6

Paying for Equity in Health and Health Care

Health cannot be a question of income.
It is a fundamental human right.

—Nelson Mandela, social rights activist and politician

Payment systems greatly impact whether and how health care systems use their resources, including nurses, to improve public health.¹ Nurses’ ability to address an individual’s social needs and the social determinants of health (SDOH) in the community, as well as to perform roles and implement interventions that can advance health equity, can be supported or inhibited by the payment systems that reimburse organizations and individual clinicians for the

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¹ This chapter focuses on payment systems that pay health care organizations and clinicians for the care they provide to individuals and payment systems that support public health and school nursing. Health insurance also helps consumers access and afford health care.

care they provide. COVID-19 has revealed what many clinicians, policy makers, and patient organizations have known for years: that individuals with more health and social risk factors, such as people of color (POC) and those with low income, are more likely to suffer worse health outcomes, and the existing health and social safety nets are frequently unable to prevent these disparities because of a lack of a robust public health infrastructure. These disparities will only be exacerbated by the health, economic, and social disruptions caused by COVID-19, which will increase the number of persons with greater health and social risks, drive up costs and spending, and place further strain on health care and social services systems that are already inadequate. The feasibility and value of innovative reforms to improve the nation’s health are highlighted by many of the temporary regulatory health care reforms enacted in response to COVID-19, such as increased flexibility and reimbursement for telehealth and expanded scopes of practice. Payment reform can help improve population health, address social needs and SDOH, and reduce health disparities, supporting the provision of effective, efficient, equitable, and accessible care for all across the care continuum instead of incentivizing the volume of care or low-value procedures and practices.

This chapter focuses on the relevance for nursing of general principles of payment systems that pay health care organizations and clinicians for the care they provide to individuals and payment systems that support public health and school nursing. The design of payment systems influences the health care provided to individuals and communities, where care is provided, and by whom. Removing such obstacles to health as poverty and discrimination and their consequences and tailoring health systems to meet the specific health and social needs of individuals will help reduce health inequity (Braveman et al., 2017). Payment systems can directly impact the ability of nurses to serve as change agents in bridging the health and social needs of individuals and communities. This chapter explains how existing and evolving payment systems present both challenges and opportunities for supporting and incentivizing nurses to address SDOH and advance health equity. To this end, it first summarizes the nursing roles and functions identified in the previous chapters. Next, the chapter outlines how the current predominant fee-for-service (FFS) and emerging value-based payment (VBP) and alternative payment models (APMs) could support these nursing roles and functions, and how it is essential for health care systems and policy makers to value, prioritize, and embrace these roles and functions if reforms are to occur. The chapter also reviews the potential roles of public health funding and social-sector resources in supporting nurses in addressing social factors and advancing health equity. The chapter then addresses the need for financial support to develop and advance mechanisms for further diversifying and preparing the nursing workforce. The final section presents conclusions.

ADDRESSING SOCIAL DETERMINANTS OF HEALTH AND ADVANCING HEALTH EQUITY BY EXPANDING NURSING ROLES AND FUNCTIONS

Chapters 4 and 5 identify major nursing roles and functions that can successfully address SDOH and advance health equity, all of which can be supported and incentivized through different payment models discussed in this chapter (FFS, VBP, and APMs). Payment models can support nurses’ roles and functions to address SDOH and advance health equity in four key areas: care management and team-based care, expanded scope of practice, community nursing, and telehealth.

Care Management and Team-Based Care

Successful care management programs require a holistic view of the patient’s health and social needs, and close monitoring and follow-up of patients to address these issues. For example, CareOregon, a Medicaid community care organization (CCO) health plan in which members receive managed physical, mental, and dental services, implemented a transitional care model and intervention called C-TRAIN (Englander and Kansagara, 2012). This program uses team-based care to assess patients during discharge to ensure that they receive appropriate follow-up care, focusing primarily on medically complex patients, people with newly identified or unmanaged chronic conditions, or those who face psychosocial barriers such as homelessness and food insecurity. Registered nurses (RNs) are essential members of the teams, and are paired with social workers for follow-ups. Typically, the care team follow-up occurs at up to 30 days, or longer in some cases. Interventions vary based on participants’ needs, but nurses are available to assist with navigating the health care system; providing medication reconciliation, health coaching, and education; and identifying specific needs, such as food insecurity, homelessness, and insufficient clothing. The long-term goals are developing strong relationships between the care team and patient and connecting people to primary care, specialists, and behavioral health services.

Effective care management and team-based care screen patients for social needs and social risk. In Spartanburg County, South Carolina, AccessHealth Spartanburg (AHS) works with medically complex people who lack insurance and are high utilizers of the emergency department (Freundlich, 2018). With a screening questionnaire, AHS assesses people’s needs and stratifies them into three categories of low, moderate, and high risk. People considered high risk are assigned to an RN case manager, those considered moderate risk are assigned to social workers, and those considered low risk are assigned to community health workers (Freundlich, 2018). These personnel help manage and coordinate care, and refer clients to a network of 10 local, county, and state organizations and programs for assistance with social needs.

Expanded Scope of Practice

A second area in which nursing roles and functions can be supported by and incentivized through different payment models to address SDOH and advance health equity involves regulations that control nurses’ scope of practice. Such regulations control how advanced practice registered nurses (APRNs) provide primary care and impact how their services are paid. Sometimes private and public health systems constrain nurses working within their facilities, preventing them from practicing at full scope. Approximately 61.47 percent of health professional shortage areas (HPSAs) are rural (HRSA, 2021). As discussed in Chapter 2, many of these rural areas lack sufficient primary care and would benefit from increased access to APRNs (Auerbach et al., 2018). Studies have found that nurse practitioners (NPs) are more likely than physicians to practice in rural areas (Barnes et al., 2018; Buerhaus, 2018). As discussed in Chapter 3, the number of NPs is expected to grow 6.8 percent annually through 2030, compared with about 1 percent for physicians, whose numbers practicing in rural areas will fall through 2030. Additionally, several reviews have found little to no difference in the quality of care received by patients from NPs and physicians (DesRoches et al., 2017; McCleery et al., 2014), and in some cases found that patients perceived a more holistic approach to care from NPs (Moldestad et al., 2020).

Thus, the growing APRN and RN workforces have the potential to improve rural health disparities. It is as yet unknown, however, whether some states² may continue to impose restrictive scope-of-practice laws that limit the capacity of the nursing workforce once the COVID-19 pandemic has ended (Lai et al., 2020). There is strong evidence of the beneficial effect of NPs providing mental health care, primary care medication prescribing, and buprenorphine waivers for the treatment of patients with opioid use disorder. Evidence shows that broadening of prescriptive authority led to decreases in mental health–related mortality, and these improvements occurred specifically in underserved areas (Alexander and Shnell, 2019). NPs, along with physician assistants (PAs), obtaining the waiver have the potential to treat 15 percent more rural patients, increasing the number of people treated per 10,000 from 15.4 to 17.7 (Andrilla et al., 2020).

In late December 2016, the U.S. Department of Veterans Affairs (VA) loosened restrictions on scope of practice for three APRN nursing roles: certified nurse midwife, certified nurse specialist, and certified nurse practitioner. An evidence brief from the VA points to the need for large and robust studies that examine the difference in care between APRNs and physicians, providing an opportunity to continue tracking patient outcomes (McCleery et al., 2014).

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² In March 2020, Florida passed House Bill 607: Direct Care Workers, which grants APRNs, beginning July 2020, the ability to work independently. This does not include certified nursing assistants.

Community Nursing

A third area in which nurses can address SDOH and advance health equity concerns their work in the community. Community nursing allows nurses to meet people in their homes, schools, and community sites, and address their medical and social needs in a timely, accessible manner. These nurses help bridge the gap between health care systems and communities, and their practice reflects the community needs. In 2016, the Josiah Macy Jr. Foundation called for the increased use of nurses in primary care and expansion of nurses’ roles in community settings. The foundation also recommended that nursing educators include primary care in nurses’ curriculum and provide students with increased clinical experiences in primary care and community settings (Bodenheimer and Mason, 2016).

