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In Colorado, Health Care Law Creates Nurse-Run Clinic

Nurse practitioner Emily Burke examines a patient at Sheridan Health Services in Sheridan, Colorado.

In a low-income suburb of Denver, Erica Schwartz and her small staff of advanced practice nurses have set up their own primary care facility. Here, they can provide services ranging from managing diabetes and prenatal care to treating depression — all for less than it costs to run a primary care clinic with a doctor in the house.

“The caring component of nursing is palpable when you walk into the center,” she said. Everyone on staff, from the reception desk to the exam room, spends a lot of time getting to know their patients, from their mental health needs to their blood glucose level.

Sheridan Health Services opened in March with a $1.5 million grant, spread out over three years, from the federal health care reform law. It’s one of first centers in the country to open under the law. The funding is part of an effort to increase the availability of primary care services nationwide by opening more clinics staffed and managed by nurse practitioners, not doctors.

That’s because primary care doctors are in short supply these days. According to the Association of American Medical Colleges, there will be a shortage of 45,000 primary care doctors in the next decade, and they expect nearly one-third of all physicians will retire in that time.

And the Sheridan community has been in need of care. Almost 23 percent of women in the community receive no prenatal care during pregnancy. Chronic conditions like diabetes and cardiovascular disease contribute to high mortality rates in the area. The suicide rate for the area is also higher than the national rate.

With more than 15,000 people in the service area living below the poverty line, and 33 percent of the adults in the community uninsured, Sheridan Health Services provides care on a sliding fee scale. A visit co-payment may be as little as $5, but that doesn’t include any lab work or medications. In their first month, they’ve seen 200 patients.

With few insurance payments to rely on, Schwartz is making every penny of that grant stretch. Sheridan Health Services is housed in a long, narrow building, located across the street from the Colorado Mental Health Institute. The building used to house mentally-ill patients, but traces from the old facility have been covered over. Volunteers have re-painted the rooms and the hallways to erase the old institution-green, and kid-friendly “Dora the Explorer” art hangs on the walls.

Erica Schwartz is the founder of Sheridan Health Services, one of the first nurse-managed clinics to open under the federal health reform law. She hopes the clinic and others like it will help improve the health outcomes for low-income communities.

Much of the equipment in the clinic, from medical supplies down to the desks, was donated or provided at a reduced cost. Schwartz shows off the conference room, where leather desk chairs bear the seals of different states, an inexpensive find at a local sale.

But the biggest source of savings in nurse-managed care is more simple: nurse practitioners have lower salaries than doctors, said Schwartz, and they can provide many of the same services. In Colorado, advanced practice nurses are capable of providing much of the same care a physician can, including writing prescriptions.

Emily Burke, family nurse practitioner at the clinic, said their philosophy towards integrated care is another advantage of this nurse-run clinic.

“I would say I get to do more of the psychosocial piece of it, and recognizing that people are not just their bodies and their quality of life [is more than] just their blood glucose level,” she said.

And Burke said she thinks that nurse practitioners do a good job of knowing when they don’t know enough to diagnose on their own. There is a family physician who donates two days of his time each week to come to Sheridan as a consultant for cases beyond the staff’s expertise.

According to Dr. Mike Pramenko, president of the Colorado Medical Society, remote rural areas of the state are in desperate need of primary care providers of all training levels, and that includes doctors.

“This is only part — emphasis on part — of the solution,” he said. “[When] you’re out in pioneer settings, it’s a different story.”

Colorado has not given physicians many incentives to practice in these remote communities, according to Pramenko. By state law, health insurance providers cannot discriminate between compensation for an advanced practice nurse and compensation for a physician in rural areas, meaning primary care physicians might get paid at a lower rate than they did before. A bill currently in the state senate would expand this parity to practices throughout the state.

Steve Holloway, primary care director at the Colorado Department of Public Health and Environment, said as provisions from the federal health care law continue to take effect, the state expects to reduce its number of uninsured patients by two-thirds. Since more people will be eligible for care, almost 200 more primary care doctors will be needed.

While the state is trying new programs to encourage nurses and physicians to practice in underserved communities, he says that non-physician providers like Sheridan Health Services are a very important part of filling the primary care gap.

“Generally speaking, adding primary care providers to a system reduces cost to the system overall,” he said. “Nurse practitioners spend more time with patients, and they are able to do that because of cost.” Physicians have a lot of economic drivers that require them to move on through primary care, which leads to spending less time with patients or simply leaving primary care practice for those with higher salaries in specialized fields.

Schwartz has recently applied for federally qualified health center status for the Sheridan clinic, which would prove it with access to more funding. She hopes that the extra funding will make the clinic more sustainable, allowing it to cover staff salaries and maybe even open a dental center and a pharmacy.

“With more primary care centers, ER visits reduce immediately,” she said. “Our goal is to improve outcomes for Colorado. That’s the focus.”

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