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Policy and politics for nurses and other health professionals : advocacy and action [Third ed.]
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Table of contents :
Cover
Title Page
Copyright
Brief Contents
Contents
Acknowledgments
Preface
Contributors
SECTION 1 Introduction
Chapter 1 Nursing’s History of Advocacy and Action
Nurses as Advocates
Advocacy and Public Health Nursing
History and Political Advocacy
Nursing Strong
Conclusion
Chapter 2 Policy and Politics Explained
Introduction
Policy Defined: A Framework for Government Action
The Policy-Making Process
What Is at Stake for Nurses and Other Health Professionals?
Chapter 3 A Policy Toolkit for Healthcare Providers and Activists
Introduction
Stakeholder Power
Expertise
Conclusion
Toolkit Case Studies
SECTION 2 Population Health
Chapter 4 Population Health Care: Access, Cost, and Quality
Lessons from Nursing History on Vulnerability, Disparities, and Political Advocacy
The Face of Vulnerability Today
Vulnerability and Disparities from a Population-Based Perspective
Political Advocacy toward Health Equity
Conclusion
Chapter 5 Global Health: A Vision for Action
The Politics of Global Health in the United States of America
Conclusion
Chapter 6 Mental and Behavioral Health
Introduction to Mental and Behavioral Health
Federal Government and Presidential Efforts to Improve the Nation’s Mental Health
State-Related Mental Health Policies
City and Community-Directed Mental Health Care Efforts
Policies Encouraging Consumer-Directed Mental Health and Behavioral Health Services (The Recovery Movement)
Challenges in the Provision of Mental Health and Behavioral Health Services
Groups Requiring Additional Political Protection
Lower Socioeconomic Status–Related Mental Health Policies
Veterans’ Use of Mental Health Services and Policy Issues
Policy Innovations to Improve Mental Healthcare Outcomes
Ongoing Challenges: A Look to the Future of Policy Making in Mental Health and Behavioral Health
Summary
SECTION 3 Affordable Care Act: From Enactment to Sustainability
Chapter 7 Affordable Care Act (ACA) Reframed and Uncertain
Health Reform in the United States: Recent and Past History
Overview of the Patient Protection and Affordable Care Act
Financing Health Reform
Quality Improvement and Prevention Initiatives
Constitutionality
States and Health Reform
Key Issues Going Forward
Conclusion
Chapter 8 Healthcare Quality
Quality Care and Public Policy
Human Error
Patient-Centered Care
Error Measurement Tools
Agency for Healthcare Research and Quality
Patient Safety Indicators
National Database of Nursing Quality Indicators
National Error-Reduction Efforts
Public Quality Reporting Systems
Centers for Medicare & Medicaid Services
Conclusion
SECTION 4 Health Financing: Payers, Markets, and Models
Chapter 9 Healthcare Costs: Follow the Money
Health Care Is Different
Resource Allocation and Market Role
Cost—The Main Problem
Health Policy—ACA and Beyond
Conclusion
Chapter 10 Private Health Insurance Market
History of U.S. Health Insurance Reform
Health Insurance Plans
Employer-Sponsored Health Insurance
Health Insurance Exchange Marketplace
Laws and Regulations Impacting the Provision of Health Insurance
The Health Reform Changes Impacting Private Insurers
ACA and Its Impact on Employers
Private Insurance Industry Response to ACA
Health Insurance Legislative Changes on the Horizon
Opportunities for Nursing
Quality Patient Care and Care Coordination Strategies
Conclusion
Chapter 11 Medicare: Protector to Innovator
Introduction
Evolution of the Passage of Medicare: Timeline and Milestones
Current Medicare Structure
Overview of Medicare Spending
How We Pay for Medicare
Medicare Quality Improvement Organizations
The Future Outlook: The Way Forward
Conclusion
Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations: A Story of Misconceptions
Introduction
Health Outcomes in the United States in Relation to 10 Developed Nations
Populations Served by Original Medicaid
Original Medicaid Is Different Program in 50 States and Washington, DC
Traditional Medicaid Costs and Variation by State
ACA Medicaid
Who Is Left Out
Health Insurance and the Health of Vulnerable People
Chapter 13 Innovation for the Delivery System of the Future: Medical Homes, Accountable Care Organizations, and Bundled Payment Initiatives
Introduction
The Innovation Center: Promoting Care Delivery Models for the Future
Rationale for New Models
The Four Major Healthcare Service Delivery Models
Conclusion
SECTION 5 Health Care and Provider and Care Delivery
Chapter 14 Hospitals: Consolidation and Compression
Hospitals’ Role within the Delivery System
Hospitals in a Historic Context
Baseline Information
Challenges Facing the Community Hospitals
Hospital Strategies in a Competitive Market
The ACA and The Rationalization of Hospital Care
Healthcare Policy, Health Reform, and the Role of Hospitals
Chapter 15 Enhanced Primary Care Roles for Nurses and Other Professionals
Why Primary Care? The Case for Change
Overtreatment, Overuse, Waste, and Healthcare Harm
Support for Value-Based Care as a Bipartisan Approach
How Payment Reform Shapes Needs and Opportunities in Primary Care
What Skills Do Nurses Need in These Advanced Primary Care Settings?
Nursing Education
Mental Health
Dental Care
Conclusion
Chapter 16 Physicians: It Is Increasingly about the Team
Medical Professionalism
Physician Supply: Who Are the Doctors?
How Are Physicians Practices Organized and Reimbursed?
Physician Accountability
Medical Errors, Physician Practice, and the Barriers to Quality Care
Overcoming the Barriers to Quality Care
Conclusion: Choices and Interests
Chapter 17 Health Information Technology and the Intersection of Health Policy
Introduction
Federal Origin and Influence in Development of HIT
Nursing and Health Information Technology
Nursing Terminology and the Data of Nursing Care
A National Action Plan: The Macro Perspective on HIT
Nursing and the Electronic Health Record: The Micro Perspective on HIT
Health IT: The Intersection of Data Security and Health Policy
Conclusion
Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices
Origins of the Nursing Profession
Nursing Definitions: Past and Present
Nurses and Policy
The Nursing Workforce
Transforming the Care Delivery System
Pathways to Nursing as a Career Choice
Specialization and the Evolution of Nursing Roles
Current State of the Profession
Enhanced Nurse Licensure Compact
21st-Century Nursing: Evolving Roles for Nurses
Policy as a Tool to Influence Nursing Professionalism and Nursing
Conclusion
Legislative Resources
Federal Agency Sites
Other Related Sites
Index

Citation preview

Policyand Politics THI R D E D I T I O N

FOR NURSES and Other Health Professionals

ADVO CACY A N D ACT I O N Donna M. Nickitas, PhD, RN, NEA-BC, CNE, FAAP, FAAN Dean and Professor Rutgers University School of Nursing Camden, New Jersey Editor Nursing Economic$, The Journal for Health Care Leaders Pitman, New Jersey

Donna J. Middaugh, PhD, RN

Associate Dean for Academic Programs College of Nursing University of Arkansas for Medical Sciences Little Rock, Arkansas

Veronica D. Feeg

Associate Dean Barbara H. Hagan School of Nursing Molloy College Rockville Centre, New York

World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Copyright © 2020 by Jones & Bartlett Learning, LLC, an Ascend Learning Company Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Policy and Politics for Nurses and Other Health Professionals: Advocacy and Action, Third Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits VP, Product Management: David D. Cella Director of Product Management: Amanda Martin Product Manager: Rebecca Stephenson Product Assistant: Christina Freitas Production Editor: Kelly Sylvester Senior Marketing Manager: Jennifer Scherzay Product Fulfillment Manager: Wendy Kilborn Composition: S4Carlisle Publishing Services

Cover Design: Kristin E. Parker Text Design: Kristin E. Parker Rights & Media Specialist: John Rusk Media Development Editor: Shannon Sheehan Cover Image (Title Page, Part Opener, Chapter Opener): © Anthony   Krikorian/Shutterstock Printing and Binding: McNaughton & Gunn Cover Printing: McNaughton & Gunn

Library of Congress Cataloging-in-Publication Data Names: Nickitas, Donna M., editor. | Middaugh, Donna J., editor. | Feeg, Veronica D., editor. Title: Policy and politics for nurses and other health professionals : advocacy and action / [edited] by Donna M. Nickitas, Donna J. Middaugh, and Veronica D. Feeg. Description: Third edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2019] Identifiers: LCCN 2018028645 | ISBN 9781284140392 (paperback) Subjects: | MESH: Health Policy | Policy Making | Lobbying | Health Care Costs | United States Classification: LCC RA395.A3 | NLM WA 540 AA1 | DDC 362.10973--dc23 LC record available at https://lccn.loc.gov/2018028645 6048 Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1

© Anthony Krikorian/Shutterstock

Brief Contents Acknowledgmentsix Prefacexi Contributorsxiii

SECTION 1 Introduction1 Chapter 1

Nursing’s History of Advocacy and Action�������������������������3

Chapter 2

Policy and Politics Explained���������������������������������������������25

Chapter 3

A Policy Toolkit for Healthcare Providers and Activists�����������������������������������������������������������������������43

SECTION 2 Population Health

63

Chapter 4

Population Health Care: Access, Cost, and Quality�������������������������������������������������������������������������65

Chapter 5

Global Health: A Vision for Action�������������������������������������87

Chapter 6

Mental and Behavioral Health �������������������������������������� 105

SECTION 3 Affordable Care Act: From Enactment to Sustainability

135

Chapter 7

Affordable Care Act (ACA) Reframed and Uncertain�������������������������������������������������������������������������� 137

Chapter 8

Healthcare Quality���������������������������������������������������������� 165

iii

iv

Brief Contents

SECTION 4 Health Financing: Payers, Markets, and Models

185

 Chapter 9

Healthcare Costs: Follow the Money ���������������������������� 187

Chapter 10

Private Health Insurance Market ���������������������������������� 207

Chapter 11

Medicare: Protector to Innovator���������������������������������� 231

Chapter 12

Medicaid and the Financing of Care for Vulnerable Populations: A Story of Misconceptions������������������������ 255

Chapter 13

Innovation for the Delivery System of the Future: Medical Homes, Accountable Care Organizations, and Bundled Payment Initiatives���������������������������������� 279

SECTION 5 Health Care and Provider and Care Delivery

289

Chapter 14

Hospitals: Consolidation and Compression������������������ 291

Chapter 15

Enhanced Primary Care Roles for Nurses and Other Professionals�������������������������������������������������� 313

Chapter 16

Physicians: It Is Increasingly about the Team�������������� 341

Chapter 17

Health Information Technology and the Intersection of Health Policy������������������������������������������ 371

Chapter 18

Political Power of Nurses: Harnessing Our Values and Voices������������������������������������������������������ 403

© Anthony Krikorian/Shutterstock

Contents Acknowledgments�������������������������������������������������������� ix

SECTION 2  Population Health

63

Preface���������������������������������������������������������������������������� xi Contributors ���������������������������������������������������������������� xiii

Chapter 4 Population Health Care: Access, Cost, and Quality ����������65

SECTION 1  Introduction1

Lessons from Nursing History on Vulnerability, Disparities, and Political Advocacy�������������������������66

Chapter 1 Nursing’s History of Advocacy  and Action ������������������������������������3

The Face of Vulnerability Today������������������������������������69 Vulnerability and Disparities from a Population-Based Perspective���������������������������������73

Nurses as Advocates����������������������������������������������������������� 4

Political Advocacy toward Health Equity�����������������77

Advocacy and Public Health Nursing��������������������������� 6

Conclusion���������������������������������������������������������������������������81

History and Political Advocacy��������������������������������������� 9

Chapter 5 Global Health: A Vision for Action������������������������������������87

Nursing Strong�������������������������������������������������������������������11 Conclusion���������������������������������������������������������������������������13

Chapter 2 Policy and Politics Explained������������������������������������25 Introduction�������������������������������������������������������������������������26 Policy Defined: A Framework for Government Action�����������������������������������������������������26

The Politics of Global Health in the United States of America�����������������������������������������������������������������������89 Conclusion���������������������������������������������������������������������������98

Chapter 6 Mental and Behavioral Health��������������������������������������� 105

The Policy-Making Process���������������������������������������������31

Introduction to Mental and Behavioral Health�����������������������������������������������������������������������������106

What Is at Stake for Nurses and Other Health Professionals?���������������������������������������������������37

Federal Government and Presidential Efforts to Improve the Nation’s Mental Health �������������107

Chapter 3 A Policy Toolkit for Healthcare Providers and Activists ��������������������������������������43 Introduction�������������������������������������������������������������������������44 Stakeholder Power������������������������������������������������������������46 Expertise�������������������������������������������������������������������������������48 Conclusion���������������������������������������������������������������������������51 Toolkit Case Studies����������������������������������������������������������52

State-Related Mental Health Policies�����������������������109 City and Community-Directed Mental Health Care Efforts�����������������������������������������������������110 Policies Encouraging Consumer-Directed Mental Health and Behavioral Health Services (The Recovery Movement)�������������������111 Challenges in the Provision of Mental Health and Behavioral Health Services�����������������������������112 Groups Requiring Additional Political Protection�������������������������������������������������������������������������� 112 v

vi

Contents

Lower Socioeconomic Status–Related Mental Health Policies�������������������������������������������������������������113 Veterans’ Use of Mental Health Services and Policy Issues���������������������������������������������������������114 Policy Innovations to Improve Mental Healthcare Outcomes�����������������������������������������������115 Ongoing Challenges: A Look to the Future of Policy Making in Mental Health and Behavioral Health�������������������������������������������������������116 Summary�����������������������������������������������������������������������������118

SECTION 4  Health Financing: Payers, Markets, and Models

185

Chapter 9 Healthcare Costs: Follow the Money ������������������������������� 187 Health Care Is Different�������������������������������������������������188 Resource Allocation and Market Role ���������������������189 Cost—The Main Problem���������������������������������������������193

SECTION 3  Affordable Care Act: From Enactment to Sustainability135 Chapter 7 Affordable Care Act (ACA) Reframed and Uncertain������� 137 Health Reform in the United States: Recent and Past History�����������������������������������������������������������138 Overview of the Patient Protection and Affordable Care Act���������������������������������������������������145 Financing Health Reform ���������������������������������������������149 Quality Improvement and Prevention Initiatives �����������������������������������������������������������������������150 Constitutionality���������������������������������������������������������������150 States and Health Reform���������������������������������������������152

Health Policy—ACA and Beyond�������������������������������198 Conclusion�������������������������������������������������������������������������200