Telehealth

Use of telehealth is a fourth area in which nurses can be supported and incentivized through different payment models to help address SDOH and advance health equity concerns. As discussed in Chapter 4, telehealth capitalizes on the proliferation of mobile devices and technology to connect with people. In 2016, the most common uses of telehealth were for physician office visits and mental health visits (MedPAC, 2018). The largest proportion of telehealth users were beneficiaries who lived in rural areas, had a disability, were dually eligible for Medicare and Medicaid (CMS, 2020b), or had a higher prevalence of chronic mental health conditions. NPs and other nurses caring for rural populations are prevented from being reimbursed for their telehealth services and from being supported by specialists located hundreds of miles away (Skinner et al., 2019). Paying for nursing telehealth services, mobile care, and remote diagnostic technology could increase access to care for rural populations and the homebound. Telehealth allows nurses the flexibility of being available during office hours and on call for symptom assessment and advice on treating minor issues or when to go to the emergency department, thereby reducing unnecessary emergency department visits.

PAYMENT SYSTEMS THAT SUPPORT AND INCENTIVIZE ADDRESSING SOCIAL DETERMINANTS OF HEALTH AND ADVANCING HEALTH EQUITY

Payment systems in the United States pay for health care based primarily on rewarding the volume of care rather than the value of care (Miller, 2009); treatment of illness rather than prevention and health promotion; and inpatient and specialty care rather than primary care, preventive care, and community/public health. Additionally, payment systems are directed predominantly toward directly reimbursing physician services while infrequently recognizing the ex-

plicit value of services of other clinicians, including nurses and advanced practice nurses working in a variety of settings. Nursing is part of labor costs for most employers of nurses and considered by Medicare to be part of “hospital services” (ANA, 2017), a position that underestimates nurses’ work and impacts resource allocation. It is critical for payment systems to be better aligned with nurses’ contributions to improving clinical performance and the quality of care, increasing revenues, and decreasing costs.

These payment designs have limited the ability of the current system to address social needs and SDOH. The inputs required to advance population health are diverse and include health care, education, housing, environmental safety, and employment. Yet, payment systems to advance population health have focused primarily on a single input: health care (Horner et al., 2019). Moreover, the main criterion for investing in interventions to address social factors has often been achieving cost savings rather than providing value or cost-effectiveness. For example, health care organizations often focus on the relatively few most resource-intensive, highest-cost patients (the “superutilizers”) in their population health management programs instead of on the broader spectrum of patients who could benefit from such interventions. Even though health disparities across race, ethnicity, and socioeconomic status (SES) cost the nation trillions of dollars in direct medical costs, indirect costs such as lost productivity, and the costs of premature deaths (CDC, 2013; LaVeist et al., 2011), individual health care organizations have little incentive to reduce these disparities for underserved populations (Chin, 2016).

Nurses’ roles in transitional care, care management, and care coordination also can reduce costs associated with chronic illness, complex patients, or dually eligible beneficiaries (NCSL, 2016) by helping to prevent hospital readmissions and emergency department visits (Naylor et al., 2012; NSCL, 2016; Ryan et al., 2019). Because health care delivery organizations employ the majority of the nation’s nursing workforce (3.6 million nurses), incentives are needed to leverage nurses’ expertise in novel ways to intervene in SDOH that block advances toward achieving health equity.

Increasingly, public and private policy makers, insurers, health associations, and health care delivery organizations are advocating for the states to remove scope-of-practice restrictions on APRNs (NGA, 2012). Team-based care is increasing, especially in primary care, and APRNs could further expand access to health care, particularly for important populations residing in rural and urban HPSAs (Gilman and Koslov, 2014; NGA, 2012; Shekelle and Begashaw, 2021).

New VBP and APM approaches theoretically can incentivize improved population health, prevention, higher performance, and better health outcomes. However, the total amount of payment at risk to health care organizations with these approaches has been modest, and the incentives provided have frequently been weak (Damberg et al., 2014). To date, therefore, the ability of VBP and APMs to improve population health and advance health equity has been limited, or close

to nonexistent (Hsu et al., 2020). The financial incentives have frequently been insufficient to have a substantial effect on modifying the behavior of clinicians or inducing the operational changes within health care organizations required to address SDOH and advance health equity meaningfully, with sometimes worse health outcomes for safety-net hospitals (Damberg et al., 2014; Hsu et al., 2020). In addition, since most health care organizations have a diverse payer mix, financial incentives need to align across payers to create rewards sufficient to incentivize health care organizations to invest in health equity strategies, considering the complexity of the individuals being served in some facilities (Stone, 2020), and the staff needed to implement these strategies, such as nurses. Yet, too often health disparities are an afterthought for policy makers, neglected or seen as unintended negative consequences of health policy. In contrast, policies need to be designed proactively to advance health equity (Anderson et al., 2018; Chin et al., 2012; DeMeester et al., 2017; NASEM, 2017; NQF, 2017).

The most effective ways to design payment systems to address SDOH and advance health equity are areas of intense policy and research inquiry (DeMeester et al., 2017; NASEM, 2017; NQF, 2017). Key questions about payment functionality³ to align incentives and behavior include the following (Gunter et al., 2021; Patel et al., 2021):

• What costs of care will a health care organization or health plan be held accountable for (e.g., primary care costs, specialty care costs, total cost of care)?
• How much money is at risk to the health care organization? For example, many existing VBP and APM programs provide relatively weak incentives for health care organizations, whereas putting more money at risk to health care organizations could have a greater influence on their behavior. (For example, will the incentive or penalty system affect 5 percent of the payment, 10 percent of the payment, or 50 percent of the payment?)
• Which patients/beneficiaries are attributed to the health care organization (e.g., accountable care organization, hospital) in determining quality performance and costs and subsequent payment based on those metrics?
• How can the data analytics capability needed by organizations to operate effectively in VBP and APM settings be ensured? For example, some safety-net providers, small practices, and rural clinics may lack robust

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³ For the purposes of this discussion, payment functionality is conceptualized as key operational issues for those mechanisms that pay for infrastructure (e.g., care management, care teams, nurse primary care functions, telehealth, workforce, and education) and those mechanisms that incentivize and reward specific processes of care and outcomes that advance health equity, such as those that address SDOH, improve population health, and reduce health disparities.

• data infrastructure and analytical capability, placing them at a disadvantage in VBP and APM models.
• How do the cost and quality of care relate with respect to payment? For example, even if a health care organization saves money, does it need to meet quality metrics to receive its share of that saved money?
• How should performance reporting and payment be adjusted for populations’ social risk in ways that neither mask disparities nor penalize health care organizations that provide care for patients with greater social risk (NASEM, 2017; NQF, 2017)?
• How will it be possible to ensure that the long-term societal benefits of improving public health are reflected in the short-term incentives provided to health care organizations to create a business case for them to address SDOH and improve health equity?
• How can the same services be paid for equitably regardless of the provider (e.g., normal delivery by certified nurse midwife [CNM] versus obstetrician-gynecologist physician; advanced practice nurse versus physician)?

The answers to these questions are evolving and will likely need to be tailored to different populations, markets, and policy contexts, and they can be informed by the input of nurses with experience in addressing SDOH and advancing health equity. Each question can also be asked from the perspective of how the payment system affects the role of nurses.

It is critical to ensure that the payment for health care services for both providers and health plans is adjusted appropriately for the complexity of the patient population. Current risk adjustment methodologies use primarily medical diagnosis and do not adequately take social risk factors into account (Ash et al., 2017; Meddings et al., 2017). The result can be underpayment to providers and plans that attract a disproportionate number of patients with social risk factors and can serve as a disincentive to innovation. For instance, if a health plan or provider develops a unique, novel, and effective program targeting complex patients experiencing homelessness and begins to attract more of these patients, it will be adversely impacted financially and could go out of business. Massachusetts has attempted to risk adjust using SDOH risk factors in its Medicaid premium payments to health plans (UMN, 2020). A key challenge to incorporating social factors is obtaining the relevant information from patients. Much work remains to refine these models and deploy them to various payer settings (Ash et al., 2017; Irvin et al., 2020).

Health care policy and payment systems are in flux as of this writing, as evidenced by the push for health systems to try new approaches through demonstration projects and grants to encourage innovative approaches. Thus, it is currently unclear what the predominant payment model will be in 2030. Accordingly, various possible mechanisms by which each of the predominant payment

models (FFS, VBP, APMs) can support and incentivize health care organizations in enabling nurses to perform key nursing roles and functions are reviewed in this chapter. The committee suggests expanding the goal and purpose of payment systems beyond traditional health care and traditional government and private payers to explore how the public health and social sectors can support nurses in using their expertise to eliminate gaps and disparities in health and health care. This section is not meant to be an exhaustive exploration of the current payment system⁴ but to give examples of the general principles by which current and future payment systems can be tailored to use nurses more wisely and effectively to improve population health and advance health equity.

