Insurance companies block nurse care

Two of Colorado’s largest insurance companies refuse to pay for their clients to see independent advanced practice nurses in urban areas even though some patients want to see them and the care would cost less.

Advanced practice nurses say the insurance companies, Anthem Blue Cross and Blue Shield of Colorado and Rocky Mountain Health Plans, are protecting doctors in a “turf war” instead of focusing on what’s best for patients and allowing free market choice.

Nicole Snelgrove, 35, has insurance through Anthem Blue Cross and Blue Shield of Colorado and has chosen to spend more than $700 out of pocket to see Deanna Tolman, an independent nurse practitioner and owner of Head2Toe HealthCare in Aurora. Snelgrove said Tolman spent considerable time with her to diagnose a complex stomach ailment that has sickened Snelgrove for years. Six months ago, Tolman confirmed that Snelgrove suffers from a condition called sphincter of oddi dyskenesia and referred her for surgery. Snelgrove now says she feels much better.

“It’s a rare diagnosis. It took a lot of time to figure it out,” said Snelgrove, who said no other medical provider had worked with her to determine what was wrong.

She and her husband will switch to UnitedHealthcare in January precisely because Anthem Blue Cross refuses to “empanel” advanced practice nurses, who like Tolman, practice in urban areas.

“It’s incredible and ridiculous that they’d rather I go to some clinic where I have no continuity of care and have no one following me for my health problems rather than coming here,” Snelgrove said.

Anthem Blue Cross allows her to get care at places like The Little Clinic in King Soopers, where, ironically, she would see a nurse practitioner, just not one who owns an independent practice.

Snelgrove, who in August started doing some medical billing work for Tolman, said she and her husband have sent several letters and pleaded with Anthem Blue Cross to change their policies.

“We have somebody who would be more cost-effective for them and is still providing better care and yet, they won’t let us see her. They haven’t budged one bit in two years,” Snelgrove said.

Insurance companies: nurses not needed

Joyzelle Davis, a spokeswoman at Anthem Blue Cross and Blue Shield of Colorado, which provides health insurance to nearly 1 million Coloradans, says there is no need for additional providers in urban areas. Managers at Anthem Blue Cross were not willing to answer questions regarding advanced practice nurses. At Rocky Mountain Health Plans, a spokeswoman said that the company’s “standard of care is to provide the best possible access to physicians.”

“It has been our policy not to empanel independent APNs in urban areas as we have access to a comprehensive network of licensed physicians in such locations. In geographic areas where access to a physician is limited and there are independent APNs available, we would, and do, consider empanelling them,” Melissa Bashara, director of marketing and corporate communications for Rocky Mountain Health Plans said in a written statement.

Rocky Mountain covers about 211,000 people throughout Colorado.

In rural areas, Anthem Blue Cross and Blue Shield also routinely allows patients to see independent advanced practice nurses, who won the right to operate nurse-run primary care practices in Colorado in 2008.

Nearly all other insurance companies — including UnitedHealthcare, Aetna, CIGNA and Humana, now allow Colorado patients to choose providers including advanced practice nurses. The nurses receive about 85 percent of the pay that doctors do for each patient they see.

The federal Affordable Care Act also includes funds to support nurse-run care. And with provider shortages projected across the country, the influential Institute of Medicine in 2010 issued a report urging more independence and a greater role for advanced practice nurses as health coverage expands in the U.S. Acomprehensive review of 30 years of studies on advanced practice nursing published last fall in Nursing Economics found that advanced practice nurses provide effective and high quality care.

Nurses continue to battle

Despite these endorsements and the need to cut costs in health care, nurses continue to battle.

Independent nurses say HCA-owned HealthONE, which operates the largest network of hospitals in the Denver area, will admit their patients, but refuses to accept follow-up orders for care such as physical therapy. Leslie Horna, a spokeswoman from HealthOne did not follow up with Solutions to explain HealthONE’s policies regarding independent advanced practice nurses.

Colorado’s public health insurance program for low-income kids, CHP+, also bars patients from seeing independent advanced practice nurses, but the state is considering reversing that policy.

“Historically there hasn’t been a need to ‘credential’ advanced practice nurses or nurse practitioners because there have been a sufficient number of physician providers in the CHP+ service areas,” said Marc Williams, a spokesman for the Colorado Department of Health Care Policy and Financing.

Williams said all providers need to be credentialed by the state managed care network in order to accept, treat and bill clients.

“However, with health reform and the need to provide services to potentially hundreds of thousands of new patients, we are looking to add advanced practice nurses to the state managed care network as credentialed providers.”

Williams said all CHP+ providers receive the same negotiated fees, so the state would not save money by using more nurses.

Advanced practice nurses have special training — ranging from a master’s degree to a doctorate — and provide primary care like family physicians and internal medicine doctors. Despite what they say is overwhelming evidence that they give good care and know when to seek consultations or refer patients for specialty care, the nurses say they’ve had to fight for legitimacy and that holdout insurance companies are simply protecting doctors.

“It’s a turf war. It’s power, money and control,” said Tolman, owner of Head2Toe. Tolman is a family nurse practitioner with a doctorate in clinical nursing from Columbia University.