Chapter 10 Private Health Insurance Market ����������������������������������� 207 History of U.S. Health Insurance Reform�����������������208 Health Insurance Plans���������������������������������������������������209 Employer-Sponsored Health Insurance������������������214 Health Insurance Exchange Marketplace���������������215 Laws and Regulations Impacting the Provision of Health Insurance���������������������������������215 The Health Reform Changes Impacting Private Insurers�������������������������������������������������������������216 ACA and Its Impact on Employers�����������������������������216 Private Insurance Industry Response to ACA �������218

Key Issues Going Forward���������������������������������������������153

Health Insurance Legislative Changes on the Horizon���������������������������������������������������������������������������219

Conclusion�������������������������������������������������������������������������157

Opportunities for Nursing��������������������������������������������219

Chapter 8 Healthcare Quality ����������������� 165

Quality Patient Care and Care Coordination Strategies�����������������������������������������������������������������������220

Quality Care and Public Policy �����������������������������������166

Conclusion�������������������������������������������������������������������������222

Human Error�����������������������������������������������������������������������167 Error Measurement Tools ���������������������������������������������172

Chapter 11 Medicare: Protector to Innovator��������������������������� 231

Agency for Healthcare Research and Quality�������172

Introduction�����������������������������������������������������������������������232

Patient Safety Indicators�����������������������������������������������173

Evolution of the Passage of Medicare: Timeline and Milestones�����������������������������������������233

Patient-Centered Care���������������������������������������������������171

National Database of Nursing Quality Indicators�����������������������������������������������������������������������173

Current Medicare Structure�����������������������������������������236

National Error-Reduction Efforts��������������������������������174

Overview of Medicare Spending�������������������������������241

Public Quality Reporting Systems�����������������������������176

How We Pay for Medicare���������������������������������������������241

Centers for Medicare & Medicaid Services�������������177

Medicare Quality Improvement Organizations���������������������������������������������������������������242

Conclusion�������������������������������������������������������������������������178

Contents

vii

The Future Outlook: The Way Forward���������������������243

Baseline Information�������������������������������������������������������294

Conclusion�������������������������������������������������������������������������247

Challenges Facing the Community Hospitals�������298

Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations: A Story of Misconceptions��������������������� 255 Introduction�����������������������������������������������������������������������256 Health Outcomes in the United States in Relation to 10 Developed Nations�����������������������257 Populations Served by Original Medicaid �������������259 Original Medicaid Is Different Program in 50 States and Washington, DC�������������������������������260 Traditional Medicaid Costs and Variation by State���������������������������������������������������������������������������261 ACA Medicaid�������������������������������������������������������������������265 Who Is Left Out�����������������������������������������������������������������266 Health Insurance and the Health of Vulnerable People�������������������������������������������������������267

Chapter 13 Innovation for the Delivery System of the Future: Medical Homes, Accountable Care Organizations, and Bundled Payment Initiatives ������������� 279 Introduction�����������������������������������������������������������������������280 The Innovation Center: Promoting Care Delivery Models for the Future �����������������������������280

Hospital Strategies in a Competitive Market���������301 The ACA and The Rationalization of Hospital Care ���������������������������������������������������������������������������������303 Healthcare Policy, Health Reform, and the Role of Hospitals���������������������������������������������������������306

Chapter 15 Enhanced Primary Care Roles for Nurses and Other Professionals������������������������� 313 Why Primary Care? The Case for Change���������������315 Overtreatment, Overuse, Waste, and Healthcare Harm���������������������������������������������������������315 Support for Value-Based Care as a Bipartisan Approach�����������������������������������������������������������������������317 How Payment Reform Shapes Needs and Opportunities in Primary Care�������������������������������318 What Skills Do Nurses Need in These Advanced Primary Care Settings?�������������������������324 Nursing Education�����������������������������������������������������������329 Mental Health�������������������������������������������������������������������331 Dental Care�������������������������������������������������������������������������331 Conclusion�������������������������������������������������������������������������332

Chapter 16 Physicians: It Is Increasingly about the Team��������������������� 341 Medical Professionalism �����������������������������������������������342

Rationale for New Models��������������������������������������������281

Physician Supply: Who Are the Doctors?���������������343

The Four Major Healthcare Service Delivery Models����������������������������������������������������������������������������281

How Are Physicians Practices Organized and Reimbursed?�����������������������������������������������������������������348

Conclusion�������������������������������������������������������������������������286

Physician Accountability�����������������������������������������������353 Medical Errors, Physician Practice, and the Barriers to Quality Care�����������������������������356

SECTION 5  Health Care and Provider and Care Delivery289 Chapter 14 Hospitals: Consolidation and Compression������������������� 291 Hospitals’  Role within the Delivery System�����������292 Hospitals in a Historic Context�����������������������������������292

Overcoming the Barriers to Quality Care���������������356 Conclusion: Choices and Interests�����������������������������358

Chapter 17 Health Information Technology and the Intersection of Health Policy ������������������������������������� 371 Introduction�����������������������������������������������������������������������372 Federal Origin and Influence in Development of HIT�������������������������������������������������������������������������������373

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Contents

Nursing and Health Information Technology�������378

Transforming the Care Delivery System�����������������415

Nursing Terminology and the Data of Nursing Care�����������������������������������������������������������������380

Pathways to Nursing as a Career Choice�����������������416

A National Action Plan: The Macro Perspective on HIT�����������������������������������������������������381 Nursing and the Electronic Health Record: The Micro Perspective on HIT���������������������������������382 Health IT: The Intersection of Data Security and Health Policy �������������������������������������������������������383 Conclusion�������������������������������������������������������������������������391

Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices������������������������������������� 403

Specialization and the Evolution of Nursing Roles���������������������������������������������������������������������������������419 Current State of the Profession�����������������������������������419 Enhanced Nurse Licensure Compact�����������������������421 21st-Century Nursing: Evolving Roles for Nurses�����������������������������������������������������������������������421 Policy as a Tool to Influence Nursing Professionalism and Nursing ���������������������������������425 Conclusion�������������������������������������������������������������������������427 Legislative Resources�����������������������������������������������������427 Federal Agency Sites�������������������������������������������������������428 Other Related Sites���������������������������������������������������������429

Origins of the Nursing Profession �����������������������������405 Nursing Definitions: Past and Present ���������������������406 Nurses and Policy�������������������������������������������������������������407 The Nursing Workforce �������������������������������������������������413

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449

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Acknowledgments It is with sincere appreciation and gratitude that we would like to acknowledge the many individuals, including family, friends, professional colleagues, and students, who have made this third edition possible. Special thanks go to those professional nurses who have gone before us paving the way by being stewards of the discipline, advocates, and activists in promoting nursing, public health, and policy. As the editors, we are profoundly grateful to continue in their footsteps, fulfilling our promise to safeguard the health of society and ensuring that future generations of nurses recognize how health and public policy are instrumental to their education and practice. To my co-editors, Donna J. Middaugh and Veronica D. Feeg, your enduring friendship, mentorship, and insight have made this book possible. With your profound trust and unwavering commitment, this third edition is offered in the ongoing quest to ensure all nurses harness the power within and bring their voices and values to the bedside, boardroom, classroom, and halls of Congress to promote policies that educate and inform the public about what nursing is, not just what nurses do. We also would like to acknowledge the superior oversight and dedication of Tricia Plummer, our team administrator, who help coordinate all the essential activities that made this third edition such a seamless success. Tricia, your professional skills and support were greatly appreciated. To my husband, Michael, whose love, presence, and encouragement has allowed me to fulfill

my professional hopes and dreams. Thank you for making this such an exciting journey and always believing all things are possible. To my children, Nick, Lili, Kate, Luke, and JP, your joy and love have fueled my energy and enthusiasm to live my life by the words of Mahatma Gandhi: “Keep your values positive because your values become your destiny.” Always be positive and be an example so that others may follow. — Donna M. Nickitas To my husband Robert and our son Robert Guy, who have awakened my soul and are my inspiration in everything I do. They have taught me to love unconditionally, enjoy life, live with purpose, take risks, and strive for excellence. Robert Guy: You have become such a compassionate, dedicated nurse! We are so proud of you! Also, to the memory of my mother, ­Alpha Duff, a teacher, who taught me to never stop learning. — Donna J. Middaugh To my husband Alan, you are my rock and my enabler. You have always given me space to do what makes me happy and wings to make me soar into new endeavors without fear of failing. You make the days easy for me to be productive in my own way. You give me understanding when I’m unraveled; you give me comfort when I need it most; you give me love in all you do. To my daughter, Kelly, you are my sun and the light of my life. You have become my teacher and my sage with your wise guidance and words

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of wisdom. You provide me with creative inspiration in my work by modeling it in yours. To my mother, Mary, and in memory of my dad, Americo “Red” DeCarolis, you both nurtured my passion for learning and supported me unconditionally and financially throughout

my years in college. You may not have finished high school but you always valued the importance of education. — Veronica D. Feeg

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Preface Sally S. Cohen Why this book? Why now? Nurses and other health professionals have many textbooks on health policy to choose from. Donna M. ­Nickitas, Donna J. Middaugh, and Veronica D. Feeg’s third edition of Policy and Politics for Nurses and Other Health Professionals has distinct features that make it a wise investment for faculty, ­students, and others seeking concise, expert, and useful information on how to understand and influence health policy. First, the editors have carefully chosen the most salient issues on government agendas and not overwhelmed readers with the plethora of all possible health policy issues around us. This is critical in order to make health policy meaningful to and within reach of students and clinicians who can be quickly overwhelmed by the world of health policy. Second, this edition’s addition of case studies is of tremendous benefit. Based on decades of teaching health policy at all levels of nursing education and to interdisciplinary and interprofessional groups of students and faculty, I am convinced that policy case studies are essential. They offer faculty options for innovative assignments and discussions that encourage students to write or speak about health policy in a nonjudgmental context. The case studies, which are strategically placed within the chapters, offer real-life scenarios. These scenarios typically have more than one possible solution to a policy problem. Case studies also: (a) facilitate discussions about policy problems, (b) teach students to articulate significant themes in health policy, (c) require synthesis of valid evidence, and (d)

demonstrate the importance of political analyses. The editors have wisely included more than one case study in some chapters to demonstrate how one policy can be applied to many different situations or issues. The third advantage of this text is that the editors have a well-honed vision of what health professionals need to know in an era of continually shifting public policy sands. Nickitas, Middaugh, and Feeg’s third edition is based on the premise that health professionals need to be as nimble in government arenas as they are in clinical settings. Moreover, they recognize that this entails linking local, national, and global health issues because of their inherent interconnectedness. With media and technology enabling rapid dissemination of information, the editors have provided content and case studies that encourage effective communication using online resources. Some of these issues primarily apply to individuals and populations with access to the Internet and other technologies. Nurses and other healthcare providers recognize that vast parts of the world lack such resources. People in such locales are struggling to find clean water, eradicate severe hunger, and prevent common and new infectious diseases. Moreover, the geopolitical terrain has become increasingly complex as war, terrorism, and natural disasters strike across the globe. The realities of climate change and environmental health risks make the sweeping differences in allocation of resources between the “haves” and “have nots” an ever-present challenge for health professionals. These global challenges are in contrast to other public health issues, including the proliferation of noncommunicable xi

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Preface

conditions such as obesity, cardiac illness, and mental health and behavioral problems (especially substance abuse and addictions). Nickitas, Middaugh, and Feeg wisely address the diversity of these issues by including chapters on global and population health as integral to the text—and not as “add-ons” at the end. By addressing poverty and other socioeconomic causes of health problems, they acknowledge the importance of health policy beyond the doors of the clinic or hospital. Similarly, they frame the chapter on physicians as an issue of interprofessional teamwork, instead of trying to present physicians or any other professional as separate components of the healthcare delivery system. By emphasizing the importance of team care, they have minimized

the risk of readers engaging in the familiar and useless “physician–nurse” games. Will this text endure forever? No health policy text can meet that challenge. However, given the complexity of health policy and the significant problems of teaching it to nurses and health professionals, this third edition of Policy and Politics for Nurses and Other Health Professionals can facilitate teaching and learning across diverse settings and student populations. In the health policy and education arenas, which can be characterized by considerable disagreement and little consensus as players vie for scarce resources, this text is a winner and one that can bring players together as they find common ground in addressing the global and local issues on which people’s lives and well-being depend.

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Contributors Nancy Aries, PhD Professor of Social Policy School of Public Affairs Director of Baruch Honors Programs Baruch College The City University of New York New York, New York Steven Baumann, PhD, APRN-BC, RN Professor Hunter College Hunter-Bellevue School of Nursing New York, New York Claudia J. Beverley, PhD, RN, FAAN Professor (Secondary), Department of Health Policy and Management Professor College of Nursing Professor (Secondary) College of Medicine Director, Arkansas Aging Initiative, Donald W. Reynolds Institute on Aging University of Arkansas for Medical Sciences Little Rock, Arkansas Linda Bradley, MSN, MPH, PHCNS-BC Assistant Professor New York City College of Technology Brooklyn, New York Pennie Sessler Branden, PhD, CNM, RN, CNE Barbara Caress Senior Consultant Service Employees International Union New York, New York

Ellen Chesler Senior Fellow Roosevelt Institute New York, New York Barbara Cohen, PhD, RN Professor of Health Services School of Health Studies Berkeley College New York, New York Wesley Cook, DNP(c), APRN, FNP-BC, CPSN Nurse Practitioner Washington, DC Brigitte Cypress, EdD, RN, CCRN Associate Professor East Stroudsburg University Department of Nursing East Stroudsburg, Pennsylvania Patricia Eckardt, PhD, RN Molloy College Rockville Centre, New York Veronica D. Feeg, PhD, RN, FAAN Associate Dean and Director PhD Program in Nursing Molloy College The Barbara H. Hagan School of Nursing Rockville Centre, New York Stephanie Ferguson, PhD, RN, FAAN, FNAP Consulting Associate Professor Stanford University Stanford, California Founder, President, and Chief Executive Officer Stephanie L. Ferguson Associates, LLC Amherst, Virginia

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Shirley Girouard, PhD, RN, FAAN Professor and Associate Dean College of Nursing SUNY Downstate Medical Center Brooklyn, New York Valerie Gruhn Doctors Without Borders/Médecins Sans Frontières Joyce Hahn, PhD, RN, APRN-CNS, NEA-BC, FNAP Associate Professor School of Nursing George Washington University Washington, DC Christine Hancock Director C3 Collaborating for Health London, United Kingdom Lauran Hardin, MSN, RN-BC, CNL Senior Director Cross-Continuum Transformation National Center for Complex Health and Social Needs Camden Coalition of Healthcare Providers Camden, New Jersey Olga S. Kagan, PhD, RN Eileen Levy, RN, PhP Nurse Practitioner at NSLIJ Huntington Hospital Huntington, New York Sandra B. Lewenson, EdD, RN, FAAN Professor College of Health Professions Lienhard School of Nursing Pace University Pleasantville, New York Jennifer E. Mannino