Fee-for-Service

Historically, most health care providers in the United States have been paid through FFS payments, in which each individual service is billed separately (Berenson and Ginsberg, 2019). To bill for these FFS payments, all types of insurance (Medicare, Medicaid, and commercial) require that two components be submitted: a CPT (Current Procedure Terminology) code and one or more ICD-10 (International Classification of Diseases, 10th Revision) codes. The CPT code describes the service being provided, while the ICD-10 code describes the reason(s) that the service was provided.

There are more than 7,600 different CPT codes (Fuchs, 2013), and each insurance company has a unique fee schedule for each service. In negotiating with insurance companies, it would be overwhelming for providers to negotiate the price of all of the individual codes. In many instances, providers will negotiate their payment as a percentage of the Medicare fee schedule (Clemens and Gottlieb, 2017; Ginsburg, 2012; MedPAC, 2019). Medicare has a set, national fee schedule published and updated every year by the Centers for Medicare & Medicaid Services (CMS), a federal government agency. Thus, the Medicare fee schedule has become the relative baseline for much of the provider payment system in the United States. Researchers have demonstrated a link between the Medicare fee schedule and specialty choice, investment decisions, and innovation within health care (Clemens and Gottlieb, 2014, 2017).

Despite growing use of APMs, such as pay-for-quality and risk-based payment, the FFS payment structure underlies the calculation of many of these payments (Berenson and Ginsburg, 2019; Ginsburg, 2012). For instance, shared savings calculations are often based on the actual versus expected FFS expenditures. Additionally, within many health care organizations, providers are often paid using incentive compensation that is based on the volume and type of services being delivered (MGMA, 2020). Thus, providers may be financially

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⁴ For further information, see Needleman (2020).

incentivized to deliver a higher volume of expensive services if they have an incentive-based contract.

CPT codes are created, governed, and owned by the American Medical Association (AMA). The CPT codes are protected by copyright and are AMA’s largest single source of revenue (Rosenthal, 2017). The federal government, states, and insurers license the CPT code set for use in their payment of providers (AMA, 2019b). The codes are overseen by an AMA-led CPT Editorial Panel with 17 members, 11 of whom must be physician members of AMA. Two members are required to be nonphysicians representing the CPT Health Care Professionals Advisory Committee, such as nurses.⁵ The existence of a CPT code and the definition of the code have a critical impact on whether a service is reimbursed.

The valuation and ultimately relative prices paid for the CPT codes are based on the work of another AMA committee, the Relative Value Scale Update Committee (RUC) (AMA, 2019c). This committee makes recommendations to the federal government on the relative value and ultimately prices of services paid for by Medicare. Between 2011 and 2015, a U.S. Government Accountability Office (GAO) study found that 69 percent of RUC recommendations became Medicare payment policy (GAO, 2015). As previously described, these valuations then become the basis for the relative prices paid by all insurers in the United States. The RUC has 31 voting members who are all physicians; nurses serve in an advisory capacity.^6,7,8

The prices in Medicare and for other insurers as well are based on a measurement called a relative value unit (RVU) consisting of three components: labor, overhead, and malpractice (Hsiao et al., 1987; MedPAC, 2020). Approximately 50 percent of the RVU measurement is based on the labor to deliver the health care service, which is called the work-RVU (Fuchs, 2013). This work-RVU is calculated by AMA’s RUC through voluntary, unverified, and self-reported surveys from physicians themselves, which have been found to be inaccurate and overstated. Survey return rates can be quite low and data confidence intervals wide (Laugesen, 2014; MedPAC, 2019). The overhead-RVU component, the second-largest component of the calculation, is based on input from an RUC expert panel, which a GAO report also found to be inaccurate. According to that report, “officials sometimes price items on the basis of a single or small number of invoices” for the overhead report, ignoring normal economies of scale (GAO,

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⁵ Keepnews, D. J. 2020. Memo on Nursing, The Relative Value Scale Update Committee Process and Payment Policy. Sent by email and received on January 22, 2020.

⁶ Keepnews, D. J. 2020. Memo on Nursing, The Relative Value Scale Update Committee Process and Payment Policy. Sent by email and received on January 22, 2020.

⁷ Reinecke, P. 2019. Relative Value Scale Update Committtee Information. Memo from Peter Reinicke to Sue Hassmiller. Submitted by email from Sue Hassmiller on November 19, 2019.

⁸ Sullivan, E. 2020. Memo on Comments Regarding Issues for Registered Nurses and Advanced Practice Registered Nurses and the Resource Based Relative Value System. Submitted by email and received on January 2, 2020.

2015). Also, as physicians get more efficient at delivering a service and the overhead drops from volume of service delivery, the data are not consistently recollected to recalculate the work- and overhead-RVUs. As a result of this system, the worth of 1 hour of provider time spent delivering a procedure can be three to five times higher than that of 1 hour spent talking to patients or coordinating care. According to Sinsky and Dugdale (2013), “Two common specialty procedures can generate more revenue in one to two hours of total time than a primary care physician receives for an entire day’s work.”

Through the CPT Editorial Panel and the RUC, AMA has had a singular and profound influence on both what gets paid and the relative value of those services in the American health care system (Laugesen, 2014). A 2015 GAO report requested by Congress states:

FFS pays for the transaction of health care services, which may often encourage reactive treatment, increasing the volume of services and procedures and resulting in overspending. FFS payment rate schedules tend to favor specialty and inpatient care and not to incentivize preventive and primary care (MedPAC, 2019; Shi, 2012).

The creation and valuation of codes for care coordination, patient assessment, end-of-life counseling, health education, and prevention services have lagged, with the focus given to highly paid, highly valued procedures. The former services, however, are especially important for patients experiencing significant SDOH risk factors. Even the choice of who may provide a service and therefore bill for that service is built into the definitions of the codes. Few codes allow for directly reimbursing for nurse-led services at the RN level. Instead, the codes attempt to value those services within the overhead-RVU component. The current system has long been criticized for undervaluing cognitive work, overvaluing procedural work, and inadequately capturing a range of nonprocedural work (Berenson and Goodson, 2016; Sullivan-Marx and Maislin, 2000; Sullivan-Marx et al., 2000). APRNs are reimbursed at 80–85 percent, compared with the full reimbursement physicians receive under the fee schedule (MLN, 2020).

Despite many weaknesses, it is possible to reform FFS payment to support key nursing roles—specifically, to allow nurses and health care organizations to bill and receive reimbursement for services that address SDOH and advance health equity at a level sufficient to support these interventions and incentivize organizations to persist in initiating and sustaining this work. Nonetheless, the committee recognizes that, while a shift away from the FFS model is under way,

fully transitioning to another system may take years. Therefore, it will be necessary to support and incentivize nurses in taking on these roles and functions under the FFS system.

Attaching relative value to complex health care services is a challenging task. In the current system, the CPT codes and associated RVUs are a bottom-up estimate of cost, which is used by CMS and other insurers as measure of relative value in their payment of providers without reference to the overall societal value of the service, the availability/supply of the service, the evidence base for benefit from the service, the quality of the service delivered, and the outcome for the individual (Berenson and Lazaroff, 2019).

Possible approaches to reforming the process of creating, defining, and valuing health care services in an FFS environment could include such changes as (1) reforming the existing two committees (CPT Executive Panel and RUC) to include meaningful representation from nursing, or (2) the creation of a new multidisciplinary committee sponsored by CMS or an independent nonprofit. Given the ownership of the CPT codes and the complexity of developing codes and valuing services, no solution would be a simple undertaking. The committee recognizes the importance of this issue and highlights the potential for developing new approaches.

CPT Codes, Care Management, and Team-Based Care

CPT billing codes could be altered to include nursing-specific functions in care management and team-based care. As noted above, the FFS model frequently does not reimburse adequately or at all for time spent on cognitive activities and coordination services, such as screening people for social risk factors and connecting them to the appropriate social services (NASEM, 2019). Adding CPT codes for such services as care coordination could provide opportunities and financial incentives for care that supports social needs.