Representatives from the Colorado Medical Society did not return calls seeking comment. While many physicians and advanced practice nurses work cooperatively, the Colorado Medical Society unsuccessfully sued to prevent nurse anesthetists from working in rural areas, so there’s a history of sparring.

Tolman, 58, says she spends considerably more time with her patients than the average doctor. She books 90 minutes for the first appointment and about 30 to 60 minutes for follow-up care. Every week, she gets calls from patients who have insurance through Anthem Blue Cross. She’s happy to see them, but tells the patients they must pay expensive out-of-network charges or a $59 upfront charge to see her.

Dawn Fetzko is an adult and geriatric advanced practice nurse who owns a clinic called Colorado Primary Care Clinic http://www.cpcci.net/default.html in an underserved area of north Aurora. She has been fighting since she opened the doors of her solo practice 2 1/2 years ago to become a recognized provider through Rocky Mountain and Anthem Blue Cross.

Both Fetzko and Tolman say employees at the insurance companies have berated them and hung up during phone calls when they have repeatedly asked to be empanelled.

“It’s almost like they’re bullying us,” said Fetzko, who is mystified about why insurance companies would want to block providers. “There are plenty of sick people to go around.”

The spokeswoman from Rocky Mountain declined to comment on employees hanging up on the nurses saying she didn’t have enough information. Davis, the Anthem Blue Cross spokeswoman, said their managers have certainly had conversations with advanced practice nurses, but that they vigorously denied hanging up on them or being rude.

“That’s not how we conduct business,” Davis said.

Advanced practice nurses fill gap for Medicaid patients

The nurses say access to care is also a vital issue.

Many low-income patients complain that they can’t find providers who will see them. Both Fetzko and Tolman said they’ll see anyone who walks in their doors. While nurse-managed clinics are a new model in Colorado, they estimate at least a half dozen are operating in the Denver area and they say advanced practice nurses are providing critical care in communities from Pueblo to Durango.

Fetzko cares for a high percentage of low-income people and deliberately located in her practice on East Mississippi Avenue in Aurora so patients could easily take the bus to see her. About 60 percent of her patients are on Medicaid and about 25 percent are on Medicare. The rest either have private insurance or pay out of pocket.

She sees better use of independent nurses as cost-effective.

“The whole name of the game is to try to save money for patients while providing good care,” said Fetzko who was a critical care nurse in hospital ICUs for 15 years and already had a master’s in nursing administration before she decided to go back to school to become a nurse practitioner. Fetzko is currently working toward her doctorate and has a state-of-the art office with electronic health records and access to specialists.

“I’m alone, but not isolated. I have a network of providers if I need consultations.”

Steve Holloway is director of the primary care office for the Colorado Department of Public Health and Environment. He primarily focuses on improving access to care for people who don’t have health insurance of for those who have Medicaid, but can’t find a provider who will accept it.

Holloway said advanced practice nurses have a track record of caring for Medicaid patients when others won’t.

“In rural parts of the state, nurse-led practices have been pretty effective at supplementing more traditional delivery,” he said.

Evidence also shows that advanced practice nurses refer patients to specialty care more often than primary care doctors.

“That’s probably reflective of their own sense of their scope of practice,” Holloway said. “That’s pretty good evidence that nurse practitioners don’t necessarily practice beyond the scope of their skill set.”

Holloway said one of the best models links advanced practice nurses with physicians.

“The view from our office is that that’s the best possible model. It’s not that nurses can’t provide good care. The collaborative relationship with a physician who has more training and education allows for better management of patients,” especially those with multiple diseases and complex health problems.

Viewing patients in the context of their lives

Danyel Nelson is one of Fetzko’s loyal and satisfied patients. She says Fetzko always answers the phone and that she can almost always get same-day appointments. Nelson says Fetzko spends considerable time with her analyzing her health in the context of what’s happening in her life.

“Dawn makes me feel like I’m her only patient,” said Nelson, who is on Medicaid.

 

Nelson, now 38, suffered from a mini-stroke called a TIA at age 35 after the birth of her second child.

On top of that health challenge, Nelson, like many of Fetzko’s patients, has experienced major stresses that affect her health. Her late husband, Robert Nelson, was Fetzko’s patient first. He was suffering from pancreatic cancer when a neighbor assaulted him and he died last July.

Nelson came to see Fetzko this week on the day of the sentencing.

“She should be a therapist,” Nelson said as she hugged Fetzko after her exam.

Fetzko and Tolman say the nursing model is more broad and aims to view patients in the larger context of their lives.

Tolman had a patient, for instance, who was having spasms in her neck. She needed physical therapy, but wasn’t getting it because she had a 7-month-old and didn’t have a babysitter. Tolman called a friend from her church who lived near the woman and was able to find a trusted caretaker who could babysit for the patient. Problem solved.

“Doctors are trained to see a problem, diagnose it and get it treated. There’s very little training on how the patient is going to manage that treatment.”

The women contend that advanced practice nurses have an important role to play.

“We believe that everyone has a right to health care and the health care of their choice from any licensed provider. We are licensed and qualified to be primary care providers. There is ample evidence to support that case,” Tolman said. “If the insurance companies admit us, their patients will have the broadest access to primary care and we think they should do that immediately.”

404