Donna Middaugh, PhD, RN Clinical Associate Professor Associate Dean for Academic Programs Coordinator, Nursing Administration Masters Specialty College of Nursing University of Arkansas for Medical Sciences Little Rock, Arkansas Geraldine Moore, EdD, RN Molloy College Rockville Centre, New York Lois Moylan, PhD, RN Molloy College Rockville Centre, New York Donna M. Nickitas, PhD, RN, NEA-BC, CNE, FAAP, FAAN Dean and Professor Rutgers University School of Nursing Camden, New Jersey Editor, Nursing Economic$, The Journal for Health Care Leaders Pitman, New Jersey Betty Rambur, PhD, RN, FAAN Routhier Endowed Chair for Practice Professor of Nursing University of Rhode Island Kingston, Rhode Island Roby Roberston, PhD Professor Emeritus School of Public Affairs University of Arkansas – Little Rock Little Rock, Arkansas Yael Rosenstock Director of Programming Center for Ethnic, Racial, and Religious Understanding CUNY New York, New York Nancy Rudner, APRN Professor of Nursing George Washington University Washington, DC

Contributors

Janice A. Selekman, DNSc, RN, NCSN, FNASN Professor School of Nursing University of Delaware Newark, Delaware Brenda Helen Sheingold, PhD, MBA, BSN, FNAP Assistant Professor Director Health Care Quality Graduate Programs George Washington University Washington, DC

Marie Truglio-Londrigan, PhD, RN Professor College of Health Professions Lienhard School of Nursing Pace University Pleasantville, New York Ralph Vogel, PhD, RN Clinical Assistant Professor College of Nursing University of Arkansas for Medical Sciences Little Rock, Arkansas

Lisa Sundean, PhD, RN Assistant Professor Department of Nursing University of Massachusetts, Boston Boston, Massachusetts

Helen Werner, PhD, RN Assistant Professor Program Coordinator, Upper Division Monroe College School of Nursing Monroe, New York

Joel Teitelbaum, LLM Associate Professor Department of Health Policy and Management Milken Institute School of Public Health George Washington University Washington, DC

Sara Wilensky, PhD Faculty Milken Institute School of Public Health George Washington University Washington, DC

Anh Phuong Tran, BSN, RN-BC, ONC Adult Health Nurse Practitioner New York, New York

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SECTION 1

Introduction CHAPTER 1

Nursing’s History of Advocacy and Action

CHAPTER 2

Policy and Politics Explained

CHAPTER 3

A Policy Toolkit for Healthcare Providers and Activists

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1

CHAPTER 1

Nursing’s History of Advocacy and Action Sandra B. Lewenson and Donna M. Nickitas

OVERVIEW The American Nurses Association (ANA) reminds nurses of the social contract between nurses and the public that “reflects the profession’s long-standing core values and ethics, which provide grounding for health care in society” (American Nurses Association [ANA], 2010, p. 10). The ANA Social Policy Statement has articulated nursing’s social obligation since it was first published in 1980. Nurses turn to this document to understand how nursing fulfills this obligation by providing ethical and culturally competent care to individuals, families, communities, and populations. It also helps nurses explain their role in the larger society, to new members of the profession, and to nurses already working in the field. New position statements about inclusivity and diversity by the American Association of Colleges of Nursing (AACN) (2017) and the American Academy of Nursing (AAN) (2016) contribute to a sense of responsibility nurses share to fulfill the social obligation to society. The AACN (2017) states that “to have equitable systems, all people should be treated fairly, unhampered by artificial barriers, stereotypes or prejudices” (p. 173). It continues to address unconscious and conscious bias of which we as nurses must be aware to make a change. Advocacy includes, and if not, should include, the notion of inclusivity and diversity. This chapter explores political advocacy in light of nursing’s role and responsibility to advocate for and act on behalf of those for whom nurses have contracted to provide care. The first section of the chapter explains why nurses need to know history to be effective advocates and why knowing history matters to advocacy. It provides historical exemplars to highlight how history informs the profession as it continues to invoke the social contract that nursing maintains with society. The second part of the chapter examines a more contemporary look at nursing’s political advocacy efforts and what it means for nurses, the profession, and the health of the public at large.

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4

Chapter 1 Nursing’s History of Advocacy and Action

OBJECTIVES ■■ ■■

■■

▸▸

Discuss why nursing history is relevant to health policy and nursing advocacy and action. Explore historical exemplars that provide evidence of nursing’s ability to advocate for individuals, families, communities, and populations. Analyze nursing’s role in how political advocacy impacts nurses, the profession, and the health of the public at large.

Nurses as Advocates

Although society reportedly trusts nurses to work toward accomplishing the goals set forth for them by the profession (ANA, 2010), nurses may not be grounded in how they reached these “long-standing core values” that the nursing profession developed over time. As nurses advocate for their patients—whether seen as individuals, families, communities, or ­populations— an understanding of nursing’s enduring and long-standing values that are rooted in its history provide depth and breadth to their efforts. To this end, it is important to know nursing’s historical role in ensuring access to care; it is important to know nursing’s contributions toward patient quality and safety measures; it is important to know how nursing interventions changed over time in response to the context in which nurses practiced; and it is important to know how nurses and the profession adapted to shifts in the social, political, economic, and cultural environment (D’Antonio & L ­ ewenson, 2011). Fairman (2017) writes that “our past shapes everything we do, whether we explicitly acknowledge it or not” (p. xi).

Why Study Nursing History? Historian and nurse educator Ellen Baer and colleagues respond to the question of why nursing history should be studied: Just as a nurse can make little progress caring for or curing a patient’s presenting problem without knowing the patient’s physiological, psychological, and cultural

history so is it for a nurse trying to make sense out of the persistent problems and possibilities in nursing and health care. To make right decisions in planning nursing’s future in the context of our complex health-care system, nurses must know the history of the actions being considered, the identities and points of view of the major players, and all the states that are at risk. These are the lessons of history. (Baer, D’Antonio, Rinker, & Lynaugh, 2001, p. 7) Some lessons from the past that support the understanding of political advocacy and action can be learned by examining how Florence Nightingale influenced the development of nursing education programs that started in 1873, and led to what became known as the Modern Nursing Movement. It began with the first three United States Nightingale training schools: the Bellevue Training School for Nurses in New York City; the Boston Training School for Nurses at Massachusetts General in Boston; and the Connecticut Training School in New Haven, Connecticut. Following the opening of these three schools, hospitals around the country recognized the value that student nurses bring to the hospital because care could be provided at relatively low cost and the hospital would have no obligation to hire the nurses when they graduated. Nurses, after their training was complete, would need to find work elsewhere, typically in private duty or in the emerging field of public health nursing. Twenty years after the opening of these schools of nursing, early nursing leaders

Nurses as Advocates

recognized the need to organize nurses to control the quality of practice and training as a way to protect the public. Between 1893 and 1912, four professional nursing organizations formed to do just that: the National League for Nurses, formed in 1893 (originally called the American Society of Superintendents of Training Schools for Nurses); the American Nurses Association, started in 1896 (originally named the Nurses’ Associated Alumnae of the United States and Canada); the National Association of Colored Graduate Nurses, which formed to address racial bias in nursing and health care and was in existence between 1908 and 1952; and finally, in 1912, the National Organization of Public Health Nursing, formed to control practice and educational standards during the rising movement of public health and public health nursing in the United States. This organization ended in 1952 when the National League for Nursing assumed its role (Lewenson, 1993). Even before women in the United States gained the vote in 1920, nurses sought legislation that would define nursing practice, and they advocated for the protection of the public by prohibiting anyone who was not professionally trained from calling him- or herself a nurse. This required convincing lawmakers, at that time only men, to support nursing legislation; the nurses knew they could not vote into law the early nurse practice acts. While nurses struggled for statewide nursing registration, they had to “fight battles against long hours of work and opposition to nursing education” (­Lewenson, 1993, p. 171). To accomplish their goals, some nurses, either individually or through the early nursing organizations, began to support the work of the suffragist movement and aligned themselves with the larger women’s movement of the early 1900s. Individual nursing leaders, like public health pioneer Lillian Wald and nursing suffragist Lavinia Dock, advocated for healthcare reforms in the community and the legislative arena. The professional organizations that formed during this period did so to protect the public from uneducated nurses and to develop standards for nursing education and practice.

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Although an in-depth history of this p ­ eriod is beyond the scope of this chapter, it is important for nurses to understand that political advocacy was part of the profession’s early identity. Political advocacy and action in nursing are not new or innovative. Nurses have a­ lways been political advocates for those in their care (Lewenson, 2012). As a result, the early efforts made by nurses and their professional organizations provide a narrative for and insight into today’s advocacy efforts, where protection of the public means ensuring a level of education for all nurses, the development of quality and safety standards, and the ability of nurses to practice to the fullest extent of their education, as recommended by an Institute of Medicine report (2010).

History Counts Fairman and D’Antonio (2013) wrote, “history counts in health policy debates” (p. 346). Bringing a historical perspective to discussions about health care deepens our understanding of the issues by recognizing the evolution of ideas across time. In the debate about control of the “newly” minted medical homes of today, understanding the roles of early public health nurses in providing primary healthcare services to individuals, families, communities, and populations in both urban and rural settings can trigger some useful ideas or solutions about what to call the new entity, who should finance it, and who should lead it (Keeling & Lewenson, 2013). The current debate centered on medical homes provides such an example. The term was first coined in the 1960s and defined a medical model of care for chronically ill pediatric patients that looked at control issues, inter- and ­intradisciplinary issues of providing care, and the financial aspects of care. Physicians led the earlier medical home movement that has evolved to mean “a model of primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective” (American Academy of Pediatrics, 2002, as cited in Keeling & Lewenson, 2013, p. 360).

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Chapter 1 Nursing’s History of Advocacy and Action

Nurses use the words that define the medical home of today to describe nursing’s work of providing accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. Knowing the history of nursing serves to highlight the profession’s strong contribution to health care in the United States.

▸▸

Advocacy and Public Health Nursing

Exploring some of the public health initiatives that Wald established—the Henry Street Settlement and the American Red Cross Town & Country—offers excellent examples of how nursing, history, and political advocacy and action intersect. By studying the work of those nurses and nursing leaders within these settings, we not only learn about the role nurses played in primary health care (as described by Keeling & ­Lewenson, 2013), but we can also learn about the healthcare advocacy that public health nurses sought for those individuals, families, and communities. We also learn about the unconscious and conscious bias shared by society, including nurses, towards black nurses and the subsequent outcome that race played in healthcare outcomes. The next section uses these two early 20th-century public health initiatives as examples of political advocacy by public health nurses.

Advocacy at Henry Street Lillian Wald graduated from nurses’ training in 1891 from the 2-year diploma-based program at New York Hospital in New York City. Within 2 years of graduating, she and her school friend Mary Brewster recognized the overwhelming healthcare needs of immigrant families living in the overcrowded and unclean conditions of the tenement houses on the Lower East Side of New York City. Filled with a sense of social obligation to improve the health of society, Wald and Brewster began the Henry Street Settlement

and found support for the venture from philanthropists and other nursing leaders. Wald’s work expanded from just nine public health nurses working in one settlement house that was established in 1893 to more than 250 nurses working throughout the New York City area in at least seven different locations (Buhler-­Wilkerson, 2001; Keeling, 2007; Lewenson, 1993). The Henry Street Settlement was one of the few public health organizations to hire black nurses to care for black patients (Pitt-Mosley, 1996). This policy of inclusion did not exist in most healthcare settings, and discrimination was typically the order of the day, whether in the north or south or whether conscious or unconscious. While caring for the families, Wald saw a close relationship between the health of the public and civil responsibility. In a speech she delivered in 1900 at the sixth annual meeting of the American Society of Superintendents of Training Schools for Nurses, Wald said that “among the many opportunities for civic and altruistic work pressing on all sides nurses having superior advantages in their practical training should not rest content with being only nurses, but should use their talents wherever possible in reform and civic movements” (Wald, 1900, as cited in ­Birnbach & Lewenson, 1991, p. 318). In keeping with her beliefs, Wald and her colleagues at Henry Street introduced several legislative initiatives that would improve the health of children, such as the introduction of nurses in public schools (Wald, 1915). Wald (1915) described how she advocated for hiring nurses in the local public schools to decrease truancy rates, given that children were sent home due to illness and lack of treatment. As of 1897, physicians had only recently been hired by the New York City Department of Health to assess children in school. Doctors sent children home from school when any contagious illnesses were found. However, this did not address some of the pressing health issues because the physicians did not provide treatment for conditions such as trachoma, a contagious eye infection that plagued schoolage children at the time. Wald (1915) wrote about her experience convincing legislators of

Advocacy and Public Health Nursing

the value of assigning public health nurses in the schools in her book The House on Henry Street. In 1902, when a reform administration came into power, the medical staff was reduced, the physicians’ salary was increased to $100 per month, and they were expected to work only 3 hours per day. The health commissioner ordered an examination of all public school pupils and was horrified to learn of the prevalence of trachoma. Thousands of children were sent away from school because of this infection. Where medical inspections were the most thorough, the classrooms were empty. It was ironic that Wald watched the children who had been turned away from school playing with the children they had been sent home to protect. Few children received treatment, and it followed that truancy was encouraged: The time had come when it seemed right to urge the addition of the nurse’s service to that of the doctor. My colleagues and I offered to show that with her assistance few children would lose their valuable school time and that it would be possible to bring under treatment those who needed it. . . . I exacted a promise from several of the city officials that if the experiment were successful, they would use their influence to have the nurse, like the doctor, paid from public funds. Four schools from which there had been the greatest number of exclusions for medical causes were selected, and an experienced nurse, who possessed tact and initiative, was chosen from the settlement staff to make the demonstration. . . . Many of the children needed only disinfectant treatment of the eyes, collodion applied to ringworm, or instruction as to cleanliness, and such were returned at once to the class with a minimum loss of precious school time. Where more serious conditions existed the nurse called at the home. (Wald, 1915, pp. 51–52)

7

Within 1 month, the experiment was deemed successful, and an “enlightened Board of Estimate and Apportionment voted $30,000 for the employment of trained nurses, the first municipalized school nurses in the world” (Wald, 1915, p. 53). School nursing continues to be a concern for those interested in political advocacy to improve the health of our young and vulnerable populations. Historian Mary G ­ ibson (2017) writes that: Today’s philosophy still reflects the protective and hopeful beliefs of leaders in education of 100 years ago concerning the influence of child health on our nation’s future. . . therefore, keeping children in school, healthy and ready to learn, is a universal goal throughout the United States. (p. 37)

Advocacy in the Town & Country Wald’s advocacy extended to families living in rural settings. One of the most compelling examples is the establishment of the American Red Cross Rural Nursing Service (later known as the Town & Country). As Keeling and Lewenson wrote (2013), this organization “served as the point of contact for families in rural communities where remoteness, isolation, and fewer physicians and nurses created barriers to care” (p. 362). Wald believed that the American Red Cross—already organized to provide nursing services during wartime and natural or manmade disasters—was the right vehicle in which to organize public health nursing services throughout the country during peacetime (Dock, Pickett, Clement, Fox, & Van Meter, 1922; Keeling & Lewenson, 2013). Through Wald’s influence, philanthropists supported the implementation of this new rural public health nursing service. During the first year, criteria were established for nurses who would collaborate with community leaders, physicians, and families to provide both curative and preventive health care in rural settings. The requirements to become a rural public health nurse were far reaching and included

8

Chapter 1 Nursing’s History of Advocacy and Action

pragmatic skills. Nurses were expected to ride a bicycle or a horse, or drive a car so that they could access their patients.