In some cases, billing codes have already been developed (e.g., for chronic care management) that allow care team members other than physicians to bill or allow for “incident-to” billing (NASEM, 2019, p. 118). Medicare reimburses nonphysicians in the category “incident to a physician’s service,” which requires working under a physician’s supervision. Records log the physician as having provided the service (Rapsilber, 2019), and reimbursements thus credit the billing provider—the physician—and not the actual provider of service at the time. The result is undercounting of the services actually provided by NPs and PAs (Morgan et al., 2019). In 2019, the Medicare Payment Advisory Committee (MedPAC) found that NPs and PAs are increasingly providing more primary and some specialty services (Coldiron and Ratnarathorn, 2014; Muteanu et al., 2020) under “incident-to” billing, concluding and recommending that Congress eliminate the “incident-to” practice entirely so NPs and PAs can bill Medicare directly and the value of their services can be measured (MedPAC, 2019).

As described in Chapter 3, the degree to which a nonphysician can practice and bill varies by state practice laws (Larson et al., 2017), with differing impacts on the population. For instance, women in states where CNMs have practice autonomy and attend births have lower rates of low birthweight and preterm birth (NASEM, 2020a; Yang et al., 2016). These outcomes are also found in other countries where care is delivered by nurse midwives (Renfrew et al., 2014). Currently, Medicare reimburses APRNs for pre- and postdischarge care as part of transitional care management under the FFS model using CPT codes 99495 and 99496 (Fels et al., 2015); however, these billing codes have frequently been unwieldy to implement in practice.

While most health systems do not allow RNs or social workers to bill for care management or other team-based services (Dormond and Afayee, 2016), there is at least one example of innovators designing processes to allow such billing. CareOregon allows RNs and social workers to bill Medicaid for each episode of care management services with custom pricing using CPT codes 99368 and 99366, without requiring incident-to billing through a physician or APRN. Although the system was challenged by electronic health records not documenting services for people not engaged in primary care (i.e., “preprimary care”), collaboration among program staff, the billing department, and the information technology (IT) department resulted in a unique documentation and coding structure to support the program.⁹

Expanding Nurses’ Scope of Practice

Nearly one-quarter of adults in the United States experience a behavioral health disorder, according to a 2018 survey by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2018). A lack of behavioral health services has contributed to increased morbidity and mortality, with rural areas facing a particular burden compounded by health care provider shortages. Nearly half of rural areas were found to lack a physician with a U.S. Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine (Andrilla et al., 2019), and there is a tremendous need for individuals with substance use disorder to be able to access a full array of treatment, including buprenorphine (Velander, 2018). Access to life-saving substance abuse disorder treatment could increase dramatically, particularly in rural areas, if more NPs were granted waivers to prescribe buprenorphine and other medications for treatment of substance abuse disorders (Barnett et al., 2019; Moore, 2019). Empowering and supporting NPs, APRNs, CNMs, and nurse anesthetists across all states to practice to the full extent of their license and training, especially in areas with maldistribution of health care providers, could expand access to an array of important health services for underserved populations (UM Behavioral Health Workforce Research Center, 2018).

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⁹ Personal communication with Jennifer Menisk Kennedy, January 29, 2020.

Reforms to the RUC’s fee schedules to reflect current work values empirically would better support the work of NPs (Sullivan-Marx, 2008).

Expanded Funding for School Nursing Services

In 2014, the U.S. Department of Health and Human Services (HHS) rescinded a policy that prevented school nurses from billing Medicaid for their services (CMS, 2014; Maughan, 2018; Ollove, 2019; Wang, 2014). As of 2019, seven states had made changes to their Medicaid policies to allow school nurses to bill—an important policy change that affects how school nurses practice and extends their services to all children (see Chapter 4). Medical associations, nursing associations, and others have ongoing advocacy efforts for policies that allow all students to have access to health services (Council on School Health, 2016; Largent, 2019). Despite following an FFS model, implementation is irregular among states, and school districts and local counties will have to decide how to pay for health services rendered to students.

Telehealth

As part of the Bipartisan Budget Act of 2018, Medicare coverage of telehealth and eligible services was expanded; however, these services were limited to certain geographic areas (rural areas designated as HPSAs or outside of metropolitan statistical areas) or services provided as part of a CMS demonstration project (CMS, 2018). Historically, payment for telehealth services also has been limited by provider category, with limits on nurses and advanced practice nurses.

In March 2020, during the beginning of the COVID-19 pandemic, CMS issued temporary waivers to expand access to telehealth services so that beneficiaries could receive services without having to travel to a health care facility. As a result, beneficiaries can continue receiving routine services and maintain contact with their providers while sheltering in place (CMS, 2020a). The CMS policy encompasses telehealth reimbursement for a wide range of clinicians, including “physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals, however, this is subject to state regulation of scope of practice” (CMS, 2020a). Some states have encouraged private payers to also cover telehealth services, but the legislative guidelines and implementation have varied across states (CCHP, 2017, 2019). Some telehealth laws aimed at private payers have required parity in covered services, meaning services that would be covered for in-person visits are also covered (CCHP, 2019). Ultimately, not all people receive the same services in all states.

Telehealth can maximize a care team’s interaction with individuals and strengthen collaborative care in rural areas. One study found, for example, that nurse-led telehealth care management for children with medical complexities

in an urban environment improved parents’ understanding of how to care for their children’s health issues (Cady et al., 2015). Project ECHO (Extension for Community Healthcare Outcomes) is another telehealth innovation designed to improve clinician collaboration by using video conferencing to connect specialists to primary care providers and care teams, which include nurses. While paying for a clinician’s time to participate in teleECHO clinics is currently difficult under the FFS system, Project ECHO can assist nurses or intermediary providers with reimbursement through the collaborative care CPT code (Hager et al., 2018).

Value-Based Payment

Because payment based on FFS is the most important contributor to overutilization of services, inefficiency, and rising health care spending, both the Obama and Trump administrations, with bipartisan congressional support, have sought changes in federal payment systems to emphasize the value of health care services over the volume of services provided (CMS, 2019a). VBP, in contrast, links to both quality and value (Werner et al., 2021). Essentially, using VBP means paying providers more for delivering higher-quality care and achieving better patient outcomes, taking into account the cost of resources used to produce the outcomes. Similarly, providers are paid less for delivering lower-quality care and worse outcomes, again taking into account the cost of resources used to produce the outcomes. In this way, providers who produce better outcomes using less costly resources are rewarded compared with those who produce poorer outcomes at higher cost. A common example is pay-for-performance, in which providers and health care organizations receive more payment if they meet preestablished clinical performance accountability metrics.

In this context, it is important for performance metrics to incentivize nursing roles and functions that address SDOH and advance population health and health equity. Nurse-sensitive indicators could be developed using Donabedian’s Structure-Process-Outcome framework for quality assessment (Gallagher and Rowell, 2003). A recommendation from the Nursing Knowledge: 2018 Big Data Science Conference included the creation of a national nurse identifier. A national nurse identifier would be useful because

Being able to track providers to patient outcomes would be beneficial overall to health systems, cost-effectiveness, and tracking of nurses’ collective and individual contribution to outcomes (Sensmeier et al., 2019). A unique nurse identifier could also benefit research aimed at measuring and quantifying nursing care and inform future education and training for nurses (Sensmeier et al., 2019).

Measurement of health disparity indicators has been recommended as part of quality of care (IOM, 2015). Performance measures can illuminate existing gaps in access and disparities while assessing the effectiveness of interventions (NQF, 2017). The National Quality Forum (NQF) (2019) recommends creating measures that align SDOH measurement and activities across health care and clinical and community-based settings. Short- and long-term goals would build on these measures and aim to have half (50 percent) of health systems using aligned screening data with measurable SDOH improvements (NQF, 2020). Clinical performance metrics could be used to identify and track disparities by stratifying such risk factors as race, ethnicity, and measures of SES. It is critical for payers to reward reductions in health disparities in clinical and population health performance measures, improvements in measures for at-risk populations, and attainment of absolute target levels of high-quality performance.

Performance metrics that incorporate disparity-sensitive measures are key for assessing interventions. For example, metrics for care coordination and team-based care could incentivize investment in nurse-led care management programs that can reduce health disparities. Chronic diseases and ambulatory care–sensitive conditions—including asthma, diabetes, heart failure, hypertension, and depression—that are prevalent in POC and underserved populations and display disparities in outcomes compared with more advantaged populations often are well suited to nurse care management/team-based care programs (Davis et al., 2007; Lasater et al., 2016; Mose and Jones, 2018; Peek et al., 2007). Another disparity-sensitive measure relevant to nursing interventions is prevention of hospital admissions and readmissions for ambulatory care–sensitive conditions. Some transitional care models (TCMs) with an APRN leader have been found to reduce hospital admissions, and studies have found lower rates of hospital readmissions and avoidable hospitalizations among Medicare and Medicaid beneficiaries in states where NPs have full practice authority (Naylor, 2012; Oliver et al., 2014). For example, the Vermont Transitional Care Nurse program, led by nurses, is an established best practice (Fels et al., 2015). In this program, to support high-risk patients transferring from the hospital, an APRN designs and coordinates care with patients, their families and caregivers, physicians, and other health care professionals (Hirschman et al., 2015).

