The Stubbornness of Facts

The excruciating debt-ceiling debate and final 74-page agreement once again underscored the root conflict between both parties in Congress—the degree to which government should involve itself in our societal problems. While it is unclear what will happen with health reform, it is clear that the “supercommittee” will become an unexpectedly powerful force. It has been given broad and binding authority to make decisions on how to cut the budget. On the table are programs such as the $86 billion CLASS act, an innovative alternative to financing long-term services and support, in which once a person gets two activities-of-daily-living limitations, funding is provided for aging-in-place, ie, in the home/community rather than nursing home. Trimming this program would shave $86 billion. The $15 billion Preventive Health Fund designed to fight obesity, reduce smoking, and promote better nutrition is also vulnerable to being pared down. A small cut in federal funding could obstruct plans for cash-strapped states to build robust healthcare exchanges. These reductions matter.  The debt-ceiling deal puts major provisions of the Affordable Care Act on the chopping block as well as across-the-board budget reductions.

We can expect more hand-to-hand combat as the Obama administration defines benefit packages in the coming months. The next giant step in the implementation of health reform has stakeholders from every corner of health care trying to influence the definition of an “essential health benefits package.” That decision is expected sometime late this year or early in 2012, after the Institute of Medicine makes its recommendations.

Advocates of all types are offering input to the Department of Health and Human Services (HHS) on how the benefits design should be structured and what it should—or should not—include. It’s not known how specific HHS will be in defining an“essential” benefit. Some experts warn that being too detailed may drive up the costs of insurance policies, and it is unclear to what degree states will be able to define their own benefits in their exchanges. The reform legislation creates 10 categories of essential benefits that every insurer in the nation must cover by 2014, including ambulatory patient services, emergency services, hospital visits, prescription drugs, and lab services.

As stakeholders position themselves to influence the details of health reform, it is in this context that the advanced-practice registered nurse (APRN) organizational structure could be far more unified. There are multiple organizations representing the four APRN roles—one each for clinical nurse specialists, nurse midwives, and nurse anesthetists and at least eight representing nurse practitioners (NPs). In 2008, the last time the feds collected data, there were 251,000 APRNs in the United States, and the number is rising rapidly each year.¹ To be sure, these groups do gather and meet and share occasional policy agenda efforts; however, the cohesion is not one of solidarity, not nearly to the degree that it could be. In order to act as a cohesive force for APRNs, in order to become stronger patient advocates, it will be our job to form our own faction, to provide stronger leadership that is infused with evidence, clarity, and certitude about our rightful place in health care, and to not accept the limitations others try to impose on us. Moreover, if we were more united, we could more forcefully and publicly advocate for patients by engaging in the debate and infusing evidence on what must constitute a minimal benefits package—what we know must be included in health insurance coverage. It is clear from the debt-ceiling debacle that the loud and the well organized get listened to in our democracy.

It is within this milieu that, on a steaming hot Washington morning this past July, two hugely important articles on APRNs were released that came to different but complementary conclusions. This will not be news to us who have been wholly committed to advanced-practice nursing for some or all of our adult lives. Or, as my husband joked, these findings are so obvious and seemingly common knowledge that they should be published in the “American Journal of Duh”!

Newhouse and colleagues published the long-awaited “Advanced practice nurse outcomes 1990-2008: A systematic review”² in Nursing Economic$. After reviewing 69 published studies, the authors concluded that APRNs have care outcomes equal to or better than those of physicians. NP outcomes measured included patient satisfaction, perceived health status, functional status, lipids, blood pressure and glucose control, emergency department visits, duration of ventilation, hospital length of stay, and mortality. The authors concluded that APRNs provide effective and high-quality patient care and have an important role in patient care in the United States. These findings should force physician groups who oppose APRN practice on the basis of patient safety to find another drum to beat. This definitive study casts a bright light on the well-known fact that APRNs can safely shore up the healthcare provider supply in anticipation of 32 million more people being swept into the ranks of the insured in 2014.