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More important, and often difficult to find, were nurses who had an education that prepared them to negotiate and collaborate with others in the community. Typical nurses’ training programs did not provide these skills. It was determined that a minimum of a 4-month education was needed to prepare nurses to work independently in communities across America (American Red Cross Rural Nursing Service, 1912–1914). Educational programs were established, like the one at Teachers College in New York, in conjunction with the Henry Street Settlement and the rural District Nursing Service of Northern Westchester, soon after the American Red Cross Rural Nursing Service formed. By 1914, the new public health nurse curriculum offered courses in sociology, municipal and rural sanitation, and experiences in rural

and urban public health settings. These courses were valuable for nurses who practiced in rural settings because they did not have the same support systems as urban areas. Black nurses faced barriers to attending some of these early public health courses and, as a result, contributed to few entering this service. Frances Elliot Davis, a graduate of the Freedman’s School of Nursing in Washington, DC, did attend the 4-month program at Teachers College and was admitted as a Town & Country nurse in 1917. She was considered the first black nurse to be admitted into the American Red Cross (Hine, 1989; Lewenson, 1993). Influenced by the returning soldiers and the influenza pandemic in 1918, Davis, along with other black nurses, were finally accepted into the American Red Cross reserves at the end of World War I. The bias of the military and, subsequently, the American Red Cross, reared itself in several ways. One of the most blatant ways was the designation of race on each of these nurses’ badges, separating them from their white colleagues. Frances Elliot Davis received her badge with the number 1-A inscribed on the back. This was one way the Red Cross that served as the gatekeeper into the Army Nurses Corps could maintain the practice of segregated living quarters and segregated health care. The National Association of Colored Graduate nurses advocated changes in these practices that eventually ended by mid-20th century (Lewenson, 2017). Wald’s advocacy extended to the use of media to show the public what a rural public health nurse could do and to garner support for the initiative. While she was at the third meeting of the American Red Cross Committee on Rural ­Nursing—the committee established by the American Red Cross in 1912 to develop the criteria for the Town & Country—Wald suggested that the committee “get in touch with the Publication Syndicate, and Rural Nursing written up possible [sic] in story form for the Ladies’ Home Journal and other popular magazines” (American Red Cross Town & Country Nursing Service, 1913, p. 2). At the same meeting, it was noted that Wald and others supported establishing a relationship with the Metropolitan Life Insurance Company

History and Political Advocacy

and the Steel Corporation whereby the Rural Nursing Service would “undertake nursing for these large concerns” (American Red Cross Town & Country Nursing Service, 1913, p. 4). Many of the communities in question were rural mining communities that required public health nursing services. The committee believed this relationship would be beneficial in many ways, including possibly raising the standards of other nursing associations and economically supporting the cost of nursing supervision in these locations. Advocacy took many forms, which ranged from sitting on national committees to seeing that care was provided at local levels. The work of the public health nurse was framed by the needs of the community, the kinds of public healthcare organizations that were organized, and the geographical location. Each Red Cross rural nurse chapter—whether in the mountains of New Hampshire, in Kentucky, or in the West—directed the kinds of work that public health nurses would do, including bedside care for frostbite, well-baby clinics, school nursing, industrial nursing, classes in home hygiene and care of the sick, advocacy on town boards, and educational and publicity efforts about their work (Fox, 1921). Sometimes there was only one public health nurse in an area. At other times, public health nurses shared a district. Sometimes a nurse faced barriers by communities that were uncomfortable with outsiders offering care. The success of these American Red Cross Town & Country nurses relied on the ability to recruit and retain those who could handle the challenges of rural settings. This concern remained a constant and enduring problem throughout the life span of the American Red Cross Town & Country.

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History and Political Advocacy

Political advocacy requires the depth and breadth of an evolving historical narrative to inform contemporary debates in health care, to reflect the variety of perspectives that history can bring to

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the debate, and to offer a “way to think about the future” (Fairman & D’Antonio, 2013, p. 346). The work of the nurses at the Henry Street Settlement and the American Red Cross Town & Country gives two examples that can stimulate discussions about healthcare reform today. Readers are encouraged to explore the many historical studies being completed and the early writings of nurses that can be found in nursing journals, such as the American Journal of Nursing. This journal has digitalized its entire collection from 1900 to the present, allowing readers to access articles online and explore nursing advocacy over time. The American Association for the History of Nursing (AAHN) (www.aahn.org) also provides information and resources for where one can go to find nursing archives, learn more about historical methods, and attend the association’s annual meeting where the latest in historical research is presented. The AAHN also publishes a well-respected journal, Nursing History Review, where readers can find outstanding historical research by leading historians. There are also many archival centers around the country, such as the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania and the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry at the University of Virginia. Centers such as these provide a wealth of archival data and support for those interested in historical research. The websites for these centers and other resources are available on the AAHN website.

Nursing’s Political Advocacy and Action The next part of this chapter moves from the historical to the contemporary and further explores the meaning of advocacy and action, as well as what that means for nurses, the profession, and the health of the public. Today nurses must be politically active in professional nursing practice and health policy issues like the nurse reformers and activists before them. Nurses who can purposefully and effectively contribute to

10

Chapter 1 Nursing’s History of Advocacy and Action

shaping public policy at the national, state, and local levels serve both the public and the profession by advancing the nation’s health and professional practice. Nursing’s historical roots in important advocacy and action have shaped the profession’s political astuteness and work to keep pace with professional regulatory, s­ tatutory, and legal changes in education, practice, and research. The profession must remain nimble and responsive to policy changes by promoting and protecting the well-being of the population and nurses themselves. How can nurses have a profound influence on health outcomes? The answer is simple: We cannot afford not to. As long as the United States lags behind other developed countries in care outcomes, despite the fact that the U.S. spends more on health care— $3.2 trillion in 2015, up 5.8% from the year before (Centers for Medicare & Medicaid Services [CMS], 2015)—nurses need to advocate and act to promote health, prevent disease, and eliminate health disparities. Access to affordable, quality health care is a basic human right for all people (Daley, 2012). In 2010, Institute of Medicine (IOM), now known as the National Academies of Medicine, published its report, The Future of Nursing, which offered a blueprint for how the nursing profession should advocate to improve the health of the nation, lead change in healthcare delivery, and increase the educational preparation of the nursing workforce. This blueprint is evidence on how nurses uphold the dignity and well-­ being of society by revolutionizing how nurses can be change agents and leaders in developing healthcare delivery systems that will address health disparities and the social d ­ eterminants of health like education, p ­ overty, transportation, and housing. To effectively manage the ever-evolving healthcare delivery system, as well as the emerging needs of populations and the profession, every nurse must understand and appreciate his or her role in advocacy. Advocacy is the ability to use one’s voice and position to address, support, and protect the rights and interest of another (Zolnierek, 2012). The American Nurses

Association suggests that high-quality nursing practice include advocacy as an essential aspect of patient care (ANA, n.d.). Advocacy is considered both a philosophical principle of the profession and a part of ethical nursing practice that ensures that the rights and safety of the patient are protected and safeguarded. Advocacy is the one professional construct that demonstrates a complex interaction among nurses, patients, professional colleagues, and the public (Selanders & Crane, 2012). It is important to note that patients have rights and nurses have a legal and moral obligation to protect those rights. As patient advocates, the ANA Code of Ethics for Nurses with Interpretive Statements (2015) offers nurses a moral framework to help shape their values to direct and influence actions so as inspire their advocacy. From the classroom to the bedside to the boardroom, nurses can leverage their professional expertise to provide the critical knowledge and analysis to transform public health policy and nursing practice. As stakeholders who are well prepared to engage in the policy-making process, nurses must stand ready to respond to an array of healthcare reforms confronting the nation’s delivery system by being full partners, with physicians and other healthcare professionals, in redesigning health care in the United States (IOM, 2010). Just as our “foremothers” before us, and in some cases fathers as well, nurses of the 21st century have an integral role in shaping and advancing policy solutions at a time when there is tumultuous political climate and a health care environment that may not clearly understand the values and contributions of nurses and nursing practice. Berkowitz (2017) recently described how important the need is for nurses to inform consumers about what nursing care is, including why and how it prevents illness, manages symptoms, treats disease, and transforms the health of communities. Nickitas and Ferguson (2017) note how critical it is to advocate for and ensure that nurses globally can practice to the full scope of their education and licensure, have equal opportunities for career development, and practice

Nursing Strong

in work environments that are free from violence, harassment, and discrimination; these concerns are essential in today’s and tomorrow’s healthcare delivery system. To become engaged in advocacy, and to set the agenda for human resources and nursing resources for health care, nurses must be at the forefront of policy engagement, dialogue, and implementation. This engagement requires sound evidence and a political strategy that allows for increased understanding of the potential impact of linking the nursing workforce with the globalization of health care, to ensure dignified and respectful health care for all persons, regardless of sexual orientation or gender identity (Nickitas & Ferguson, 2017). The demands for increased access and better healthcare outcomes will require nursing to widen its influence in policy areas that address the health and healthcare needs of underserved and minority populations (Villarruel, Bigelow, & Alvarez, 2014). Nurses are essential healthcare providers and make significant contributions to the body of knowledge of improving health and health care in the United States. One way nurses can impact the nation’s health is to meet the 21st-century challenge of population health management and population health. To meet this challenge, the Robert Wood Johnson Foundation (RWFJ; 2015) has committed to advancing a national initiative called the Culture of Health by addressing key social determinants of health and empowering support mechanisms to help people live healthier lives. A Culture of Health involves creating increased collaboration among healthcare systems. For community organizations, this means making health a shared value, creating healthier and more equitable communities, and strengthening the integration of health services and systems (Martsolf et al., 2016). As political advocates, nurses are uniquely positioned to lead system change to improve care for populations and contribute to a Culture of Health in their communities by focusing on the patient and family-centered care. Nurses naturally view their patients holistically and seek to include all aspects of family, community, and

11

work environment in their care (Smith, 1995). By strengthening the protection of human rights and health equity, and promoting a Culture of Health, all can prosper and thrive. The next section of this chapter discusses how nurses will continue to amplify their voices and advocate to meet the changing landscape of health care.

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Nursing Strong

Professional nursing care is essential to the healthcare system. Of the more than 3.6 million licensed registered nurses (RNs), approximately 84.7% are employed in nursing (62% in hospitals), and approximately 10% are employed in primary care or home care (U.S. Department of Health and Human Services, 2010, 2013), making registered nursing the largest healthcare profession (ANA, n.d.). As such, nurses must advocate by bringing problems to the government and seek decisions in the form of programs, laws, regulations, or other official responses that create innovations and care models to transform the delivery and advance the nation’s health. To begin, nursing must advocate for changes within the profession. To successfully advance health care, the nursing profession must make significant strides to change the composition of the future workforce. This will require greater efforts toward the successful recruitment of underrepresented minorities into n ­ ursing. ­Calculations of data from the U.S. Census ­Bureau (n.d.) reveal that the ­current RN workforce ­remains primarily f­ emale; the percentage of men in the workforce has ­increased to 12% from only 9% in 2001. Nurses from minority backgrounds represent 24% of the RN ­workforce. Considering racial/ethnic backgrounds, the RN population is composed of 75.8% white, 11.5% black or African ­American, 4.8% Hispanic or Latino, 5.8% Asian, 0.5% American Indian, 0.028% Native Alaskan, 0.2% Native ­Hawaiian/Pacific ­Islander, 0.1% Other Native, and 1% multiracial background (DATAUSA, 2018). The profession must do better to ensure that future nurses mirror the patient population

12

Chapter 1 Nursing’s History of Advocacy and Action

for which they will provide nursing care. The recruitment of indivdiuals from underrepresented groups in nursing—­specifically men and individuals from African American, Hispanic, Asian, American Indian, and ­Native Alaskan backgrounds—is a major priority for the ­nursing profession. There is a moral imperative to achieve equity and diversity, which involves increasing underrepresented groups in nursing, embracing the policy process, and creating a culturally and linguistically diverse care environment. A diverse healthcare workforce increases both minority participation in the health professions and a commitment towards cultural competency in the treatment of all patients. A U.S. Department of Health and Human Services report (2006) ­reveals that increased diversity among healthcare professionals leads to improved patient satisfaction, improved patient– nurse communication, and greater access to care for racial and ethnic minority patients who are best served by providers who are knowledgeable about their backgrounds and cultures. ­Increasing workforce diversity, ensuring fair and equal access to quality health care and healthcare resources, eliminating health disparities, and achieving health equity is where nursing’s political advocacy and action upholds the dignity of all people through our actions and our words. The U.S. Department of Health and ­Human ­Services and Healthy People 2020 (2013) define health equity as the attainment of the highest level of health for all people. Achieving health equity for all requires a collective effort across all disciplines and all sectors, including those outside nursing. Therefore, nurses must align themselves with other healthcare professionals to address health disparities and health equity, specifically within the context of the social determinants of health. As an interprofessional healthcare team, all professionals must “draw upon their moral responsibility to respond to human suffering and become acknowledged participants in the nation’s efforts to correct health disparity” (Harrison & Falco, 2005, p. 261).