Measures of population health could reflect the impact of addressing SDOH. For example, the NQF recommended in 2019 that stakeholders such as public and private payers, social services providers, health care organizations, and community-based organizations improve the collection of data on SDOH in their

community. The data collected should include key measures that prioritize local communities’ needs, and are then used to create clinical and community outcome measures (NQF, 2012, 2019). In a 2019 report, the National Advisory Council on Nurse Education and Practice (NACNEP) strongly supported value-based care through funding measures or initiatives that develop nurse competencies (NACNEP, 2019); incentivize nurse care management and team-based care; and include population health measures, measures of the extent to which SDOH are identified and addressed, and measures to reward reductions in health disparities (NASEM, 2020b).

Alternative Payment Models

APMs are predominantly non-FFS models designed to promote value and cost-efficiency. APMs frequently incorporate VBP principles, such as taking on “substantial financial risk to deliver high quality care at lower cost” (Werner et al., 2021), and in practice many still use FFS models to distribute payment. APMs could provide effective mechanisms and incentives to fund nursing for addressing SDOH and advancing health equity (DeMeester et al., 2017). For example, various forms of capitated payment and global budgeting could provide up-front funding to support these key nursing roles and functions, as could payment systems that provide per member per month payments to health care organizations. The value argument for cost-efficiency of APMs and investments in nursing is that many of these nursing interventions prevent clinical deterioration and costly emergency department visits, inpatient care, and procedures.

APMs provide special opportunities and flexibility not present with FFS to reward high-value nursing activities. These payment mechanisms could support nurses in their SDOH-related work, such as increased home visits, health education, and care coordination ranging from prevention to chronic care and palliative care (Dahlin and Coyne, 2019).

Accountable Care Organizations

Some APMs are shared savings programs in which payers and health care organizations share any cost savings. An example of an APM that could incentivize value and cost-efficiency in care is accountable care organizations (ACOs) (Albright et al., 2016), many of which have rapidly expanded their use of NPs (Nyweide et al., 2020). ACOs are responsible for the health and costs of a predetermined population of patients. They frequently work with a fixed budget and often are required to meet clinical performance metrics to share with the payer in any cost savings. One of the earliest promising examples of ACOs’ potential role in supporting nurses in addressing SDOH and advancing health equity comes from the state Medicaid programs in Oregon (see the description of the C-TRAIN transitional care model earlier in this chapter). ACOs are required to

meet standard quality measures established by CMS (2019b), which are adjusted for high-risk beneficiaries (AMA, 2019a; CMS, 2019b). Overall, the Medicare Shared Savings Program has demonstrated cost savings with physician-group ACOs compared with hospital-integrated ACOs, which have not (McWilliams et al., 2018), along with high-average composite quality scores (Gonzalez-Smith et al., 2019).

Accountable Health Communities

Accountable health communities (AHCs), also known as accountable communities for health, accountable care communities, or community health innovation regions, are coalitions of partners from “health, social service, and other sectors working together to improve population health and clinical-community linkages within a geographic area” (Spencer and Freda, 2016, p. 2). AHC implementation requires a bridge organization that can operate as a hub to coordinate efforts across partners, conduct screenings, and make referrals to address health-related social needs for Medicare and Medicaid beneficiaries (CMS, 2019b).

Minnesota, considered one of CMS’s pioneer states, created 15 AHCs—8 in urban areas, 6 in rural areas, and 1 with a presence in both urban and rural areas (Au-Yeung and Warell, 2018; Spencer and Freda, 2016). The AHCs in Minnesota use nurses in community care coordination and team-based care roles. At Morrison County Community-Based Care Coordination, a team consisting of a social worker, nurse, and doctor assists aging and other adults with mitigating overuse of prescription narcotics (Au-Yeung and Worrall, 2018). And another AHC used community health workers and medical assistants for less complex patients and tasks and employed RNs to care for more severe cases (Au-Yeung and Worrall, 2018). Nurses are present in community and health system settings, and their inclusion on these teams can potentially streamline complex cases from treatment to follow-up to referrals.

Medicare Advantage

Medicare Advantage plans, in which the federal government pays private insurance companies a fixed monthly amount to care for beneficiaries, have been available since 2000. These plans feature increased flexibility that allows funding to go beyond traditional Part A and B services to support such nonmedical benefits as transportation and home improvements for chronically ill beneficiaries, healthy meals, and other services (Green and Zook, 2019). Flexible funding allows health care organizations to adapt services that address SDOH and advance health equity to suit local contexts and beneficiaries (Thomas et al., 2019).

Program of All-Inclusive Care for the Elderly

Program of All-Inclusive Care for the Elderly (PACE), another alternative model, benefits elderly people who are dually eligible for Medicare and Medicaid, require long-term support services, and are eligible for nursing facility–based care. Medicare and Medicaid give providers capitation payments for enrollees.¹⁰ Interdisciplinary teams, which often include a nurse, provide such comprehensive services (CMS, 2020b) as diet and nutrition counseling, social services, transportation, physical therapy, and personal care attendants (CMS, n.d.b; NPA, n.d.).

Health Insurance Contracting Requirements

Payers such as Medicare and Medicaid can incorporate incentives to address SDOH in their contracting requirements with insurance companies. For example, the Medical Loss Ratio provision of the Patient Protection and Affordable Care Act (ACA) requires most health insurance companies that cover individuals and small businesses to spend at least 80 percent of premiums on health care claims and quality improvement rather than on administration, marketing, and profit (KFF, 2012). Subsequent clarification of the regulations allows investments addressing SDOH to count toward required medical loss ratio spending (Machledt, 2017). A March 2020 review of 404 studies showed that Medicaid expansion under the ACA improved access to care, financial security, some health outcomes, and economic benefits to states (Guth et al., 2020). For example, Medicaid expansion was associated with lower rates of maternal and infant mortality (Searing and Ross, 2019). Thus, APMs can enable payers to incentivize addressing SDOH and support nursing infrastructure to this end.

SUPPORTING SCHOOL AND PUBLIC HEALTH NURSES TO ADDRESS SOCIAL DETERMINANTS OF HEALTH AND ADVANCE HEALTH EQUITY

School and public health nurses play crucial roles in improving the health of school-age children and their families, as well as the health of community members who are more likely to receive preventive care or treatment through community resources (APHN, 2016; Bogaert et al., 2020; NACCHO, 2020; NASN, 2016). These nurses provide direct care and advocacy, make referrals to partner organizations, and connect with nonhealth sectors related to the well-being of children and others. They regularly address individuals’ social needs, promote health, and work to prevent illness. Therefore, school and public health nurses can reduce the demand for downstream treatment of individuals in costly health care

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¹⁰ See https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/CapitatedModel (accessed July 23, 2021).

delivery systems. The nursing workforce is a crucial component of Public Health 3.0,¹¹ providing health care and supporting the community (DeSalvo et al., 2017).

Some of the highest-value health and societal outcomes derive from the care received by children when they are very young. School and public health nurses are therefore valuable resources for addressing population health and health equity; however, they are underfunded (IOM, 2011; Sessions, 2012). In the United States, each locality has control over school and public health funds, and structural inequities exacerbate underfunding in many low-income and marginalized communities (Beitsch et al., 2015). Some states require school nurses, while others leave those decisions to local school districts, which are often faced with very limited funding. Those communities with the most complex health issues and social risks often cope with especially severe underfunding of often limited public health services (Welker-Hood, 2014).

Frequently, existing funding streams are insufficient to support school, public health department, and other community-based health efforts, the impact of which has been exacerbated by the COVID-19 pandemic. Indeed public health departments operate differently within each community and state (Beitsch et al., 2015). Thus, there exists a need to apportion more government general funds for these services or identify other dedicated revenue streams (Sessions, 2012). In the present context, creating consistent funding streams that support the health of children and communities by capitalizing on the expertise of school and public health nurses can be a key component of achieving health equity.

