How Medicare Graduate Nurse Education Demonstration Increases Primary Care Workforce

Armen Hareyan's picture
Primary Care

The Report to Congress on the Centers for Medicare and Medicaid Services (CMS) Graduate Nurse Education Demonstration has just been released documenting health care workforce gains addressing the nation’s shortage of primary care.

Advertisement

The $200 million initiative is the first to test whether Medicare funding of graduate clinical education of Advanced Practice Registered Nurses (APRNs) would help meet national health care workforce needs similar to residency training for physicians. The answer is yes. Access the full report here.

The evaluation report to Congress concluded, “The GNE demonstration had a positive impact on APRN growth, and helped transform clinical education within participating GNE schools of nursing.” The evaluation documented better clinical training outcomes for demonstration schools of nursing compared to schools not affiliated with the demonstration. Specific findings include:

  1. Significantly greater APRN enrollment and graduation growth in demonstration schools than comparison schools, thus enhancing healthcare workforce capacity.
  2. The majority of all clinical training hours took place in community settings, a significant achievement in view of the national shortage of community-based primary care, and demonstrating that Medicare funding to hospitals could achieve training in community settings where it is most needed.
  3. The majority of growth in APRNs in the demonstration was in nurse practitioners, who are in great demand nationally to improve access to care.
  4. The cost of clinical training of an APRN to graduation was estimated to be less than $30,000, a very good investment compared to the cost of community-based residency training of primary care physicians in the Teaching Health Center demonstration of $150,000 per year.
  5. The funded demonstration sites included two models: geographic consortia with a hospital hub and from 4 to 9 nursing school partners and many community-based training sites; and a teaching hospital/health system and its primary affiliated nursing school. Both models were successful; the cost per incremental APRN trained was lower as the number of nursing schools in each demonstration hub increased. The geographic consortia projects covered the Greater Philadelphia Region, the Texas Gulf Coast, and the state of Arizona. This was the first major test of the consortia model of graduate medical education that was proposed by the Institute of Medicine two decades ago.
  6. The affiliation of a school of nursing with a hospital decreases the average school of nursing costs of APRN education.
  7. The APRNs trained under the demonstration have entered practice in a variety of settings in both rural and urban areas including federally qualified health centers, nurse-managed clinics, ambulatory medical practices, and retail clinics as well as hospital practice. The five site demonstration has a national footprint in terms of training sites and location of graduates.

In 2012, five US hospitals were competitively selected by CMS to partner with schools of nursing with clinical graduate programs and community health care providers to increase the number of APRNs including Nurse Practitioners, Nurse Midwives, Nurse Anesthetists, and Clinical Nurse Specialists. The demonstration is currently in its sixth year and according to the independent CMS evaluation it has resulted in a significant increase in primary care providers.

The funded hospitals are Duke University Hospital, Durham, NC; Hospital of the University of Pennsylvania, Philadelphia, PA; Memorial Hermann-Texas Medical Center, Houston, TX; Rush University Medical Center, Chicago IL; and HonorHealth Scottsdale Osborn Medical Center, Scottsdale, AZ. These hospitals are affiliated with 19 university schools of nursing* and hundreds of community clinical partners and collaborating health systems.

Advertisement

The GNE demonstration will conclude at the end of June 2018. In the meantime, the five GNE projects are collaborating with major national stakeholders interested in improving access to affordable health care to design and promote consideration of national permanent funding to roll out this successful program nationally.

The original Medicare legislation enacted in 1965 recognized in its funding policies the value to Medicare beneficiaries of excellent clinical training of physicians, nurses, and allied health professionals. Since the passage of Medicare, important new advanced practice roles for nurses have developed. Many studies show that advanced practice nurses contribute to improving access to affordable care, especially in primary care which is nationally in short supply. Advanced Practice Nurses (APRNs) are specialty certified RNs with master’s in nursing or doctor of nursing practice (DNP) degrees. They have a broad scope of practice depending upon their specialty that includes people of all ages. They provide primary care including wellness care and treatment of common acute illnesses, and they contribute to the management and symptom control for people with stable chronic illness. They provide maternity and women’s health care, anesthesia services, and care of acutely ill hospitalized patients.

While Medicare is a major source of funding for the clinical training of physicians and allied health professions, APRNs did not exist when Medicare was implemented and thus their clinical training does not generally qualify for Medicare educational support for historical reasons despite their important roles in care of the elderly and improving access to affordable care for underserved people. The CMS GNE demonstration was undertaken to determine if Medicare reimbursements through hospitals to practicing clinicians to supervise the clinical training of APRN students would result in increasing the number of APRNs available to meet the health needs of the US population.

The Demonstration shows that it is feasible and affordable for Medicare to pay hospitals to facilitate the expansion of clinical training opportunities for APRNs in the community as well as hospital settings, similarly to Medicare’s support of clinical residency training for physicians.

By Ed Federico of University of Pennsylvania

Advertisement