Fostering interprofessional education and practice builds the health team’s capacity to view high-risk vulnerable and underserved populations as a moral imperative and, as such, bring important perspectives to designing and ­delivering health services that are transformative to ­improving health, lowering costs, and increasing patient satisfaction. To address care gaps and avoid service duplication, improve the quality of patient-centered care, and control costs within and across settings, nurses must understand and interpret legislation and health policy. By being able to interpret healthcare reform from a nursing perspective, nurses can determine how to best distribute resources to individuals, families, and populations. For example, chronic disease is the central healthcare problem in the United States and is the leading cause of disability and death in the United States (Centers for Disease Control and Prevention, 2015; Miller, Lasiter, ­Bartlett Ellis, & B ­ uelow, 2015). In fact, nearly one in two A ­ mericans suffers from chronic conditions such as diabetes, arthritis, hypertension, and kidney disease; these account for 7 of 10 deaths among Americans each year and 75% of the nation’s healthcare spending (Conway, Goodrich, Macklin, Sasse, & Cohen, 2011). The obesity epidemic and growing levels of preventable diseases and chronic conditions greatly contribute to the high costs of health care. Additionally, an aging population has increased the demand to address end-of-life care in a cost-effective manner (Rice & Betcher, 2010). Because chronic disease remains the primary healthcare problem in the United States, nurses can lead change to improve the healthcare system at the population level (Lathrop, 2013; Miller, ­Lasiter, Bartlett Ellis, & Buelow, 2015). As skilled researchers and clinicians, nurses are in key positions to advocate, lead, and participate in interprofessional initiatives, community ­coalitions, and policy enactments. Being a nurse advocate means joining the ranks of the nation’s care decision makers in order to become full partners in redesigning health care (IOM, 2011; Peltzer et al., 2015).

References

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Conclusion

The concepts of advocacy and action serve as a reference and model for the future, demonstrating that all nurses can develop their influence and policy acumen to equip themselves with the knowledge and tools needed to serve the profession, healthcare organizations, and society. As the nursing profession reflects upon its historical roots in advocacy and action, nurses will strive to find innovative ways to advance the nation’s health to reshape healthcare delivery, policy, and payment. These innovations must address the key social determinants of health that will empower and support all people to lead healthier lives. Developing competencies in advocacy and action requires a clear understanding of how to create healthier and more equitable communities as well as strengthening health services and systems, creating diverse policy solutions, and building a consensus for evaluating policy solutions. For those who are just beginning to learn the advocacy process, it is important to recognize that there will always be divergent views around policy solutions, but the best solutions are those where diverse viewpoints are always heard, considered, and reflect consensus. With over 3 million strong, nurses have provided evidence and reasoned solutions to healthcare problems. This chapter has addressed how nurses have had a long and vital history of advocacy and social action. It is through this effort towards improving health outcomes for individuals, families, communities, and populations that nurses are a valuable link to educate policymakers about health issues and promote policies to address contemporary public health issues. These issues include public health and emergency preparedness, food safety, hunger and nutrition, climate change and other environmental health issues, public health infrastructure, disease control, international health, and tobacco control (American Public Health Association, 2017). Fairman and D’Antonio (2013) note that “nurses successes in moving policy forward will

13

depend on their ability to give voice to a historical perspectives that recognize the political and contextual forces that shape health care and place nursing at the center of long-standing debate about health services delivery, knowledge formation, patient safety, technology and education for practice” (p. 351). To design and deliver health services that are transformative in the direction that our nation needs at this moment in time, we must remember how nursing’s historical influences of the past shape our advocacy and actions of the future.

Discussion Questions 1. 2. 3. 4.

How does history inform nursing’s efforts to provide primary health care? What is the relevance of nursing’s history to political advocacy today? Describe the role of advocacy within the history of nursing’s development in the United States. Select a community or population with which you could become a full partner in re­designing and improving health outcomes to address a contemporary public health issue impacting this community or population, such as access to care, transportation, water safety, pollution, or gun safety.

References American Academy of Nursing, Diversity and inclusivity statement. (2016). Retrieved from https://higherlogic download.s3.amazonaws.com/AANNET/c8a8da9e -918c-4dae-b0c6-6d630c46007f/UploadedImages/docs /Governance/2016%20AAN%20Proposed%20Revised %20Diversity%20Statement_FINAL.pdf American Association of the Colleges of Nursing. (2017). American Association of the Colleges of Nursing (AACN) position statement on diversity, inclusion, and equity in academic nursing. Journal of Professional Nursing, 33(2017), 173–174. Retrieved from http:// dx.doi.org/10.1016/j.profnurs.2017.04.003 American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession (2010 edition). Silver Spring, MD: Author. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

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Chapter 1 Nursing’s History of Advocacy and Action

American Nurses Association. (n.d.). Advocacy. Retrieved from http://www.nursingworld.org/Main-MenuCategories /ThePracticeofProfessional-NursingPatientSafetyQuality /Advocacy.aspx American Public Health Association. (2017). Topics & issues. Retrieved from https://www.apha.org/topics-and-issues American Red Cross Rural Nursing Service. (1912–1914). Circular for application. Rockefeller Sanitary Commission microfilm (Reel 1, Folder 8, Rockefeller Archives). Pocantico, NY: American Red Cross Town & Country Nursing Service. American Red Cross Town & Country Nursing Service. (1913). Minutes of the third meeting of the Committee on Rural Nursing. Rockefeller Sanitary Commission microfilm (Reel 1, Folder 8, Rockefeller Archives). Pocantico, NY: American Red Cross Town & Country Nursing Service. Baer, E. D., D’Antonio, P., Rinker, S., & Lynaugh, J. E. (2001). Enduring issues in American history. New York, NY: Springer Publishing Company. Berkowitz, B. (2017, July–August). Valuing science. Nursing Outlook, 65(4), 351–352. Birnbach, N., & Lewenson, S. (Eds.). (1991). Work of women in municipal affairs. First words: Selected addresses from the National League for Nursing 1894–1933. New York, NY: National League for Nursing. Buhler-Wilkerson, K. (2001). No place like home: A history of nursing and home care in the United States. Baltimore, MD: Johns Hopkins University Press. Centers for Disease Control and Prevention. Leading causes of death and numbers of deaths, by sex, race, and Hispanic origin: United States, 1980 and 2014 (Table 19). Health, United States, 2015. Retrieved from https://www.cdc .gov/nchs/data/hus/hus15.pdf#019 Center for Studying Health System Change. (2008, December). Making medical homes work: Moving from concept to practice. Policy Perspective: Insights into Health Policy Issues. Retrieved from http://www.hschange.org/CONTENT /1030/1030.pdf Centers for Medicare & Medicaid. (2015). National health expenditures 2015 highlights. Retrieved from https:// www.cms.gov/Research-Statistics-Data-and-Systems /Statistics-Trends-and-Reports/NationalHealthExpendDate /downloads/highlights.pdf Conway, P. H., Goodrich, K., Macklin, S., Sasse, B., & Cohen, J. (2011). Patient-centered care categorization of U.S. health care expenditures. Health Services Research, 46(2), 479–490. Daley, K. (2012, September–October). Health care as a basic human right. The American Nurse. D’Antonio, P., & Lewenson, S. B. (Eds.). (2011). Nursing interventions over time: History as evidence. New York, NY: Springer Publishing Company. Dock, L. L., Pickett, S. E., Clement, F., Fox, E. G., & Van Meter, A. R. (1922). History of American Red Cross nursing. New York, NY: Macmillan.

Fairman, J. (2017). Foreword. In S. B. Lewenson, A. M. McAllister, & K. M. Smith (Eds.), Nursing history for contemporary role development. New York, NY: Springer Publishing Company. Fairman, J., & D’Antonio, P. (2013). History counts: How history can shape our understanding of health policy. Nursing Outlook, 61(5), 346–352. Fox, E. (1921). Red Cross public health nursing, out to sea. Public Health Nurse, 13, 105–108. Gibson, M. E. (2017). School nursing: A challenging strategy in rural health care in the United States. In S. B. Lewenson, A. M. McAllister, & K. M. Smith (Eds.), Nursing history for contemporary role development (pp. 37–58). New York, NY: Springer Publishing Company. Harrison, E., & Falco, S. M. (2005). Health disparity and the nurse advocate: Reaching out to alleviate suffering. Advances in Nursing Science, 28(3), 252–264. Hartman, M., Martin, A. B., Benson, J., & Catlin, A. (2013). National health spending in 2011: Overall growth remains low, but some payers and services show signs of acceleration. Health Affairs, 32(1), 87–99. doi:10.1377/ hlthaff.2012.1206 Hine, D. C. (1989). Black Women in White: Racial Conflict and Cooperation in the Nursing Profession 1890-1950. Bloomington, IN: Indiana University Press. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Keeling, A. (2007). Nursing and the privilege of prescription, 1893–2000. Columbus, OH: Ohio State University Press. Keeling, A., & Lewenson, S. B. (2013). A nursing historical perspective on the medical home: Impact on health care policy. Nursing Outlook, 61(5), 360–366. http://dx .doi.org/10.1016/j.outlook.2013.07.003 Lathrop. B. (2013). Nursing leadership in addressing the social determinants of health. Policy, Politics, & Nursing Practice, 14(1), 41–47. http://dx.doi.org./10.1177/15271544 13489887 Lewenson, S. B. (1993). Taking charge: Nursing, suffrage, and feminism in America, 1873–1920. New York, NY: Garland Publishing. Lewenson, S. B. (2012). A historical perspective on policy, politics, and nursing. In D. J. Mason, J. K. Leavitt, & M. W. Chafee (Eds.), Policy and politics in nursing and health care (6th ed., pp. 12–18). St. Louis, MO: Elsevier Saunders. Lewenson, S. B. (2017, September). Designation 1-A: The African-American experience in the American Red Cross Town and Country, 1912–1918. Paper presented at the American Association for the History of Nursing, Fairport, NY. Martsolf, G. R., Gordon, T., May, L. W., Mason, D. Sullivan, C., & Villarruel, A. (2016). Innovative nursing care models and culture of health: Early evidence. Nursing Outlook, 64(4), 367–376.

References Miller, W. R., Lasiter, S., Bartlett Ellis, R., & Buelow, J. M. (2015). Chronic disease self-management: A hybrid concept analysis. Nursing Outlook, 63(2), 154–161. Nickitas, D. M., & Ferguson, S. (2017). Investing in nursing: Improving health, gender equality, and economic growth. Nursing Economics, 35(4), 158, 183. Orszag, P. R. (2008). The overuse, underuse, and misuse of health care. Testimony before the U.S. Senate Committee on Finance. Retrieved from http://www.cbo.gov/sites /default/files/cbofiles/ftpdocs/95xx/doc9567/07-17 -health-care_testimony.pdf Peltzer, J. N., Ford, D. J., Shen, Q., Fischgrund, A., Teel, C. S., Pierce, J. Jamison, M., & Waldon, T. (20153, March– April). Exploring leadership roles, goals, barriers among Kansas registered nurses: A descriptive cross-sectional study. Nursing Outlook, 634(2), 117–123. Phillips, J., & Malone, B. (2014). Increasing racial/ethnic diversity in nursing to reduce health disparities and achieve health equity. Public Health Reports, 2(129), 45–50. Pitt-Mosley, M. O. (1996). Satisfied to carry the bag: Three black community health nurses’ contributions to health care reform, 1900–1937. Nursing History Review, 4, 65–82. Rice, E., & Betcher, D. (2010). Palliative care in an acute care hospital: From pilot to consultation service. MEDSURG Nursing, 19(2), 107–112. Robert Wood Johnson Foundation. (2015). From vision to action: Measures to mobilize a Culture of Health. Princeton, NJ: Author. Selanders, L. C., & Crane, P. C. (2012). The voice of Florence Nightingale on advocacy. Online Journal of Issues in Nursing, 17(1) Manuscript 1. Smith, M. C. (1995). The core of advanced practice nursing. Nursing Science Quarterly, 8, 2–3. U.S. Census Bureau. (n.d.). American FactFinder. American Community Survey. 2014–2015. Retrieved from http:// www.census.gov/programs-surveys/acs

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U.S. Department of Health and Human Services Health Resources and Services Administration. (2013). The U.S. nursing workforce: Trends in supply and education. Bureau of Health Professions, National Center for Health Workforce Analysis. Retrieved from http://bhpr .hrsa.gov/healthworkforce/reports/nursingworkforce /nursingworkforcefullreport.pdf U.S. Department of Health and Human Services. (2006). The rationale for diversity in the health professions: A review of the evidence. Retrieved from http://bhpr.hrsa.gov /healthworkforce/reports/diversityreviewevidence.pdf U.S. Department of Health and Human Services. (2010). The registered nurse population: Findings from the 2008 National Sample Survey of Registered Nurses. Rockville, MD: Author. U.S. Department of Health and Human Services. (2013a). Health equities and disparities. Office of Minority Health. National Partnership for Action to End Health Disparities. Retrieved from http://www.minorityhealth.hhs.gov /npa/templates/browse.aspx?lvl=lvlid=34 U.S. Department of Health and Human Services. (2013b). Foundation health measures: Disparities. HealthyPeople. gov. Retrieved from http://www.healthypeople.gov/2020 /about/disparitiesAbout.aspx U.S. Department of Labor. (2014). Labor force characteristics by race and ethnicity, 2014. Retrieved from http://www .bls.gov/opub/reports/race-and-ethnicity/archive/labor -force-characteristics-by-and-ethnicity-2014.pdf Villarruel, A., Bigelow, A., & Alvarez, C. (2014). Integrating the 3Ds: A nursing perspective. Public Health Reports, 2(129), 37–44. Wald, L. (1915). The house on Henry Street. New York, NY: Henry Holt & Company. Zolnierek, C. (2012). Speak to be heard: Effective nurse advocacy. American Nurse, 7(10), 1.

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Chapter 1 Nursing’s History of Advocacy and Action

CASE STUDY CASE STUDIES

Strength Is in Coalitions Pennie Sessler Branden

Purpose of the Case Study The purpose of this case study is to describe an exemplar where nursing advocacy can be more effective through strong coalitions and partnerships.

