Comprehensive, team-based care and enabling services in NMHCs result in excellent outcomes for patients. Studies have shown that NPs provide high-quality primary care with outcomes similar to those of physicians (Mundinger et al., 2000; Lenz, Mundinger, Kane, Hopkins, & Lin, 2004). An evaluation of 11 NMHCs in Pennsylvania (funded by the Centers for Medicare and Medicaid Services) found that NMHCs also had higher patient retention rates and lower patient hospitalization rates when compared with similar safety-net providers (i.e., physician-managed community health centers) (Hansen-Turton et al., 2004, p. 5). NMHCs consistently receive high patient satisfaction ratings, with patients giving especially high marks in areas such as “being treated with respect” and “explaining things to you” (Benkert, George, Tanner, Barkauskas, Pohl, & Marszalek, 2007, p. 107).

In addition to providing services directly to clients, NMHCs also play an important role in health professions education. More than 85 nursing schools operate NMHCs that provide care to patients and enhance learning and practice opportunities for students and faculty (NNCC, 2009a). A member survey conducted by NNCC in 2009 found that the largest percentage of health professions students completing clinical rotations in NMHCs were bachelors-level nursing students (49% of all students), followed by masters-level NP students (22%) (NNCC, 2009b). These centers also provided clinical opportunities to students in associates degree and doctoral nursing programs. Also, hundreds of students in medicine, social work, pharmacy, and dentistry programs complete clinical rotations annually in NMHCs (Institute for Nursing Centers, 2008).

NMHCs are safety net providers for patients regardless of their ability to pay. About 35% to 40% of NMHC patients are uninsured (Institute for Nursing Centers, 2008). NMHCs use a sliding fee scale to collect payment from uninsured patients, but these contributions alone do not cover the actual cost of care. As a result, they rely heavily on charitable grants in order to make up the difference, which translates into greater year-to-year budget instability for many health centers. Lack of access to predictable governmental funding and inconsistent reimbursement from insurers compounds the problem, leaving hundreds of thousands of low-income and vulnerable patients throughout the country at risk of losing their primary source of health care.

Many NMHCs in the U.S. were initially launched with start-up grants from the Health Resources and Services Administration (HRSA) Bureau of Health Professions’ Division of Nursing. Recognizing the important role that NMHCs could play in providing clinical education placements for nursing students and faculty, the Division of Nursing funded NMHCs through its “special projects” program (King, 2008, p. 14). However, these grants were nonrenewable and many schools found themselves unable to identify and secure sustainable long-term funding once the grant period had ended. As a result, many NMHCs closed their doors after Division of Nursing funding dried up. Meanwhile, the remaining health centers focused on acquiring funding from private foundations and improving reimbursement from third-party payers, all with varying degrees of success.

A small minority of the surviving academic NMHCs have been able to achieve fiscal sustainability by becoming part of the FQHC program, administered by the HRSA Bureau of Primary Health Care (a separate administrative entity from the HRSA Bureau of Health Professions). However, this was not an option for many academic NMHCs. The fact that many NMHCs are affiliated with schools of nursing often prevents them from qualifying for FQHC program funding because they cannot meet the program’s governance requirements.¹ Inability to qualify for the FQHC program threatens the sustainability of NMHCs, because it prevents them from accessing the many benefits that the government makes available to FQHCs. For example, FQHCs are able to receive enhanced reimbursement for services provided to Medicaid beneficiaries. FQHCs were also able to qualify for special funding opportunities through the American Recovery and Reinvestment Act of 2009 (e.g., for capital improvement projects or increased staffing) that were unavailable to non-FQHCs. Without access to ongoing federal support (like that provided to FQHCs by the Bureau of Primary Health Care), NMHCs struggle to provide care to uninsured patients while remaining financially solvent.

Lack of access to federal funding is not the only barrier to NMHC sustainability. Although many patients seen by NMHCs are uninsured, a significant proportion has publicly-funded or commercial insurance that could provide reimbursement for services. Unfortunately, many insurers do not recognize NPs as primary care providers and will not reimburse them directly. A 2008 study of managed care policies conducted by NNCC found that only 53% of insurers credential NPs as primary care providers (Hansen-Turton, Ritter, & Torgan, 2008). While some of these restrictive insurer policies appear to be attributable to a lack of understanding about NPs’ ability to provide high-quality primary care to patients, the problem is compounded by confusing state regulations regarding the legal authority of NPs to work in NMHCs with off-site physician involvement (Hansen-Turton, et al., 2008). Even though NPs are able to serve as primary care providers in all 50 states, insurers are considerably less likely to recognize NPs as primary care providers when state laws contain language requiring physician “supervision” or “delegation” for NP practice (Hansen-Turton et al., 2008). As a result, many NMHCs are not reimbursed by insurers for the care that they provide to patients, and they are less able to attract insured patients who could offset the cost of providing care to the uninsured. Recognizing that insurer policies like these result in fewer primary care access points for patients, lawmakers in Massachusetts recently passed new legislation requiring insurers to contract with NPs as primary care providers, which could serve as a model for other states (Craven & Ober, 2009).

There are a variety of state laws and policies that can impact NMHCs and their ability to serve patients (Ritter & Hansen-Turton, 2008). Because they are managed and staffed by advanced practice nurses, scope of practice, licensing, and physician collaboration laws can all have a big impact on care provided in NMHCs. Meanwhile, state laws regarding managed care insurers can either encourage or discourage patients from selecting a NMHC as his or her primary care home. In addition, some state governments with an interest in improving health care have made additional funding and other resources available to primary care practices through “medical home” demonstration projects and other quality improvement initiatives. These initiatives may or may not include nurse-led models.

One example of a recent effort that provided additional support and recognition for NMHCs is Pennsylvania Governor Edward G. Rendell’s Prescription for Pennsylvania health reform plan (Hansen-Turton, Ritter, & Valdez, 2009). Launched in 2006, this multifaceted policy initiative was designed to increase access, reduce costs, and improve health care quality by implementing an array of strategies touching a broad cross-section of the health care industry (including insurers, hospitals, providers, and others) (Commonwealth of Pennsylvania, 2009). Some of the first components of Prescription for Pennsylvania to be implemented successfully were three bills designed to improve the practice environment for NPs, certified nurse midwives, and clinical nurse specialists. These laws removed long-standing barriers to efficient advanced nursing practice by granting NPs the authority to order home health and hospice care, granting certified nurse midwives prescriptive authority, and, for the first time, defining the specific education and training requirements needed to practice as a clinical nurse specialist (Hansen-Turton et al., 2009, p. 9). In subsequent years, the Governor’s Office of Health Care Reform also spearheaded efforts to implement a medical home pilot project in southeastern Pennsylvania that is inclusive of nurse-led practices, and also inserted language into its Medicaid managed care Request for Proposals (RFP) encouraging insurers to better utilize NPs and other non-physicians in their provider networks (Pennsylvania Department of Public Welfare, 2008). Although they have not removed all barriers to independent advanced nursing practice, this combination of cost-effective policy efforts, driven by both the executive and legislative branches and championed by Governor Rendell throughout his tenure, has made it easier for NMHCs in Pennsylvania to continue providing care to low-income and vulnerable patients.