In a second publication, “Gaps in the supply of physicians, advance practice nurses, and physician assistants,”³ Sargen and colleagues build the case that healthcare reform will create a surge in demand, even as physician shortages widen and APRNs and physician assistants (PAs) play larger roles. The objective of the study was to assess the capacity of this combined workforce to meet the future demand for clinical services. Projections were constructed to the year 2025 for the supply of physicians, APRNs, and PAs. If training programs for APRNs and PAs grow as currently projected but physician residency programs are not further expanded, the aggregate per capita supply of APRNs and PAs will remain close to its current level, which will be 20% less than the demand in 2025. The authors conclude that the nation faces a substantial shortfall in its combined supply of physicians, APRNs, and PAs, even with the implementation of aggressive training scenarios, and deeper shortages if a surge in the supply is not achieved. The authors recommend stronger efforts to expand the output of clinicians in all three disciplines, while also strengthening the infrastructure of clinical practice and facilitating the delegation of tasks to a broadened spectrum of caregivers and new models of care.

The policy implications of these two studies suggest that there is no question of APRN safety and quality—and we need more APRNs. Even as most of us work in fee-for-service models focused almost entirely on disease and illness rather than wellness, we still appear to be practicing in a manner that is different and sometimes more effective than our physician colleagues. These two studies can help us amplify with certitude and volume the case for making APRNs central to healthcare delivery and removing unnecessary barriers.

Health reform has made a change in our delivery system—a reimagining of health care—a high priority. It is clear from these studies, as well as the 4 decades of research on the quality and safety ofAPRNs, that policymakers must remove restrictions on APRN practice and reimbursement schemes must be modernized to promote innovative models of care. Healthcare reform is creating an urgency to promote APRNs as providers who are used to the full extent of their education. At the very least, billing practices must indicate the actual provider of care, ie, NP, certified nurse midwife, clinical nurse specialist, certified registered nurse anesthetist, PA, or physician. A more lofty and pressing need is for all four APRN roles to merge their political power into a single strong voice because of a persistent fact that bears repeating—the loud and the organized get listened to in our democracy.

Health care in the United States is a state of transition. NPs need to be informed about several areas of healthcare reform.

The accountable care organizations (ACOs) that Medicare will launch in January of 2012 are being developed with highly specific language. From the big picture standpoint, the Centers for Medicare & Medicaid Services (CMS) is projecting savings from the program of $510–$960 million over a 3-year period. It is clear that there will be considerable start-up costs, ie, around $1.74 million to start and operate an ACO in year one! However, an ACO can recoup those costs and take in considerably more money if outlays for the care of beneficiaries are well below its yearly spending target, while achieving a good  enough quality score. Conversely, ACOs will have to pay penalties when they exceed their spending targets. It is still bewildering why CMS published rules excluding NPs from leading ACOs. These rules are in no way final, and we can only hope that the ACO model will be broader and encourage more practice innovations and APRN-lead initiatives. Each ACO has to enroll at least 5,000 Medicare beneficiaries for whom it coordinates care and monitors quality while also striving to become more efficient. The ACO must score well enough on 65 measures of quality to justify receiving any savings—after all, spending less to provide treatment is no accomplishment if quality is watered down. The measures will apply to five “quality domains”: the patient’s experience of care, care coordination, patient safety, preventive health, and the health of at-risk or frail populations. ACOs will be measured on factors such as ensuring timely appointments, how well providers communicate with patients, hospital readmission rates, surgical infections, and blood pressure management. Care must be evidence-based and will rely heavily on electronic medical records to reduce unnecessary testing, avoid medication errors, report on the 65 care measures, and monitor patients to make sure they are taking their medicines and getting the appropriate preventive care.

Who will do all of this? Enter the APRN! It seems that APRNs would be well suited to be central players in ACOs. We APRNs must take a keener interest in how healthcare reform gets rolled out. We all work in health care and have a common interest in the success of ACOs. This innovation is a way of avoiding perpetual fee-for-service payment cuts to providers; it addresses poorly-coordinated, fragmented care and directly attempts to stem the tide of rising healthcare costs.

As part of the reform efforts to make insurers more accountable and to protect patients, US health insurance companies must fully cover women’s birth control and other preventive healthcare services under the Obama administration rules released in August. A product of health reform, the guidelines require insurers to do away with copayments on coverage of preventive-care services for women in all new plans, beginning in August 2012. These preventive care services include:

“Under the law, we’re making it illegal to charge women more just because of their gender,” Health and Human Services Secretary Kathleen Sebelius said when the rules were released in August. The rules are expected to create a surge in demand for health care since 34 million women age 18–65 will be in plans covered by these rules. Public comment will be received and the ruling finalized this autumn.