The Case Study Breast cancer is the second most common form of cancer in women and is the second leading cause of cancer deaths. According to the American Cancer Society (ACS) (2017) breast cancer will affect 1 in 8 women during their lifetime and about 1 in 37 women will die of breast cancer. The statistics show that women of color and those in poverty have a higher incidence of breast cancer than white middle- and upper-class women. Breast cancer screening has been utilized to diagnose breast cancer early enough to improve the treatments, interventions, and outcomes for breast cancer. With 90% of registered nurses (RNs) being female, the American Nursing Association (ANA) (American Nurses Association, n.d.) has educated nurses to better understand breast cancer risk factors and the importance of regular screening. Nurses and other healthcare providers look to the ACS recommendations for mammogram schedules. These recommendations have gone through a number of permutations, but since 2015 the American Cancer Society recommendations state: Women with an average risk of breast cancer—most women—should begin yearly mammograms at age 45. Women should be able to start the screening as early as age 40, if they want to. At age 55, women should have mammograms every other year—though women who want to keep having yearly mammograms should be able to do so. Regular mammograms should continue for as long as a woman is in good health. Breast exams, either from

a medical provider or self-exams, are no longer recommended. (American Cancer Society, 2015) Therefore, women should have mammograms as desired or as suggested by their healthcare provider based on their personal medical history and risk factor(s). This relies on the fact that a person has health insurance that covers these costs or is able to go to a free or reduced cost clinic such as Planned Parenthood (PP) for health care and screenings. Planned Parenthood and other clinics rely on funding from the federal government to assist in the costs for these services. Planned Parenthood follows the recommendations of the American Cancer Society regarding breast self-exam and can refer a person to a medical site where mammograms are done as needed. Planned Parenthood may be the only option for a woman to receive the necessary care for a breast cancer screening referral. However, if the U.S. Congress decides to reduce or completely remove funding to Planned Parenthood, what will those women do for breast cancer screening? Congress assesses what monies will go to what groups and establishments based on a number of factors, including what is the agenda of the president and Congress at the time, what is beneficial for and needed by certain congressional districts, and other special interests. According to the American Public Health Association (APHA) (2017) and other websites, the federal government does not directly fund Planned Parenthood, but rather reimburses states that have paid Medicaid bills for services by such clinics as Planned Parenthood. According to their annual report in 2015–2016, Planned Parenthood received 41% of their operating costs from government health services reimbursement and grants. With a portion of this money, Planned Parenthood did 321,700 breast exams and diagnosed 72,012 incidences of cancer through breast exams and Pap smears. If PP did not have this funding, these numbers would probably be much lower because some women would not have this care due to the inability to pay for it. For the past few years there has been a rolling debate about healthcare access and whether the federal and/or state governments will fund the health care needed by the working poor and uninsured who may not have the funds to pay for a mammogram. Initially, it seemed as though

Case Study

have recognized the importance of building partnerships and coalitions in order to maximize their efforts and have deliberately partnered with groups and organizations that support the many issues that nurses support. If Congress is only looking at the cost of care given by Planned Parenthood clinics we must look at the entire picture of cost of preventive care versus the cost of breast cancer treatment. With these statistics, one would think that breast cancer screening, which can reduce cost and suffering, would be covered by insurance. The Affordable Care Act (ACA) covers an annual mammogram, as do most insurance companies as mandated by the ACA. The average cost for a mammogram is $456 (MDsave, 2018). According to a retrospective analysis by Blumen, Polkus, and Fitch (2016), the costs of complete breast cancer treatment for 1 year were from $60,637 for Stage I/II treatments up to $134,682 for Stage IV treatments. Not only will there be costs for breast cancer care but there will be potential loss of wages affecting partners and families in addition to an immeasurable psychologic toll. This huge disparity in costs for preventive mammograms and the overall cost for treatment seems to emphasize the importance of preventive care over the need to wait and treat women who get breast cancer. However, with the potential changes in the ACA and the current unemployment and underemployment numbers, what happens to those women who cannot afford the cost of a mammogram or the cost of insurance? Blumen and colleagues (2016) report that support for programs for breast cancer screening need to be implemented and strengthened to diagnose breast cancer and begin treatment earlier. With all of the political wrangling that occurs over the health and well-being of women, nurses have become advocates for these issues, and with their coalition partners have taken to Capitol Hill to educate their representatives and senators about the importance of healthcare coverage to include things like breast cancer screening. To accomplish this, (1) nurses will continue to educate their colleagues, patients, and families; (2) nurses will continue to meet with their representatives on the state and federal levels; (3) the ANA will continue to write position statements and nurses will testify in front of legislators; and (4) nurses need to bring real stories to their legislators about women with breast cancer who have benefitted from healthcare

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the Affordable Care Act (ACA) would reduce these disparities, and it has. However, some state governments have found ways to reduce the potential advantages that the ACA offers. For example, in New Jersey (NJ), Medicaid funding for clinics that gave patients family-planning and well-women care along with referrals for mammograms was completely eliminated by Governor Christie in 2010 (Culp-Ressler, 2015). Christie vetoed those spending bills five times in 5 years. Consequently, between 2010 and 2015, there was a 25.1% increase in breast and cervical cancer cases in Latina women in New Jersey. This was five times higher than women overall in that state (Culp-Ressler, 2015). Clearly the elimination of this funding has affected and will affect overall screening and care of vulnerable groups unable to pay for these expensive services. Contrary to this, a mid-July 2017 article by Brodesser-Akner reports that NJ legislators have enough votes with Democrats and Republicans together to override a governor’s veto for $7.5 million for funding to family-planning clinics, including Planned Parenthood. They believe that the previous vetoes have significantly reduced opportunities for NJ women to obtain necessary health care and that this funding is integral to improving the health of all NJ women. New Jersey is just one example of the ongoing divisiveness that has taken place over the funding of family planning and women’s health clinics by state and federal governments. This is not a new debate but one that has been in discussion for decades. The American Public Health Association (APHA) published a policy statement in 1991 emphasizing that minority women are at higher risk of death from breast cancer than white women and that education and regular screening are integral to the efforts of healthcare providers to reduce the occurrence of breast cancer and to improve overall outcomes. Even with this data-driven information, the federal government currently wants to eliminate funding to Planned Parenthood, thus potentially reducing access to breast exams and early detection of breast cancer for the millions of women who utilize these clinics annually. Nurses have been involved in lobbying efforts to better educate and assist our representatives to understand the importance of breast screening for all women regardless of socioeconomic status. Further, nurses

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Chapter 1 Nursing’s History of Advocacy and Action

access and insurance, as well as stories where a person suffered due to lack of access and/or insurance. Nurses will continue to advocate for their patients and what is best for them by enlarging their reach through coalitions and partnerships. The Connecticut Nurses Association (CNA) is guided each year by their Connecticut (CT) legislative agenda and their prioritization of issues, which is informed by nurses and their relationships and partnerships with organizations across the healthcare and health spectrum. The CNA regularly engages in advocacy on health and nursing throughout the year and during the legislative session. To address the widespread impact of healthcare reform, the CNA is actively involved in the campaign entitled Protect Our Care CT (PCCT) (Connecticut Nurses Association, 2017). PCCT represents a coalition of organizations and individuals to support and represent the health needs of people of CT, including those who rely on the ACA, Medicare and Medicaid, and women’s health programs (personal interview Clear Sandor, 2017). For example, the CT Senate Bill 586 supported state Medicaid expansion of health benefits for children and women (State of Connecticut General Assembly, 2017). There is a long history of CNA’s active participation in the state regarding access to essential services and their partnership with other groups and coalitions; the CNA has supported this bill for increased essential benefits and access to care and members have been very vocal about this to their legislators through lobbying efforts, letters, etc. Although the bill does not increase funding for or access to breast screening mammograms, it does mandate breast cancer counseling, genetic testing, and risk assessment. In the future this bill could be expanded to include mandated mammograms no matter what a person’s insurance status is. This is an example of the impact of indirect action by multiple groups, including nurses, in strong coalitions. The CNA works collaboratively with its coalitions to strategically exert its influence and increase its voice on multiple healthcare issues that affect women. Coalition building is a key piece of being heard and getting legislation passed. Coalitions have provided nurses with a strong voice and enhanced their ability to provide high-quality, safe care.

Summary This case study is one relevant example of the potential for possible negative outcomes related to decreased funding by governmental agencies; it also delineates the potential positive outcomes that are achieved with partnering, collaboration, and coalition building. Even though the issue of continued funding for Planned Parent clinics is not addressed directly, successes can be made incrementally that will increase support of important healthcare programs moving forward. Advocacy, in order to influence policy, is best operationalized through partnerships, collaboration, and coalitions. Although someone in power, such as Governor Christie, can veto a bill to reduce funding to a particular group, the representatives in the New Jersey legislature can introduce bills that can, with a bipartisan majority, override a veto by the governor. Similarly, the Connecticut Nurses Association maximizes its efforts through collaborating and partnering with various groups to form strong influential coalitions that can educate legislators about all of the pieces of breast cancer prevention and care. The combined efforts, along with the increased numbers of individuals actively participating in the process, enhances the work of lobbyists, who in turn influence the policymakers. The overall consequence is the increase in the voice of the public that influences the outcomes. This influence enhances the possibility of providing more adequate healthcare services to all citizens.

Case Study Questions 1. This case is a good example of nursing power through building partnerships and coalitions that have similar missions. Can you identify two coalitions that your state nursing association actively works with? Can you describe the policy issues that these coalitions address? 2. Successful advocacy is best defined as moving toward the ultimate goal(s) in a positive, substantive manner. Explain what advocacy you have done, besides direct patient advocacy, to support health care in your nursing specialty.

References American Cancer Society. (2015, October 20). American Cancer Society releases new breast cancer guideline. Retrieved from

Case Study

http://www.nj.com/politics/index.ssf/2017/07/christie _facing_open_rebellion_as_gop_lawmakers_vo.html Connecticut Nurses Association. (2017). CT coalition to advocate for health coverage. Retrieved from http://cqrcengage .com/ctnurses/home Culp-Ressler, T. (2015, February 26). The human costs of Chris Christie’s attack on Planned Parenthood. ThinkProgress. Retrieved from https://thinkprogress.org/the-human -costs-of-chris-christies-attack-on-planned-parenthood -b565d0bd790d MDsave Incorporated. (2018). How much does a mammogram screening cost? Retrieved from https://www.mdsave .com/procedures/mammogram/d786fcc5 Personal interview: Kimberly Clear Sandor. (August 1 and 9, 2017). Planned Parenthood (2017, July 26). Annual Report 2015-2016. Retrieved from https://www.plannedparenthood.org /uploads/filer_public/18/40/1840b04b-55d3-4c00-959d -11817023ffc8/20170526_annualreport_p02_singles.pdf Reger, A. (2015, September 23). State statutes on breast cancer screening and coverage. Connecticut Office of Legislative Research Research Report 2015-R-0210. Retrieved from https://www.cga.ct.gov/2015/rpt/pdf/2015-R-0210.pdf State of Connecticut General Assembly. (2017, January). Senate Bill No. 586. Retrieved from https://www.cga .ct.gov/2017/TOB/s/2017SB-00586-R01-SB.htm

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https://www.cancer.org/latest-news/american-cancer -society-releases-new-breast-cancer-guidelines.html American Cancer Society. (2017). About breast cancer. Retrieved from https://www.cancer.org/content/dam/CRC/PDF /Public/8577.00.pdf American Nurses Association. (n.d.). Women’s health. Retrieved from https://www.nursingworld.org/practice-policy/work -environment/health-safety/healthy-nurse-healthy-nation /womens-health/ American Public Health Association. (2017). Cervical and breast screening. Retrieved from https://www.apha .org/policies-and-advocacy/public-health-policy -statements/policy-database/2014/07/29/13/51 /cervical-and-breast-screening Blumen, H., Polkus, V., & Fitch, K. (2016, February) Comparison of treatment costs for breast cancer, by tumor stage and type of service. American Health & Drug Benefits for Payers, Purchasers, Policymakers, and Other Healthcare Stakeholders, 9(1). Retrieved from http://www .ahdbonline.com/articles/2076-comparison-of-treatment -costs-for-breast-cancer-by-tumor-stage-and-type -of-service Brodesser-Akner, C. (2017, July 12). Christie faces rebellion from 5 Republican lawmakers over Planned Parenthood funding. Advance Media for New Jersey. Retrieved from

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CASE STUDY A Career in Politics to Role Model: Bethany Hall-Long’s Nursing Pathway to the Lieutenant Governor’s Office in Delaware Veronica D. Feeg

A career in politics might be the aspiration for a college student in political science or pre-law, but is seldom one for a nursing student. In fact, courses in health policy or politics may be absent or scarce in nursing undergraduate or graduate curricula, and the notion to become active in politics is unlikely. In fact, Bethany Hall-Long, first woman Lieutenant Governor of Delaware, would be the first to admit that it was not in her plans in the beginning of her personal journey. In fact, she attributes her current position, stated with candor in her numerous inspirational presentations to nurses over the years, to her tardiness for class when the only seminar topic left for students to choose was about nurses in politics—and she was “stuck with it” (personal interview Hall-Long, 2017). Although she only learned after she won her first race in 2002 that her great-grandfather had been a member of the Delaware House of Representatives, she had little kitchen table discussion about politics growing up. In fact, her farm upbringing and spiritual roots in rural Delaware taught her about taking care of people— “where much is given, much is expected, and it is how you treat the least among us” (personal interview Hall-Long, 2017)—but not about public policy. What is noteworthy in this model career

in politics, which she defines as “public service,” is her early commitment to caring for the homeless in community health nursing, which became the foundation of her academic career: to understand policy and serve “the many.” She attributes her incremental successes, beginning from the day when she was late to her graduate school class, to being coached by mentors such as Catherine Malloy in Charleston, South Carolina, with whom she continued to work throughout her doctoral program in nursing administration and policy at George Mason University. Using what she learned from her study of health policy, she became active in her local city government and organizations such as the League of Women Voters and a federal health clinic that served the homeless. In these experiences, public policy was “made real” and prompted her continued volunteer service in other nonprofit organizations. She claims that she learned from working with these groups that as nurses, we do not have to stay in our lane of just working with other nurses. She learned how to organize, to use her health knowledge to work for things that people care about, and to build coalitions of groups for action. She says that a leader at the League of Women Voters told her that she “had what it takes—drive, personality, and skills—to think about running for office,” which she tucked away at that time. With her husband in the military at the time, she moved to Washington D.C. Entering the doctoral program, still moonlighting as a nurse, she continued to grow into real public policy experiences that were fueled by taking care of homeless veterans and at-risk populations. To make a real impact, she believed that we had to elect nurses who could make a difference, but she realized she needed experience to be taken seriously. Along the way, it was nurse mentors who connected her with Capitol Hill opportunities on an assignment that would influence a dissertation and numerous other connections, including Bob Dole and Ted Kennedy from a U.S. Senate Committee. While a student, she served as a U.S. Senate Fellow and a U.S. Department of Health and Human Services policy analyst for the Secretary’s Commission on Nursing. In her own words, she was not afraid to pick up the phone, encouraged by her mentor, and ask if the national commission studying the nursing shortage needed a policy graduate student—for

Case Study

issues that matter to nurses—jobs, environment, transportation, and environmental justice, as well as health care in general and women’s health in particular. Returning as a faculty member to Delaware, her home state, she decided that her public health and health policy student assignments gave her reasons to run because: (a) she desired to make a significant contribution; (b) she had been well prepared to understand process and as a nurse, she already understood the needs; and (c) the opportunity presented itself to run for the Delaware General Assembly. In her own words, her public life since 2000 did not begin smoothly—she won the primary but lost her first race by 1% in a race against a long-term male incumbent. But she says that she learned from that experience, pulled herself up by her bootstraps, ran again in 2002, and won in a tough election against the local school board president. She served continuously as the first nurse elected to the Delaware General Assembly from 2003 to 2017, as a member of the Delaware House of Representatives from 2003 to 2009, and then in the Delaware Senate from 2009 to 2017. She lists among her accomplishments cosponsoring a range of legislation including the Governor’s Cancer Council and the Health Fund Advisory (Master Tobacco Settlement) Committee. She was the prime House sponsor of legislation creating a cancer consortium for Delaware. She cosponsored a blue ribbon task force to analyze the problem of chronic illness in Delaware and make policy recommendations. She cosponsored needle exchange legislation that has made an impact on HIV infection rates, and she updated the state’s indoor tanning laws to prohibit children under age 14 years from using tanning beds and for those age 14 to 18 years to require parental consent (Hall-Long, 2007, 2012). Among her legislative accomplishments during her Senate years, she chaired several important committees including health care, community and county affairs, transportation committee, veterans committee, and insurance committee, among others, where nurses can play a significant role. Her political campaigns and subsequent elections over these years are remarkable (see TABLE 1-1), but she acknowledges that it is not easy to run for office. She describes “running” for office as just that: experiences good and bad teach us how to continue on a path if we are passionate