School Nurses

As described in Chapter 4, the average school nurse works simultaneously in three schools and is responsible for caring for diverse students with complex medical, health, and social needs (Willgerodt et al., 2018). The American Academy of Pediatrics (AAP), the American Nurses Association (ANA), and the National Association of School Nurses (NASN) recommend that all students have full access to a school nurse who can coordinate care, provide health education, administer medications, direct care, and help meet community and public health needs (ANA, 2007; Council on School Health, 2016; NASN, 2016). A cost/benefit study of the Massachusetts Essential School Health Services (ESHS) program found a net benefit of nurse health services. The study compared program costs, including the cost of nurse staffing and supplies, with program benefits, measured by savings related to avoided medical procedures, loss of teacher or instructor productivity, and parents’ loss of productivity (Wang et al., 2014). The study ultimately found that each dollar invested in ESHS programs would yield $2.20 in savings per student.

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¹¹ Public Health 3.0 refers to public health practices that include cross-sector collaboration and extends beyond traditional public departments (DeSalvo et al., 2017).

However, about 25 percent of schools do not employ a school nurse, and about 35 percent employ one only part-time (Willgerodt et al., 2018). On average, schools with more students who qualify for free or reduced-price lunches have less access to a school nurse (NCES, n.d.). The lack of school nurses in schools that serve disadvantaged communities reflects the larger association between school funding and school resources that adversely affects children from low-income families (Jackson et al., 2016). According to a 2015 NASN survey, moreover, the availability of school nurses varies greatly by region: the survey found that western states had the highest percentage of schools without a school nurse (Mangena and Maughan, 2015).

Additionally, there are inconsistencies in how school nurses are paid and in general oversight. School nursing remains underfunded as school district budgetary constraints force administrators to decide annually which resources to pare down or keep (Leachman et al., 2017). The NASN survey found that 85 percent of responding school nurses worked for public school districts; 90 percent of these respondents indicated that most of their funding came from public education department funds and the rest from special education funds (Mangena and Maughan, 2015). Outside of educational funding, public health departments and private or nonprofit hospitals are the major funders of school nurses (Becker and Maughan, 2017). In Massachusetts, for example, the ESHS program has been supported by the Department of Public Health since 1993 to support and fund nurse-managed health services and school-based health centers (Massachusetts Department of Health, 2012).

About 45 million children are enrolled in Medicaid. Since December 2014, federal law has allowed school nurses to bill Medicaid for services to beneficiaries (CMS, 2014), but only a handful of states have taken advantage of this opportunity (Ollove, 2019). Currently, only seven states allow students to receive free care under Medicaid (Ollove, 2019). In the NASN survey of school nurses, 57.6 percent of respondents affirmed that they or their employers billed Medicaid for reimbursement, but two-thirds did not know how the reimbursements were used (Mangena and Maughan, 2015). In a 2018 survey of school superintendents, 70 percent of respondents indicated that any revenue generated through Medicaid billing went toward salaries for health professionals. However, the administrative burden of billing poses a significant challenge for schools; the schools not taking advantage of Medicaid funding tend to be located in small rural school districts (AASA, 2019). Given the familiarity of rural hospitals with Medicaid billing, these institutions could explore partnering with their local small rural school districts to develop billing infrastructure.

Schools may need to take advantage of multiple funding sources to support robust school health programs and school nurses. For example, Grand Rapids Public Schools in Michigan partnered with Spectrum Health to improve student health outcomes and used for that purpose funds from the school district budget, Spectrum Health, the local intermediate school district, and the state department

of education (Spectrum Health, n.d.; TFAH, n.d.). Grand Rapids Public Schools uses a model whereby 34 RNs direct licensed practical nurses (LPNs), health aides, and other health professionals in conducting health screenings and follow-up, administering immunizations, and connecting students to outside medical care through referrals (TFAH, n.d.).

More intensive work can be done in school settings to bridge social and health services and more broadly engage SDOH in communities. Nurses in the lowest salaried positions tend to be those working in community settings, and in contrast with Medicare and Medicaid, these are settings where funding streams are often tied to the local tax base and grant funding.

Public Health Nurses

Public health nurses address social issues through policy development, planning, and advocacy, as well as community involvement (APHA, 2013). As noted in Chapter 3, in the 2018 National Sample Survey of Registered Nurses, 1.7 percent of all responding RNs (n = 47,060) reported providing public/community health care. Public health nurses are funded by federal, state, and local public health budgets, as well as grants for specific programs. Current public health funding is complex, with sources including the federal government; all 50 states and Washington, DC; and several thousand local municipalities (IOM, 2012). Public health funding is discretionary spending that is often subject to reductions (TFAH, 2018a). Federal public health funding is a combination of funds from the Centers for Disease Control and Prevention (CDC), HHS, and the U.S. Department of Agriculture (USDA). Most federal funds flow through CDC, which saw a 10 percent decline in public health funding between 2010 and 2019, after adjusting for inflation (TFAH, 2019). State-level funding for public health has decreased over the past few years as well, with only 19 states and Washington, DC, maintaining their budgets. At the local level, the 2008 recession led to more than 55,000 staff positions being lost in local health departments as a result of layoffs or attrition, with most cuts not being restored (TFAH, 2018a). One of every five local health departments reported decreases in its public health budget during fiscal year 2017.

In the face of these reductions, the Public Health Leadership Forum estimates that “there is a $4.5 billion gap between current funding and what is needed to build a strong public health infrastructure nationwide” (DeSalvo et al., 2018; TFAH, 2019, p. 18). As of 2017, public health spending accounted for only 2.5 percent of health-related spending (about $274 per capita) (TFAH, 2019). In a survey of 377 state and local health departments, most public health nurses reported finding strengths in their departments. However, they also cited “barriers, such as a lack of promotion opportunities for RNs, job insecurity, lack of budget to hire vacant RN positions, and inability to offer a competitive salary to RNs” (Beck and Boulton, 2016, p. 149).

Sustaining public health infrastructure with continuous funding that supports the work of public health nurses is essential for healthy communities, particularly for communities of color and those of lower SES. By some estimates, moreover, the return on investment for public health dollars may be as high as 14 to 1 (TFAH, 2019).

ROLE OF THE HEALTH AND SOCIAL SECTORS IN SUPPORTING NURSES TO ADDRESS SOCIAL DETERMINANTS OF HEALTH AND ADVANCE HEALTH EQUITY

Historically, the health and social sectors (e.g., housing, transportation, food insecurity, employment, education, criminal justice) have had siloed funding streams and accountability metrics for judging and financially rewarding organizations. Policy makers, health care administrators, clinicians, social-sector leaders, and communities are increasingly recognizing the importance of coordinating the health and social sectors to address SDOH and advance health equity. Yet, efforts to increase communication, collaboration, and synergies between the two sectors raise difficult issues in such areas as governance (e.g., Who should be at the table? Who is in charge? Who has the power?). In addition, it has been challenging to devise suitable joint accountability metrics with which to align and reward desirable behaviors, and in the present context, to organize funding that supports nurses in addressing SDOH and advancing health equity.

Braiding and Blending Funding

Braiding and blending are two funding mechanisms that can support community interventions and services (TFAH, 2018b). Braiding coordinates two or more funding streams while imposing restrictions and regulations on the use of those funds. Activities and data, including expenses and performance measures, can be tracked and attributed to the original source of funding. Blending pools two or more funding sources into one funding stream and allows for more flexibility in the use of the funds because of fewer restrictions and regulations (Cabello, 2018). Through these mechanisms, the conjoined efforts of the health and nonmedical social sectors can support nurses working across settings and domains—community-based organizations, public health, education, health systems, and others (Clary and Riley, 2016).

Early Head Start, Head Start, and other child development programs are examples of such combined funding strategies that address community needs across public, private nonprofit, community-based, and faith-based organizations (OHS, 2020; Wallen and Hubbard, 2013). In a similar way, braiding and blending funding from the health and social sectors can support local public health departments in prioritizing health equity. The Bridging for Health Blueprint report from the Georgia Health Policy Center (2019) assesses a series of case

studies to determine the kind of technical assistance local health departments and communities would need to sustain funding for health programs. A common characteristic identified in the case studies is pooling of community wellness funds, and a requirement for up-front capital and braiding and blending of funding from many sources.

