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something about Mary |
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something about Mary |
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by
Christina Sponselli When was the last time you saw a group of nurse practitioners in your provider directory? A year ago, the Columbia Advanced Practice Nurse Associates persuaded several New York insurers not only to list CAPNA in their directories, but also to reimburse its NPs at the same rate as physicians. The program is the brainchild of Columbia University School of Nursing Dean Mary Mundinger, DrPH, RN, FAAN, who has convinced several insurers that their overall costs will be reduced by having NPs do what they do best: help patients understand their health conditions, adopt healthier lifestyles, and seek preventive care. So far, the practice has about 300 patients with nearly two dozen being added each month. Contrary to CAPNA’s initial research, its patients are not Generation X-ers, but 40-somethings with chronic conditions who are disenchanted with the healthcare system. And rather than steal patients from physician colleagues at Columbia, CAPNA is tapping into a new market—less than 10 percent of CAPNA patients have ever seen a Columbia physician. After a Robert Wood Johnson fellowship on Capitol Hill in the mid-1980s, Mundinger returned to New York and went to work as assistant medical school dean at Columbia. Soon after, she was asked to take over as the acting dean of the nursing school. She initially declined the job, but later accepted with the condition she have an office in the medical school, which is across the street from the nursing school. "I took a little office over there so I could be hanging around where everybody talks by the coffee machine," she said. Although Mundinger no longer has an office in the medical school, "that doesn’t mean I don’t go over there and visit my colleagues on a regular basis to make sure they know what I’m up to," she said. Mundinger’s political education began 20 years ago in a small New York hospital when she began fighting for the professionalism of nurses. NurseWeek spoke with Mundinger in San Francisco in June.
A: I wanted to put in place this new model, primary nursing. It was a way for a hospital and a nurse to really operationalize professionalism. For example, if I were the primary nurse, I wouldn’t be there 24 hours a day, seven days a week, but I would be there five of those shifts, 20 in a month. I would determine what all the other caregivers would do for that patient, even in my absence. Because I felt that it was a very accountable position, I didn’t feel that we could ask nurses to do that unless they were full time. Most of the nurses in the hospital were part time. But when this model came along, all of a sudden all kinds of nurses found they could work full time.
It was expensive for the hospital because they had to start having yearly pay increases and benefits. It also meant that the nurses who qualified for these positions were more likely to have a baccalaureate degree than an associate degree or diploma, so they qualified for higher salaries too. Because of the higher cost, and because the doctors didn’t like it, the hospital asked me to dismantle it and take it back down to some level of team. I understood they were going to do it, but I couldn’t do it. Q: What did you learn from this? A: Primary nursing was expensive, but I didn’t think to evaluate it. Did it save money for the hospital in the end? Were we making a difference that would balance the cost of salary and benefits of these nurses? Q: When did you realize you needed to analyze the cost? A: After I left. I had to do a lot of thinking about why did I not succeed with this, and I realized that the physicians were the ones who were really going to be upset by a new authoritative group. Nurses who had stood up and given them their chairs and gotten them their coffee were all of a sudden saying, "These are my patients too, doctor, and I need this to happen for them." I should have known physicians were the major stakeholders in that hospital. I should have worked with them to understand what I was trying to do, why it was good for them, why their patients would like it, and how we could do it together, which is what I’ve done here with some success at Columbia. Q: What things did you do when planning CAPNA? A: We made sure that it was going to benefit the people whom we needed to support us. For instance, we were much closer to three other medical centers in New York than we were to Columbia Presbyterian, but I made sure that when we began the idea for CAPNA that we would refer all our patients to Columbia physicians. I purposely and honestly put this together so there wouldn’t be any losers, among the people who had authority in my world, by this pilot succeeding. Q: Who is paying the CAPNA practitioners’ salaries? A: The school [Columbia University School of Nursing] is paying their salaries and taking the full risk for this practice. I’m betting that we’re going to be self-sustaining within two years. That’s our business plan. Our school is very unusual. We’re completely autonomous financially. I have to bring in all of the money to run the school, and I pay all the bills to the university. There are no subsidies to the school of nursing, none. Therefore, if I want to invest money in something and I want to make the leap of faith that it’s going to pay off, I make sure everybody knows about it. I don’t want any surprises that could cause the administration to think we’re a little on edge and reign us in. But the financial piece is entirely in my lap. So if it fails, I’m responsible for that. Q: Where did you learn the basic skills of reading a spreadsheet and understanding finances? A: got a doctorate in health policies, so I did some of these things in that program. I have always had male mentors, and a lot of them were in the business world, not in health care.
Q: How did you raise the money for CAPNA? A: I got a lot of corporate and foundation support. I got managed care to buy into this because they’ve taken such a hit in terms of reducing choice for patients. Here’s a new choice, and it won’t cost you any more. They don’t have to pay us more than they do doctors, and, of course, when they said, "Well, that wasn’t the issue, the issue was why shouldn’t I pay you less," I explained that to pay us less would put us in price competition with doctors and the doctors would hate them because there are a lot of studies that show if you pay 10 bucks less on your premium, you’ll switch providers. So I said, "You don’t want that to happen. You don’t want people coming to us because of $10 a month. You want to pay us exactly the same." There are two reasons Columbia physicians agreed to support CAPNA. One, they are really good, and they know they’re good. They get the best opportunities of any doctors in any medical center, so they weren’t worried about competition from us. Second, all of the chairmen of the departments are researchers and also manage practice plans of the doctors in their department. They understand that a role of an academic medical center is to test new ways of doing things, so they looked at what I was doing as a research project. Q: At the start of the CAPNA program, you said it was important for Columbia’s physicians to be sitting at the table and buying into this idea. A: It still is important because since we found patients with so much co-morbidity, we’ve used our referral sources to a great extent. We thought up front that we would not be simply stealing patients away from our Columbia colleague physicians. We thought we had a broader market scope than simply people who were in our medical center thinking they wanted to try a different provider. We’re funded for two years. But after one year, we’re going to do a satisfaction survey. We know the two things that are going to keep us in business. First, patient satisfaction, if they want to come to our practice after the novelty of trying us out wears off. Second, we must give the kind of wonderful care that we give, with lots of time spent with patients and not cost their insurer any more than if they went to a physician. If we’re going to be more expensive, managed care companies are not going to keep us in their directories. Q: Have you done any analysis?
We’re still hypothesizing that patients who use this style of service will, in the long run, incur fewer costs to the healthcare system because they’ll take on more preventive care, they’ll seek care early, and they’ll take on more of the new behaviors they need to stay healthy. It won’t necessarily show up in the first six months. But if these people stay with us, they may use fewer services than they did in the year before they came to us. Q: And will you publish your findings? A: Yes. We’ll publish the randomized control trial from our first practice this fall, and then a year and a half later, we’ll have our CAPNA results. Q: Where will you publish it? A: We haven’t submitted it yet, but I hope in a journal that lots and lots of people are going to read because it’s going to be good stuff. Q: Physicians, as well as nurses? A: That’s right—especially physicians. |
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Q:
You were director of education at a hospital in the ’70s and quit
your job over a difference of opinion with the administration. What
happened?
A:
We
haven’t done any analysis yet. We think our patients were heavy users
before they came to us, so our evaluation will be a retrospective
evaluation. We’ll look at those patients’ use of health care the year
before they came to us and the year after they came.