CASE STUDIES

free. This opportunity gave her access to the four presidents of the Tri-Council for Nursing (American Nurses Association [ANA], National League for Nursing [NLN], American Association of Colleges of Nursing [AACN], and American Organization of Nurse Executives [AONE]) at age 25. She grew friendships and experience that laid the framework for her dissertation. Lt. Governor Hall-Long’s doctoral dissertation is noteworthy: A Policy Process Model: Analysis of the Nurse Education Act (NEA) of 1991–1992. Along with her work in politics, she studied the policy process, knowing clearly that public service mandates an understanding of public policy. This exploratory case study examined a theoretical model and applied it to explain the Tri-Council for Nursing’s political efforts during the reauthorization of the Nurse Education Act that year. She interviewed members of the Tri-Council for Nursing, U.S. Division of Nursing, and U.S. Congressional staff, and examined 75 public documents and records as secondary sources of data. Her findings supported the conceptual categories and organization of the model and its ability to discern differences among political actors and corresponding policy stages. This grounding and depth of understanding would serve her well in her subsequent political journey, recognizing fully that in order to improve services or make substantial change for the health of constituents, one needs to know the underlying policy and politics that are successful. Over these years, she became active with the Democratic Party, working on political campaigns and serving to connect with nonprofit organizations and groups. She worked on community issues that were important and continue today: homelessness, housing, jobs, economic opportunity, and women’s and children’s issues, particularly infant mortality prevention through improving access for disadvantaged young mothers. She developed relationships in the community and in politics. She says that it was working with Mark Warner, who became Governor of Virginia and is currently a U.S. Senator, that she got her grassroots experience on the campaign trail together. She believed that she could enlighten and inform policymakers who do not understand nursing or health care. To most politicians, nurses are all the same and she was determined to be at the table to educate about

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TABLE 1-1  Chronology of Bethany Hall-Long Elections Year

Campaign/Election

Outcome

2000

Ran against Republican Representative incumbent Richard Cathcart for District 9 seat.

Lost

2002

Redistricted to District 8; ran unopposed in Democratic primary and against Republican nominee William Hutchinson in general election.

Won (60.7%)

2004

Ran unopposed for Democratic primary and in general election.

Won

2006

Ran unopposed for Democratic primary; ran against Republican nominee Edward Colaprete in general election.

Won (77.0%)

2008

Ran unopposed for District 10 Senate seat; ran against Republican nominee James Weldin in general election.

Won (64.9%)

2012

Incumbent; ran unopposed for Senate seat; ran unopposed in general election.

Won

2016

Ran against Republican La Mar Gunn in Lieutenant Governor race.

Won (59.4%)

Compiled from State of Delaware general election official results. (November 7, 2000; November 5, 2002; November 2, 2004; November 7, 2006; November 4, 2008). Dover, DE: Delaware Commissioner of Elections.

(Hall-Long, 2007, 2012). She loves meeting people on the campaign trail and she believes that being a nurse gets her past the doorbell when going door to door in a race because people can instantly relate to you. She believes that her communication skills come directly from her nursing experience and her connection with the community. She encourages nurses to think beyond healthcare committees—to recognize that we are good at solving problems that may be outside our usual reach, and there is no limit to the list of public policy problems that we can tackle, including, but not limited to, childhood sports activities, palliative care, or opioid addiction, depending on our clinical expertise and interests. In January 2017, Bethany Hall-Long became the 26th Lieutenant Governor of Delaware. Her understanding of the policy process model that she developed in her dissertation continues to serve her well, and she notes that, although she

grew up in a rural household, she is a descendent of Delaware’s 15th governor, so it might have been her destiny to have a life in politics. She serves as the President of the Senate, a legislative body she has known for 8 years. As Lieutenant Governor she is proud to be able to influence the policy agenda in some roles and serve the state in her leadership role in moving systems issues such as health reform, workforce training, and mental illness. The political career of Bethany Hall-Long should be an inspiration for nurses who are dissatisfied with the status quo and passionate about making change to serve the needs of individuals who are disadvantaged. Her message to nursing students and professional nurses is that they should not leave policy making and governing to men in closed rooms anymore; they should seek out ways to influence and consider running for office. She attributes her passion and strength to her grandmother with an 8th grade

Case Study

Case Study Questions 1. Which of Lt. Governor Hall-Long’s list of nursing accomplishments played a role in her journey in politics? 2. What knowledge and characteristics are natural components of nurses’ professional

backgrounds that help them seek a public service life? 3. How can a political career unfold synergistically with a nurse’s ambition to run for political office? 4. Why is “running for office” described by politicians as a challenging personal experience?

References Hall-Long, B. (2007). Vignette: farmgirl, nurse and legislator: My journey to the Delaware General Assembly. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy and politics in nursing and health care (5th ed, pp. 720–723). St. Louis, MO: Elsevier Saunders. Hall-Long, B. (2012). Chapter 17: Taking action: nurse, educator and legislator: My journey to the Delaware General Assembly. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy and politics in nursing and health care (6th ed, pp. 579–582). St. Louis, MO: Elsevier Saunders. Hall-Long, B. (1993). A policy process model: Analysis of the Nurse Education Act of 1991–1992. Dissertation at George Mason University, Fairfax, VA. University of Michigan, Ann Arbor, MI. Personal interview: Bethany Hall-Long. (February 20, 2017).

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education who vociferously advocated that women should be well educated. Lt. Governor Hall-Long’s advice to those with aspirations to impact “the many” is to get prepared, study the policy process, and become experienced in ways to communicate with all types of stakeholders on the issues, from classrooms to boardrooms to community involvement. Volunteer and do not be intimidated. This public servant, from rural roots to a nursing graduate education that includes a PhD, brought her passion for people and her skills in community nursing to the State House in Delaware, second to Governor Carney, and still has gas in the tank to go farther. Her career story should inspire other nurses—who she claims already have the skill set and knowledge to work with people—to pursue public service in the political arena so that the most vulnerable among us can be heard.

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CHAPTER 2

Policy and Politics Explained Nancy Aries

OVERVIEW Nurses and other healthcare professionals must understand how the government, providers, insurers, and consumers interact in the health policy process. This chapter provides an overview of the essential cornerstones that drive the policy-making process and shape the organization and delivery of health care in the United States. By understanding the framework within which policy is made and the politics of policy making and program implementation, all healthcare professionals, regardless of where they perform their duties, will be better prepared to advocate for a healthcare system that best meets the population’s needs.

OBJECTIVES ■■ ■■ ■■

■■

Define policy (generally) and health policy (specifically). Explain the role of the market and the government in framing policy. Describe the policy-making process, including: •• Competing concepts of federalism that create the structure within which policy is determined •• Opposing interests and their influence on policy outcomes •• Policy formation and the policy making •• Policy implementation and its ramification for future action Identify different approaches to influence and shape policy and programmatic outcomes that can be used by healthcare advocates.

© Anthony Krikorian/Shutterstock

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Chapter 2 Policy and Politics Explained

Introduction

The Patient Protection and Affordable Care Act (ACA), also known as “Obamacare,” was signed into law in 2010. Since 2013, the number of Americans without health insurances has dropped from 41 million to a low of 28.5 million, or 10.5% of the population (Kaiser Family Foundation [KFF], 2016). As a result, more people are accessing care, and health outcomes show improvement (Peterson Center on Health Care and Kaiser Family Foundation [PCHC-KFF], 2017). Also, the rate of healthcare spending has slowed (­McMorrow & Holahan, 2016). Despite these successes, there is a tremendous divide in political opinion about the ACA. President Trump made the repeal of Obamacare a cornerstone of his political agenda. As the U.S. Senate considered repealing and replacing the law in July 2017, 50% of adults were favorable, and 44% were unfavorable (KFF, 2017). How can facts lead to such divergent understanding of whether the legislation has been successful or not? It suggests significant disagreement in our understanding of the government’s role in helping to shape the organization, delivery, and financing of health care. This chapter explains the purpose of government in the policy and policy-making process as a first step to providing the necessary tools to those who want to influence the organization and delivery of care. The first section of the chapter expands on the definition of policy as government actions that advance the well-being of society and considers how policy shapes our experience of the healthcare system. When health care works, it is often the result of policies that enable it to succeed. When there is a failure, it can also be the case that policies have created an environment in which it is difficult to operate. The second section of this chapter highlights the different ways government policy and programs intervene in the organization and delivery of health services to assure greater social equity in the access to affordable and high-quality health care. The choice of tools is determined by the balance established between the market and the government in overseeing the organization of

healthcare delivery. Although the United States operates under a mixed system, the market and the government each present a different set of opportunities and constraints for policymakers. The remaining sections start with an examination of the changing concepts of federalism or the role of the federal versus state governments. The federalist framework within which policy is constructed is essential as it determines under whose jurisdiction healthcare policy falls. Once the dynamism of this relation is clarified, the actual programmatic tools the government uses to achieve its goals is explored. The policy-making process is explained in the following section. The groups that have a stake in the development of public policy and programs are reviewed, as are the issues about which they are most concerned. From there, the chapter explains the differential ­influence of interest groups and their ability to shape the decision-making process to achieve what they perceive to be more favorable ­outcomes. This chapter does not explain legislative procedures; that is better left to a civics text. Rather, this chapter explains the points at which decisions are made and the political dynamics of decision making. The final section brings the discussion back to the nurses and healthcare professionals for whom this text is written. A better understanding of policy helps explain the experiences of those seeking and providing health care. It also provides a framework for understanding how healthcare professionals can be more effective players within the policy-making process and have greater influence as a result.

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Policy Defined: A Framework for Government Action

Policy in the broadest sense is the manifestation of ideology or belief systems concerning public purpose (Weissert & Weissert, 2012). Public purpose refers to actions that benefit the population as a whole. Public policy, the term used to describe government action, is typically divided

Policy Defined: A Framework for Government Action

into three areas: foreign policy, economic policy, and social policy (Lowi & Ginsberg, 1998). The objective of foreign policy is to defend national sovereignty. Economic policy is designed to promote and regulate markets. Foreign and economic policy both seek to promote the political and economic well-being of American society, but policies in these areas do not have equal impact on all sectors of society. Some groups may benefit, whereas others might suffer undue consequences. For example, the North American Free Trade Agreement benefited the overall economy, but many Americans who held manufacturing jobs were laid off as production moved from the United States to countries with lower production costs. Social policy often becomes the means by which these unintended consequences are addressed. Through government actions, the provision of the basic ­necessities—food, shelter, health care, and ­education—are assured (­Midgley & L ­ ivermore, 2008). Social policy, therefore, is redistributive by its very nature. Its goal is to advance social equity. Health policy exists within the larger realm of social policy. Because policy is rooted in social values and ideologies, the discussion of health policy begins with the recognition of the values and ideologies upon which the organization of the healthcare system is based. The historic course of American health policy is best described regarding shifting beliefs about access to care. Sometimes we stridently pursue health care as a right and look for ways to make services more readily available. Sometimes we treat health care as a privilege and look to individuals to take responsibility for their care (Knowles, 1977). These competing values (i.e., a right versus a privilege) are simultaneously and continually at work. The assumed trajectory has been towards redistributive justice, but that is currently under critical scrutiny. Until the Great Depression, ethnic and religious communities assumed primary responsibility for providing social and economic support to persons in need of assistance. That responsibility shifted to the federal government in the 1930s (Kernell & Jacobson, 2006). The Social Security Act of 1935 included economic support

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for the elderly, financial and social support for poor children, and limited health care for mothers and children. Its goals were further advanced by President Lyndon Johnson’s War on Poverty, whose healthcare initiatives included Medicare and Medicaid. Medicare, which covers practically all Americans older than age 65, was deemed a right. It is a universal entitlement because it makes health services available to a defined population regardless of ability to pay. Such programs tend to be expensive because they are all inclusive, but they also tend to have broad political support because everyone can expect to receive the program’s benefits (Brown & Sparer, 2003). In contrast, Medicaid makes health benefits available to distinct groups of low-income persons, which initially included families receiving public assistance, the disabled, and some older persons. States determine the specific eligibility cutoff as well as covered services. Medicaid is labeled a selective program because of the limits on eligibility. A result is that it enjoys less political support. First, it serves needy populations whose claim to services is often considered questionable, and second, its level of service can be greater and less expensive than the services received by persons whose incomes are slightly above the cutoff. Passage of the ACA represented the next major effort to expand access to affordable health care. It was passed in response to the rising number of uninsured that resulted in part from rapidly increasing healthcare costs that led to high out-of-pocket costs for individual policies as well as deductibles and coinsurance. The goal of ensuring that all Americans had access to affordable health insurance is difficult to achieve given differing ideas about rights and privileges. The ACA settled on a plan that combined expanded access to Medicaid and a combination of subsidies for individuals up to 200% of the federal poverty level and tax credits for individuals up to 400% of the federal poverty level. Although the ACA made health insurance more affordable to a large number of individuals, a third of individuals whose family incomes were greater than 200% of poverty reported that health insurance remained out of reach financially (Collins,

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Chapter 2 Policy and Politics Explained

Gunja, Doty, & B ­ eutel, 2017). The challenge posed by cutoffs is that the ACA has been neither as s­ uccessful as those who called for greater ­government intervention anticipated nor as costly as those who called for no government intervention suggested.