In Rhode Island, a Health Equity Zone (HEZ) initiative was launched to capitalize on place-based community efforts to address local health needs (RIDOH, 2018) using braided funds from local, state, and federal sources. Eleven HEZ zones were established statewide, each focused on local priority issues and services, including providing psychological first aid, screening patients for depression and identifying patients at risk of suicide, developing safer roadways, banning smoking and vaping in town parks to ensure smoke-free areas, improving vacant or abandoned properties and addressing housing as a social determinant, building community linkages through the use of community health workers, and creating a community drop-in clinic for adults with substance abuse disorders (RIDOH, 2018). The initiative creates opportunities for people already living and working in their communities to improve health care access and health equity. Nurses can play critical roles in such community programs that braid funds to improve health equity (e.g., working at the front line to screen people in health care settings or schools, or serving as health care representatives to support housing policy).

Louisiana developed the Louisiana Permanent Supportive Housing (PSH) program following the devastation and destruction of Hurricane Katrina, which exacerbated the difficult circumstances of people already living with complex physical and behavioral health conditions. The PSH program recognizes stable and safe housing as an essential need that can support people’s health. This cross-agency partnership between Medicaid and the state housing authority braided funding sources from disaster recovery funds, housing assistance programs such as Section 811, Medicaid, and SAMHSA. Nearly half of all beneficiaries were homeless before participating in the program (Clary and Kartika, 2017). Housing providers focused on housing needs, while Medicaid-enrolled clinicians provided health care to the tenants. Although roles and responsibilities of nurses are not called out as part of the PSH program, opportunities exist for nurses to provide transitional care that complements the social services people need, such as housing.

Pay-for-Success/Social Impact Bonds

Pay-for-success (PFS) models, sometimes referred to as social impact bonds (Galloway, 2014), allow private investors, rather than traditional investors such as government, to provide up-front capital for scaling social interventions that benefit the public sector—specifically, an underserved population (Iovan et al., 2018; Urban Institute, n.d.). PFS models have been used in such interventions

as job training, criminal justice reform, reentry for formerly incarcerated people, and early education (Golden, 2014; NFF, n.d.). Interventions are considered successful when predetermined outcomes have been achieved, and investors are then repaid (Urban Institute, n.d.).

Iovan and colleagues (2018) evaluated more than 80 PFS interventions, several of which addressed multiple determinants of health and focused mainly on downstream and midstream factors. Most interventions were initially supported by a combination of public and private investors, and were implemented at the federal or the state or provincial level. In the United States, 11 interventions analyzed by Lantz and colleagues (2016) involved more than one investor, and several included banks and private foundations or philanthropic organizations.

One pay-for-success example is the Nurse-Family Partnership (NFP) in South Carolina. The NFP is a national public health intervention that allows nurses to build relationships with new mothers. The program has resulted in improved behavior and improved performance in school among young children (Karoly et al., 2005; Kitzman et al., 2019) and improved educational attainment and employment among mothers (Flowers et al., 2020), and has demonstrated cost-effectiveness (Dawley et al., 2007). The NFP focuses on first-time low-income mothers in 29 of the 46 state counties. Investors included BlueCross Blue-Shield of South Carolina Foundation, the Duke Endowment and other private funders, and the South Carolina Department of Health and Human Services (Urban Institute, 2016). Partnered with Social Finance, the focus on the NFP in South Carolina are outcomes that will yield payments include reducing preterm births, reducing child hospitalization, increasing birth spacing, and targeting first-time mothers in zip codes with high levels of poverty (SCDHHS, 2016).

WORKFORCE AND EDUCATION

Reforms in workforce development (see Chapter 3) and education (see Chapter 10) are required to support the nursing profession in markedly expanding and strengthening roles and functions needed to address SDOH and advance health equity. Achieving those reforms will require financial investment to incentivize and support nursing education programs responsible for educating nurses to make the necessary changes.

Diversifying the Nurse Workforce

As discussed in Chapter 3, a diverse workforce helps reduce health disparities. Nurses from diverse racial, ethnic, and socioeconomic backgrounds are more likely to work with diverse, underserved communities and provide culturally tailored care (IOM, 2004). This includes financial support to diversify the workforce and create opportunities for students who otherwise would not have the resources to fund their education.

Income share agreements (ISAs), a type of pay-for-success program, provide tuition assistance for the education and training of nurses to help diversify the workforce. ISAs are especially useful for low-income nursing students. For many individuals, the nursing workforce pipeline often begins in community colleges and in associate’s degree in nursing (ADN) or LPN programs. Community colleges are frequently more affordable than 4-year public institutions¹² and serve a higher percentage of non-White students (Mann Levesque, 2018; NCES, 2020). However, students with large financial burdens often have difficulty bridging the gap between ADN or LPN programs and bachelor of science in nursing (BSN) education (NASEM, 2016). With ISAs, up-front costs of tuition are covered by private funders, and trainees are responsible for paying back the cost of their tuition based on their income. ISAs are predicated on students obtaining good jobs; when their income meets a minimum threshold, they begin paying back a fixed amount for a fixed term or until they reach a repayment cap (Social Finance, 2020).

Career impact bonds (CIBs) are a type of ISA specific to education investment that covers program costs and connects repayment to outcomes. As with ISAs, students are responsible for repayment only when they gain employment, at which point they begin repaying over a fixed duration or until they reach a repayment cap (Social Finance, 2020). Both ISAs and CIBs include such wraparound services as counseling and transportation subsidies.

Educating the Nursing Workforce About Social Determinants of Health and Health Equity

As noted in Chapter 10, RNs in public or community health or school health surveyed in the 2018 National Sample Survey of Registered Nurses said their performance in their roles would have benefited from more training in SDOH. For example, in addition to training in effective communication, shared decision making, and cultural humility when working with diverse populations (Foronda, 2020), nurses need training in screening for social risk factors, partnering with community-based organizations to address social needs, providing trauma-informed care, and understanding the underlying structural drivers of such inequities as structural racism and social privilege (Peek et al., 2020). Structural racism, for instance, is a reflection of the fact that inequities do not occur by chance but because of concrete decisions by government and private industry, as in the case of segregation of African Americans from Whites in housing, which resulted from zoning laws, the concentration of public housing, discrimination in mortgage loan practices, and preferential steering of clients to specific neighborhoods by real

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¹² There was a higher percentage of non-White students enrolled at public 2-year institutions (52 percent) than at 4-year public institutions (45 percent) in 2018 (https://nces.ed.gov/programs/coe/indicator_csb.asp [accessed June 3, 2021]).

estate agents (Rothstein, 2017). As discussed in Chapter 7, the ability of nurses to understand and address this history and its complex legacy will depend on faculty development, academic–practice partnerships, and other investments to create a quality education that includes a substantive, sustained focus on issues of SDOH and health equity.

Federal Government Programs

For many decades, federal government agencies, including HHS, the Veterans Health Administration (VHA), and the U.S. Department of Defense have supported general graduate medical education (GME), and in recent years, CMS has provided modest support for graduate nurse education (GNE). The VHA has a transition-to-practice nurse residency program for all new nurses entering their first nursing role, including new graduates of ADN, BSN, and entry-level master’s degree programs (VA, 2019). While the vast majority of HHS funding goes to physician medical training, HHS supports APRNs through a number of programs, including Advanced Nursing Education Residency, Nurse Faculty Loan, Advanced Nursing Education Workforce, and Nursing Workforce Diversity (GAO, 2019). The ACA supported a pilot program that funded residency training for APRNs, and CMS funded an evaluation of this program, but funding for this initiative was not continued. Additionally, training for nurses is hindered by a lack of preceptors and limited clinical placement sites that still persists (Copeland, 2020).

The 2016 National Academies report (NASEM, 2016) assessing progress toward the actions recommended in the 2011 The Future of Nursing report (IOM, 2011) does note an increase in diversity among younger nurses, a trend expected to continue into the current decade (NASEM, 2016) (see Chapter 3). Public and private payers can support diversification of the nursing workforce through focused recruitment and thoughtful hiring practices. The nursing pipeline can also be diversified through increased funding for educating nurses in SDOH and SDOH research, especially among nurse scientists from and with personal connections to underserved communities, and expanding nurses’ roles in advancing health equity (BCBSIL, 2019; FNU, 2017; HHS, 2011; Jackson and Garcia, 2014; NQF, 2017). Training programs within HRSA could be adapted to further incentivize diversification of the nursing workforce and improve training in addressing SDOH and advancing health equity (Strickland et al., 2014). HRSA provides grants to fund multiple health professional programs, six of which are focused on nurses. One grant specifically targets diversifying the nurse pipeline and workforce, while others target professional development. Between 2015 and 2019, HRSA provided more than 180 grants focused on nursing diversity (HRSA, 2020).

