The Door of Last Resort: Memoirs of a Nurse Practitioner

2. Health Care: Perspectives from the Street Level

25 Health Care Perspectives from the Street Level Chapter 2 At the Philadelphia’s Mary Howard Health Center, my primary care practice deepened with immersion into the health care reimbursement system . Credentialed as a primary care provider by Keystone Mercy Health Plan and Health Partners, I became reimbursable. No longer a billable externality along with laundry management, my services to my Medicaid patients were reimbursed to the Public Health Management Corporation , the owner of a network of nurse-managed health centers in the city. With an administrative infrastructure emulating ambulatory physician practices embedded in manicured suburban landscapes, these federally qualified health centers are financially sustainable facilities. Caring for homeless patients at Mary Howard forced me to take a position on the value dualism deeply embedded in the U.S. delivery system: care of patients versus management of disease. Caring for patients from their standpoint, I intensified my definitions to include the possibility of negotiation and compromise at every turn. How risky to practice primary care with the patient at the wheel. How liberating to abandon disjuncture. Demands by insurance payers swirl at the boundaries of my practice. We are to focus solely on patients’ chief complaints rather than their stated health needs.We are to follow the paramount mantra: No Margin, No Mission! Yet such demands themselves reveal the underutilization of registered nurses in the system, providers with a capaciousness of skill untapped in primary care delivery. Framed in the door of a nursemanaged health center is a physician, stating with exasperation that you simply cannot do primary care in this place! My experiences proved him 26 The Door of Last Resort wrong, so very wrong. Balancing mission with margin, my work at Mary Howard helped me to understand nursing’s unique contributions to primary care. * As I walked down South Broad Street in Philadelphia in August 2010, wide sidewalks steamy with heat, I felt light, sure, confident. I had an appointment with Tine Hansen-Turton, JD, chief executive officer of the National Nursing Centers Consortium (the Consortium for short), an organization of nurse-managed health centers serving vulnerable people across the country. The Consortium , headquartered in Philadelphia, is housed on the eighteenth floor of the Atlantic Building at 260 South Broad Street, just two blocks from City Hall. (A neighboring historic building—the Bellevue-Stratford, built in 1904—houses the Independence Foundation, a private, not-for-profit philanthropic organization also involved with nursing centers.) The Atlantic Building, located in the city’s arts district, was constructed in Art Deco style in 1923. A twenty-onestory building historically at full occupancy, it is a site for sophisticated, discerning businesses eager to claim an address in this landmark reminiscent of modernism. On the corner of Spruce and South Broad Streets, one can smell steaks sizzling on pans in Ruth’s Chris Steak House, a restaurant on the first floor of the Atlantic Building. The aroma permeates the entrance to the building during the early afternoon and evening hours. By Jewelers’ Row No margin, no mission, Tine told me emphatically during my visit. Her message was consistent: the nurse–managed model of care must be sustainable; nurse practitioners need to focus, focus, focus, on reimbursement issues, policy, and politics. The chief executive officer of the Consortium since 1998, Tine grew nurse-managed health centers from 11 to over 250 nationally in a little over ten years. In 2010, the Consortium’s budget was over $6.5 million. Tine is good with money; she is also skilled at establishing and sustaining relationships. The Consortium is an affiliate of the Public Health Management Corporation (PHMC), a nonprofit public health institute founded in 1972. Also headquartered on the eighteenth floor of the Atlantic Building, PHMC and its staff work closely with the Consortium on health and human services projects, given their congruent missions and goals. PHMC’s administrative structure and tax status facilitate the operation of nursing centers as federally qualified health centers, a designation critical to sustainable care to underserved people. The ties between Health Care: Perspectives from the Street Level 27 PHMC and the Consortium provide a partnership that is wonderfully conducive to taking advantage of opportunistic ventures, which is important to nurse practitioners. Together, the Consortium and PHMC evaluate health services provided in the centers, creating an evidence-based portfolio used to match services to needs, reduce costs, and improve health indices of the patients they serve. Of critical importance...