project to evaluatenurse-managed health clinics in urban andrural areas across Pennsylvania, the state withthe most nurse-managed clinics.”30 Specifi-cally, the objectives of the evaluation were to“create an extensive descriptive evaluation ofclients served and services provided in primarycare nurse-managed health clinics; and to com-pare select population-based measures of qual-ity and health care resource use to nurse-man-aged health clinics with those of like providersincluding community health clinics.”30
In response, an extensive descriptive evalu-ation was conducted at primary care nurse–managed health clinics in Pennsylvania, andselect population-based measures of qualityand health care resources were compared be-tween nurse-managed health clinics and thoseof like providers, such as community healthclinics.30 Patients were surveyed using theMedical Outcomes Trust Patient Satisfaction
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tool. Analysis of questions pertaining to patientaccess to health care and manner of health caredelivered to patients by their primary careproviders showed mean aggregate scores rang-ing from 4.03 to 4.19 on a five-point scale.Findings suggest that patients were satisfiedwith the accessibility and delivery of care atnurse-managed health clinics.31 This finding co-incides with existing literature, which hasshown that patients consistently have ratedtheir satisfaction with care from NPs as high.Results showed that patients receiving care atnurse-managed health clinics experience signif-icantly fewer emergency room visits, hospitalinpatient days, specialist visits, and are at sig-nificantly lower risk of giving birth to low-birth-weight infants compared to patients in conven-tional health care.31 These results suggest thatnurse-managed health clinics reduce costs ofhealth care through preventive health care.
QUALITY CARE IN CCCs
Quality care and quality assurance are criticalto the long-term survival of the CCI. Thus, stan-dardized protocols assist providers in clinical de-cision making at most CCCs. These protocols areused as a tool or guideline and are not intendedto replace the critical thinking or the providers’clinical judgment, but to enhance and assist inthe decision-making process. For example, theleading CCCs’ guidelines are grounded in evi-dence-based medicine and guidelines publishedby the major medical bodies such as the Ameri-can Academy of Pediatrics and the AAFP.
Most of the clinics are incorporating rigorousquality assessments into their evaluative struc-tures. Both internal and external reviews arebeing built into these new entities; for example,formal chart review by collaborating physi-cians and peer-review by NPs with additionalstandard coding auditing. Credentialing ofNPs and thorough work history is establishedas well as a process for ensuring adequate ex-perience level to work in this new independentrole. Most NPs are master’s prepared and na-tionally certified in their specialty. CCCs striveto establish a referral base with physicians andother health care providers in the best interest
of their patients, their NPs, and for the conti-nuity of health care within the medical com-munity. The CCI adheres to all state regulationsregarding practice issues for the APN.
HEALTH CARE PAYORS
While the United States spends more annu-ally on health care than any other country inthe world, it still only ranks 37 of 191 in healthsystem performance, according to the WorldHealth Organization’s 2000 evaluation ofhealth systems worldwide.32 Most westerncountries have socialized medicine with mini-mal baseline health care coverage for all citi-zens. However, health care in the United Statesis still primarily employer based and providedthrough private health insurance programs. Anew report from the Commonwealth Fundshows that 34% of Americans pay more than$1,000 in out-of-pocket medical expenses dueto coverage lapses, compared to 14% in Canadaand Australia and 4% in the United Kingdom.33
The per capita purchasing parity power for theUnited States amounts to 14.6% of the gross do-mestic product. The rise in the number of unin-sured from 38.7 million in 2000 to 45.6 millionin 2002 to a projected 54 million in 2007 is as-sociated with a growing number of smaller em-ployers not offering health care benefits to theiremployees and their families.8 Currently, em-ployer-sponsored health insurance providescoverage for 160 million Americans, reachingnearly three of every five of the non-elderly.With the costs of health care coverage increas-ingly shifting back on consumers and employ-ees, the CCI is well positioned as an attractive,cost-effective alternative to often expensive andtime-consuming emergency room visits.
Many CCI companies have contracts with in-surance companies and health plans, resultingin the patient only being charged a co-pay fora visit to a clinic. The CCI has had strong in-terest from employers who are self-insured. AllAmericans would like to reduce health carecosts, which are expected to be $1 for every $5spent in this country by 2015. Some insurers areactively encouraging patients to use CCCs bylowering the co-pay. For those companies that
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accept insurance plans, the cost of health carecan be reduced because the cost of services atCCCs is far less expensive than other healthcare options (eg, the emergency room) for iden-tical conditions. A recent cost comparison oftreating a patient for strep throat showed thatretail-based clinics were the most cost-effectiveand emergency departments the most expen-sive.2 For small businesses, regardless of in-surance coverage, the easy access of a visit to aCCC can reduce the time away from work toreceive care. The affordability of a visit to aCCC encourages patients to receive care earlyon, which could help prevent lengthy andcostly absences from work and could result inthe early identification and treatment of condi-tions that might otherwise have resulted in de-layed treatment and poor outcomes.
“The key to NPs unequivocal market accessrests in the ability to bill third-party insurersindependently and receive equitable pay fortheir services.”8 Although the managed caremodel began among commercial insuranceplans, state governments trying to control ris-ing Medicaid costs have passed laws and reg-ulations in the past decade to promote thespread of managed care among publicly-funded health care programs as well. Accord-ing to a 2005 report from the Centers forMedicare and Medicaid Services, thirty-ninestates have shifted the majority of their Medic-aid beneficiaries into managed care plans.34 In2004, 163 million people in the United Stateswere enrolled in commercial insurance plans35;90% of those people received their health ben-efits through a managed care plan.36
To date, 40% of CCI companies are con-tracted as service providers with managed careorganizations. Thus, a challenge to CCI growthand expansion lies in its ability to continue togrow reimbursement from managed careplans. For example, to date only 33% of man-aged care companies have a uniform policy al-lowing NPs to be credentialed as PCPs. Ap-proximately 40% of Medicaid managed carecompanies credential NPs despite the 1997 Bal-anced Budget Act, which strongly supports theinclusion of NPs on health insurance plans.Among plans that admit NPs to their networks,only 52% reimburse them at the same rate as
PCPs.37 The Balanced Budget Act of 1997 (BBA,P.L. 105-33) encouraged states to move Medic-aid recipients into managed care and to use pri-mary care case managers as gatekeepers in fee-for-service. However, despite congressionalintent, it failed to fully recognize APNs, partic-ularly NPs, as participants in these plans. Whilethe Act encouraged states to ensure that NPsand other APNs are included in managed careprovider panels, the fact that only 40% of Med-icaid managed care companies include NPsshows that this policy has largely been a failure.The most popular reason for not credentialingNPs is weak state laws, which do not requiremanaged care companies to credential NPs.37
As more sophisticated companies emerge inthe CCI, coupled with strong consumer de-mand, it is expected that contracts betweenCCCs and payors will increase rapidly. Inmany cases, CCCs already have contracts cov-ering over 90% of insured lives in their respec-tive markets.
CONCLUSION
CCCs have evolved at a time when ourhealth care system is floundering. The focus ofthe CCI is quality, convenience, and consumerchoice. They have established standards, em-ploy competent professional health care pro-viders, and use ongoing quality improvementmechanisms including the incorporation of ev-idence-based practices in the care of their pa-tients. Health care delivery systems are chang-ing in multifaceted ways and are constantly influx. CCCs have identified the need for changeand are filling a niche by moving to bridge thechasm between a failing health care system anda rising new model of care that offers high-quality, cost-effective, and timely health care.
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