HRSA administers and oversees the Nurse Corps Loan Repayment Program (LRP) and Scholarship Program (SP), which provide an incentive for nurses to

work and serve in HPSAs. For the LRP, participants commit 2 service years to repay 60 percent of the outstanding principal and interest on their nursing education loans, with an additional 25 percent repayment for participants who work for a third year (HRSA, 2018a). However, the LRP and SP programs face challenges, such as a limited number of award recipients and low representation for some groups (HRSA, 2018a). In 2018, the number of applications for the LRP and SP programs was 7 times higher than the number of awards (7,833 applications versus 1,042 awards to residents of 49 states and the District of Columbia). In addition, only 7 American Indian/Alaska Native nurses, 40 Asian nurses, and 183 Black/African American nurses received LRP and SP awards, compared with 698 White nurses (HRSA, 2018a). Therefore, investing in similar programs is important for increasing the number of nurses with the proper education and training to provide care for underserved populations in critical shortage areas, including rural areas, and for people who need access to substance abuse disorder treatment (HRSA, 2018b).

The Indian Health Service (IHS) has resources that could potentially increase the diversity of the nursing workforce and the numbers of nurses working in rural areas, including Civil Service (IHS, n.d.), a 2-year post with the Commissioned Corps of the U.S. Public Health Service within IHS, and Direct Tribal Hire (IHS, n.d.). There are also programs that can award up to $20,000 per year toward health education loans, including the IHS Loan Repayment Program and Supplemental Loan Repayment Program, which can provide an incentive to enroll in nursing programs and complete nursing degrees.

One of the major factors limiting enrollment in advanced practice programs is the lack of preceptors, which is related to the paucity of federal funding for advanced nursing education relative to medical education. The GNE demonstration¹³ project authorized CMS to fund five hospitals to partner with clinical education sites, schools of nursing, and community-based care settings (CCSs), such as FQHCs and rural health clinics, with the goal of expanding clinical education for APRN students (Hesgrove et al., 2019; HHS, 2018). CMS made reimbursements to the five GNE sites annually for 3 years between 2012 and 2015. Each site, including hospitals, schools of nursing, and CCSs, was designated as a “network” and used the funding in various ways, including hiring clinical placement coordinators; creating or supporting administrative databases to oversee the clinical placement process; and implementing innovative education

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¹³ The Center for Medicare & Medicaid Innovation (CMMI) is responsible for developing and evaluating new payment models in health care and new service delivery models with the aim of lowering costs, improving the quality of patient care, and aligning systems with patient-centered practice (CMS, n.d.a). The five hospitals chosen for the GNE demonstration were the Hospital of the University of Pennsylvania in Philadelphia, Pennsylvania; the Scottsdale Healthcare Medical Center in Scottsdale, Arizona; the Duke University Hospital in Durham, North Carolina; the Rush University Medical Center in Chicago, Illinois; and the Memorial Hermann-Texas Medical Center Hospital in Houston, Texas (CMS, 2012).

models, such as interprofessional education, which allowed the APRN students to work alongside pharmacy, medical, and psychology students. Interprofessional education, recommended in the 2011 The Future of Nursing report (IOM, 2011) and reviewed in the 2016 report assessing progress toward the 2011 report’s recommendations (NASEM, 2016), improves medical students’ perceptions of nurses, team-based care, self-efficacy, and patient-centered care (Butterworth et al., 2018; Homeyer et al., 2018; Nash et al., 2018). The GNE demonstration project strengthened relations between hospitals and schools of nursing, increased APRN student enrollment and graduation (HHS, 2018), increased clinical education hours for APRN students, and ensured that at least half of those hours were in CCS. The project gave APRN students holistic experiences in engaging in team collaboration and addressing SDOH.

Despite these successful outcomes, however, many networks described the challenge of sustaining the GNE activities without funding in the post-demonstration years. Finite financial support for nursing education can stimulate APRN student growth for only a limited time. Sustainable funding would benefit future APRN trainees and CCS. Spending on overall GME from public organizations and private funders amounted to about $15 billion annually between 2011 and 2013 (IOM, 2014); in contrast, the GNE demonstration allocated only $50 million per year from a single funder, CMS. Funding for GNE is crucial in building the APRN pipeline for HPSAs both as providers and alongside physicians in teams.

CONCLUSIONS

Improving the health of the nation’s diverse population needs to be the primary goal of health care and its payment systems. Thus, payment systems need to be intentionally designed to support key nursing roles, including care management and team-based care, expanded scope of practice, community nursing, and telehealth, as well as diversification of the workforce and improved training in addressing SDOH and advancing health equity. Private insurers, governmental payers, policy makers, hospitals, health organizations, and social services agencies can incorporate health care and health equity into their fundamental goals and missions to help give all Americans the opportunity to attain better health and well-being. These important stakeholders can advance those vital goals by incorporating strategies that further leverage nursing, a powerful component of the health care workforce with expertise and presence across inpatient and community settings.

Nurses are critical to whole-person care. However, nurses cannot be utilized in new and developing roles if not supported by the health infrastructure at large. By supporting team-based care, improved communication, and proven interventions and strategies that can reduce health disparities (Chin et al., 2012; NASEM, 2016b), payment systems can enable nurses to make these essential contributions to improving care and outcomes for all individuals.

New payment models, such as ACOs, AHCs, and VBP strategies, can give health care organizations the flexibility to pursue these goals. For example, pay-for-performance strategies can reward successful efforts to address SDOH that impact population health, while capitation payments can support nurses who work with patients at social risk. Specific activities of nurses to address SDOH might include, for example, identification of social risks through routine screening; referral of individuals at social risk to community supports and services; regular communication and follow-up with individuals regarding their health; monitoring of individuals’ adherence to treatment; facilitation and coordination among providers, patients, and support services; and education and advocacy directed at public policy makers from the community to the national level with respect to addressing social needs and SDOH. It is essential for nurses to help shape and use opportunities created by new payment models to sustain and replicate models of care that support them in addressing SDOH and advancing health equity.

The 2016 National Academies report (NASEM, 2016) assessing progress toward the recommendations in the 2011 The Future of Nursing report (IOM, 2011) includes the recommendation to “promote the involvement of nurses in the redesign of care delivery and payment systems.” Nurses are strongly encouraged to collaborate with the public and private sectors to improve the health care delivery system. Other partners identified as facilitating redesign include retail clinics, insurance companies, professional groups and associations, and local government agencies. The present report strongly supports the recommendation that nurses participate in the redesign of care delivery and payment systems, particularly as they take on new functions and roles in health care and health equity.

Conclusion 6-1: To enable nurses to more fully address social needs and social determinants of health, improve population health, and advance health equity, current payment structures and mechanisms need to be revised and strengthened and new payment models intentionally designed to serve those goals. The current health care system does not value addressing social determinants of health.

School and public health nurses are valuable segments of the nursing workforce with great potential to help improve population health and health equity by intervening at early ages, focusing on prevention, and connecting with the community to understand and address social needs and SDOH. As content experts, schools and public health nurses are also valuable resources that can benefit nurses and other health care providers in other settings. Yet, those nurses are inadequately supported by current funding mechanisms.

Conclusion 6-2: Underfunding limits the ability of school and public health nurses to extend health care services and create a bridge between health care and community health. Adequate funding would

enable these nurses to expand their reach and help improve population health and health equity.

In addition, workforce and education policies greatly impact nurses’ roles and capabilities.

Conclusion 6-3: Payment mechanisms need to be designed to support the nursing workforce and nursing education in addressing social needs and social determinants of health in order to improve population health and advance health equity.

The United States spends a very large and growing amount of money on health care (CMS, 2020c), and these funds pay for very few services addressing social factors that negatively affect health and well-being, and do little to improve health equity so that everyone can have a fairer and better chance of living a healthier life. Until current payment systems include payment for services to address upstream social needs and SDOH that negatively affect health, the nation will continue to spend more on costly health care, depleting resources available for other important social, economic, and environmental programs (Butler, 2020; Horwitz et al., 2020; Squires and Anderson, 2015).

Changing the way the nation pays for health care will cause discomfort among some, but will also stimulate those who seek innovative ways of maximizing the population’s health.

REFERENCES