state’s insurance regulations to recognize NPs as PCPs in the private as well as the public market. Massachusetts was thereby able to expand the supply of its PCPs without changing its scope-of-practice laws (Craven and Ober, 2009). The policy differences among states may have to do with different scope-of-practice regulations or differences in the states’ insurance industries. There is some evidence that insurers are more likely to recognize NPs as PCPs in states where NPs have independent practice authority (Hansen-Turton et al., 2008).

The actions of private insurance companies toward APRNs are having an effect on government-funded programs as well. Nurse-managed health centers (NMHCs) have long provided care for populations served by Medicare, Medicaid, and children’s health insurance programs. However, federal and state governments are increasingly turning to the private sector to manage these programs (Hansen-Turton et al., 2006). The insurance companies’ continued policy of not credentialing and/or recognizing NPs as PCPs—and the federal government’s refusal to mandate that they do so—creates a barrier for NMHCs as they seek to continue serving these populations (Hansen-Turton et al., 2006).

One specific model of the medical/health home—the Patient-Centered Medical Home™ (PCMH)—does not permit management by nurses. In other words, a nurse may manage an organization that in every way adheres to the principles of PCMHs, but the practice will not be recognized as a PCMH by NCQA, a “not-for-profit organization dedicated to improving health care quality” (NCQA, 2010). Without public recognition, nurse-led medical/health homes cannot qualify for insurance reimbursement, which in turn leaves substantial populations underserved. NCQA, which administers the recognition for the medical homes, is a physician-dominated organization receiving its member dues from physicians. Its board, although currently reconsidering its stance on whether NPs can lead medical homes, has decided that physicians are more able to serve in PCMH leadership positions. The original concept for the medical home came from physicians, and NCQA adopted their principles of operation.22 Several state agencies have contacted NCQA to request that it recognize NPs’ ability to lead PCMHs. NCQA has appointed an advisory committee to review the policy that medical homes must be physician led. Meanwhile, the Joint Commission is developing a competitive certification program that will allow for leadership by NPs.23

High Turnover Rates

As the health care system undergoes transformation, it will be imperative that patients have highly competent nurses who are adept at caring for them across all settings. It will be just as important that the system have enough nurses at any


Personal communication, Greg Pawlson, Executive Vice President, NCQA, January 5, 2010.


Personal communication, Greg Pawlson, Executive Vice President, NCQA, January 5, 2010.

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