Markets versus Government The premise of direct governmental responsibility for the care of dependent populations, settled during The New Deal launched by President Franklin D. Roosevelt in 1933, has been reopened after eight decades. Rather than looking to government to secure social welfare, there is a growing desire in some quarters for government to retreat from the role of social provider of last resort. This call for smaller government is rationalized by a belief that government restricts freedom and the market is capable of meeting individual needs. The terms market and government are shorthand expressions that describe the two ways in which society conducts its business. Market means reliance on generally voluntary exchanges between private parties. Sometimes these exchanges are mandated and regulated by the government, as in the case of mandatory immunization for school children. Government means reliance on the direct provision of a service by government employees, as in the case of Veterans Affairs hospitals. It is not uncommon to use a combination of markets and government, as in the case of Medicare and Medicaid, where the government pays private providers to care for the elderly and poor. Most goods and services, including health care, are acquired through the market. The underlying reliance on the market as the arbiter of who gets and who does not get is based on a belief that market outcomes best serve individuals and, by extension, enhance the collective good. Consider the housing market’s response to an aging population’s need for supportive services. As the number of persons looking for housing alternatives not readily available in single-family or multiunit dwellings grew, companies such as

Marriott entered the senior housing market in response to this demand. This market-based solution, however, is limited to elderly consumers with sufficient purchasing power to afford Marriott’s products. For others, a government solution may be needed. Business can also influence consumer healthcare market behavior. The direct marketing of pharmaceuticals through television, print, and electronic advertising is intended to inform and direct consumers towards possible remedies for their health conditions. As these two examples make clear, a fundamental problem with market-based solutions is their inability to respond when affordability determines what can be purchased. Those who cannot afford essential goods and services must do without. However, what about services that ensure individual welfare, such as lifesaving, but expensive, surgery? In these cases, the market is almost always inadequate. It fails to assure distributive justice because it is premised on the unrealistic assumption that the transaction is an exchange among equals. Such an exchange is not possible in a society with an unequal distribution of income (Arrow, 1963). These are the situations where government intervenes (Stone, 2012). The government’s role is necessitated by this fundamental tension between the economic organization of the production and the distribution of goods and services and the social value of distributive justice. The market, left alone, tends to pull in the direction of economic inequality, but political beliefs demand a counterbalance regarding the distribution of rights and opportunities. The government becomes the counterbalance for persons who cannot provide for themselves through the market exchange of goods and services (Arrow, 1974). Through its policies and programs, the government provides for those who cannot fully participate in the market. It is this mechanism by which a society seeks to achieve greater equality. Its policies and programs are redistributive, which means that its actions are intended to benefit those who cannot care for themselves or may suffer losses given their inability to purchase needed goods and services in the market.

Policy Defined: A Framework for Government Action

Again, it is this basis on which the current debate about Obamacare is premised (Krugman, 2017).

Federalism The various concepts of responsibility for health policy are also tied to the American federalist system of government (Bovbjerg, ­Wiener, & ­Housman, 2003). When the nation was founded, the states ceded certain responsibilities to the federal government but retained others for themselves. According to the framers of the U.S. Constitution, the central government has express powers to levy taxes, declare war, and oversee interstate commerce. All power not expressly delegated to the federal government falls under the jurisdiction of the states. Also, within the federal government, there is a separation of powers among the legislative, executive, and judicial branches. This further constrains the power of the national government by dividing the government against itself. Finally, the Constitution limits both the federal and state governments by protecting individual rights that cannot be denied except through extraordinary procedures. Federalism refers to this dual system of state and federal governance, which limits the jurisdiction of the federal government. This system provides the context in which the patchwork pattern of health policy exists. Although there is a strong national government, the states were initially more important than the federal government in virtually all policies governing the lives of Americans, such as economic regulation, public health, and education. When President Franklin Pierce vetoed a law setting aside millions of acres of federal land to benefit the mentally ill, he reasoned that mental health was a state, not a federal, responsibility (Rothman, 1971). Despite individual welfare being defined as a state responsibility, there has been a constant expansion of federal power in this area since the Civil War. While the Constitution gave responsibility for individual welfare to the states, the Constitution gave the federal government authority to raise taxes for common defense and general welfare. The dire need caused by the Great Depression

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brought this contradiction between the states’ responsibility for the public’s welfare and resources of the federal government to provide for the public’s welfare into sharp focus. States did not have the financial capability to protect the well-being of their citizens because they had limited ability to raise funds through taxation or deficit financing. One result was a shift from a system of dual federalism to a system of cooperative federalism (Kernell & Jacobson, 2006). The federal government began to play an essential role in creating and funding social programs. Using grants-inaid programs, Congress appropriated money to state and local governments with the condition that the money be spent for the particular purposes defined by Congress. The Maternal and Child Health Service, whose goal was to improve the health of low-income mothers and children, is such a grants-in-aid program. From a policy perspective, cooperative federalism is necessary because Congress set national goals and guided state activity in the realm of social policy.

Courtesy of the Library of Congress, Prints & Photographs Division, preproduction number ppmsca 09733.

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Chapter 2 Policy and Politics Explained

The federal government assumed an even larger role regarding shaping and funding social welfare programs starting in the 1960s. The expansion of federal authority was in part a response to civil rights advocates who demanded greater regulation of state implementation of federal programs to achieve racial and social equality. The administration used the regulatory process to impose national standards on the states (Conlan, 2006). In addition, the federal government created categorical programs that funded community-based providers, bypassing state governments (Davis & Schoen, 1978). The Office of Economic Opportunity’s community health center program is an example of such a categorically funded program. In the late 20th century there was one more shift in the relationship between the federal government and the states. Starting with President Nixon, and affirmed during Reagan’s presidency, the push was to return authority to the states. Initially called the new federalism, it involves the devolution of authority to the states to define the parameters of federally funded social welfare programs (Anton, 1997). The expressed goal is to enable states to accommodate their unique needs better. This is not possible when the federal government is perceived as imposing a onesize-fits-all approach to social programs. Block grants became the mechanism by which greater discretion was given to the states to shape social welfare programs. The block grants essentially combine funding from several grant-in-aid programs and allow states to determine how the money will be spent to achieve broad programmatic goals. While early in the Trump presidency, the intent is to both shift power back to the states and make government smaller. The varied proposals for replacing the ACA are all premised on massive federal cuts that involve the elimination of the Medicaid expansion, and the devolution of authority to the states to address the health needs of its citizens. Federalism results in a fragmented system of governance (Steinmo & Watts, 1995). One consequence is the fragmentation and duplication of services arising from laws addressing

similar needs being passed at the federal, state, and local levels. Examples of such service gaps and duplication are easily recognized by those who serve older persons. An individual seeking long-term care is confronted with myriad programs, including Medicare and Medicaid as well as social service block grants developed under both the Social Security Act and the Older Americans Act, and state-initiated programs. Individuals must navigate this maze of programs to determine their eligibility for services, while providers must integrate the various funding streams to provide coordinated and comprehensive services where alignment does not necessarily exist. Fragmentation also impacts the ability to create a program of national health insurance. Given the dual regulatory system governing health insurance, neither the states nor the federal government could easily mandate employers to offer health benefits because neither governing body has regulatory authority over all businesses in a particular area (Mariner, 1996). The ACA amended the federal law to require employers of 50 or more persons to provide health insurance or pay the penalty. The ACA also mandated individuals not covered by the employer mandate to purchase health insurance. The U.S. Supreme Court upheld the constitutionality of the individual mandate in June 2012 as well as the penalty under the federal government’s power to collect taxes (Jost, 2012). However, the Internal Revenue Service (IRS), in response to the Trump administration’s effort to reduce the burden of the ACA, is not enforcing collection of the individual penalty. This revenue is used to support the Medicaid expansion and is essential to the financial viability of the ACA (Pear, 2017). The loss of revenue will further fragment access to services.

Governmental Intervention The government has several tools at its disposal to intervene when the market cannot adequately address a problem (Stone, 2012). Among these are taxation, service provision, and regulation.

The Policy-Making Process

Taxation is often considered the means by which government raises money to support its spending and influence behavior. Many states tax the sale of cigarettes to influence cigarette use (DeCicca, Kenkel, Mathios, Shin, & Lim, 2008). Higher cigarette taxes have resulted in lower rates of consumption. Medicare Part A, which covers hospital care, is financed by payroll taxes paid by employers and employees. The ACA is funded through multiple sources of taxation, including the extension of the Medicare payroll tax on high earners and a tax on unearned income from taxable interests and dividends, for example. Current bills to repeal the ACA are estimated to result in tax cuts of over $50,000 to persons earning more than $1 million dollars (Huang & Van De Water, 2017). Another tool is government support of service provision. In some cases, the government is the actual provider of services. Public hospitals were locally financed institutions organized to serve persons who cannot afford care. The Veterans Health Administration is a comprehensive healthcare system supported by the federal government for individuals with medical problems resulting from service-related injuries after discharge from the service. Alternatively, the government can purchase services from the private sector. Medicaid is an example of such a program. Medicaid enrollees seek services from approved providers whose bills are paid by a combination of state and federal funds. Such spending is designed to increase access to the market for persons with limited income. The government can also produce and purchase services. This is the case with biomedical research. The National Institutes of Health (NIH) has a large biomedical research complex that supports numerous researchers. Also, the NIH funds independent researchers at universities and research laboratories across the country. The purchase of services may also take an indirect form whereby the government subsidizes sellers to participate in markets that might not be competitive based on price. For example, medical education is extremely costly. Hospitals that train physicians cannot compete on price

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with nonteaching hospitals given the additional costs incurred for resident and faculty salaries and the additional resources used for patients seen by residents. As a result, Medicare funds residents’ salaries, thus subsidizing the hospitals where they train (Institute of Medicine, 2014). Another example is the orphan drug program. The government subsidizes pharmaceutical companies to research drugs that are used by a small number of persons and are therefore not profitable to develop and produce. Through these types of programs, the government encourages program expansion in areas that are not otherwise profitable (McCaughan, 2017). A third programmatic tool is government regulation of the market. Regulations are legal restrictions aimed to produce outcomes that otherwise might not occur. Examples of regulation include the licensure of physicians and other healthcare professionals (Grumbach, 2002). These regulations were adopted in the early 20th century as a way to protect the public from unqualified practitioners. Through a series of educational and practice requirements and a series of examinations, states determine who can and cannot provide medical and healthcare services. Another example of government regulation is state-mandated nursing-to-patient ratios for hospital-based care (Conway, Konetzka, Zhu, Volpp, & Sochal, 2008). These regulations are designed to protect patients by maintaining minimum staffing levels at all times.

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The Policy-Making Process

The policy process is often described in rational terms as a step-by-step series of decisions and actions that lead to a reasonable outcome. The process begins with agenda setting and continues through policy formulation and adoption, policy implementation, evaluation, and reevaluation (Kingdon, 1995). While the process can be broken down into a number of discrete events, the complexity or variance of what occurs is

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Chapter 2 Policy and Politics Explained

essential to understand that it may be possible to rationally explain how decisions were made at any point of the cycle, but not their content. There may be agreement as to the problem. For example, the problems in the healthcare system are generally described regarding the number of uninsured individuals, the high cost of health care that limits access, or the uneven quality of care. However, the agreement stops there. The attribution of causation and the presentation of solutions reflect the diversity of ideas held by the multiple stakeholders; each is attempting to define the problem and desired outcomes based on what they deem as “best.” This means there is no objective best answer. There is typically a range of competing best answers depending on the perspective from which one views the problem. “Best” is thus an important but always-loaded term because the process is a political one. At each twist and turn in the policy processes, best is determined by the stakeholders that hold the greatest sway over the decisions that will be made. The government’s role typically becomes one of mediation between these interests as it formulates, creates, and implements policies and programs that aim to achieve broader social goals.

Interest Groups in the Health Field The healthcare field is composed of many players, both inside and outside government. Because health and health care are fundamental to our well-being, it is a sphere of activity in which everyone has a vested interest. While it is possible to speak about the public’s interest, interest groups typically refer to people and organizations with the most immediate stake in a problem and its resolution (Stone, 2012). These groups are known and identifiable. They represent multiple interests, and each one is trying to influence the direction of government policy. The challenge for someone interested in the ­policy-making process is to understand how

these interests are organized, their policy perspective, and the influence they wield in shaping what policy is adopted at any particular point in time. In the following section, the primary stakeholders or interest groups in the healthcare arena are identified as well as the changing power of these groups to influence policy outcomes. The American public’s health and well-being is the focus of health policy, but Americans do not speak with a single voice. There is tremendous variation in health status by age, socioeconomic status, and racial and ethnic background. As a result, many different organizations advocate on the public’s behalf. In each case, they are concerned with enabling the population groups they represent to access services that would improve the quality of their lives, ­including a greater voice in the decisions that affect their health (Schneider, 1998). They want to become active participants in their care. Some organizations support better treatment modalities and financing for discrete services, such as the American Cancer Association, the American Lung Association, and the National Mental Health Association. Others represent the needs of population-based groups. The largest groups active in policy making represent women, older persons, the disabled, the poor, and racial and ethnic minorities. Typically, the public’s first point of contact with the healthcare system is when they seek services. The organization and delivery of services can broadly be categorized in terms of two groups: clinicians and the organizations where they work. Their interests lie with the nature of services provided and how well or poorly they are organized and delivered. On the provider side, one can speak about physicians, nurses, and other practitioners and technicians. On the institutional side, there are hospitals and nursing homes, and community-based providers such as community health centers. These groups do not speak with a single policy voice as their perspectives differ. Historically, the technical expertise of physicians justified their control over the organization

The Policy-Making Process

and delivery of medical services (Freidson, 1970; Starr, 1982). Their authority extended to state-supported control over the healthcare field. Physicians determined the regulation of medicine through state licensing procedures. Physicians as a group are represented by the American Medical Association (AMA). The power of the AMA was legendary, but also circumspect. Physicians actively advocated against programs, such as national health insurance, because they feared it would enable the government to regulate the provision of health services and the ­physician–patient relationship. The AMA’s interest typically remains at the broadest level as they avoid specific policy issues when the benefit of their members can be at odds. As a result, the different medical specialties are represented by their organizations. The nursing profession’s interests diverge from those of physicians because they focus more on the process of care as opposed to cure (Glouberman & Mintzberg, 2001). However, like physicians, nurses are represented by m ­ ultiple organizations, including the American Nurses Association, American Association of Colleges of Nursing, the National League for Nurses, and the Association of Nurse Executives. They often work jointly when addressing issues surrounding health, health care, and nursing practice, but take independent positions on specific ­issues such as unionization. The same holds true for institutional providers. On the ­provider side, the American Hospital Association is the primary advocacy group for the hospital i­ ndustry, but voluntary, public, and forprofit hospitals each have their own associations, as do a­ cademic health centers. Their interests are often focused on how the financing of care can be structured to assure access for the populations they serve. Critical to the system are organizations that pay for health services. Each of these groups has a concern for the well-being of the population, but each one also has a stake in developing financing and reimbursement methods that are responsive to their particular concerns.

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The business community, for example, is the prime purchaser of health care. They are interested in controlling what they spend on employee health benefits while providing a package of service that meets employees’ needs. There is a plethora of organizations that represent business interests, including the U.S. Chamber of Commerce, which advocates on behalf of small businesses. The business sector typically works in conjunction with insurance companies that are represented by the Health Insurance Association of America. The federal and state governments are also major purchasers of services. The U.S. Department of Health and Human Services (HHS) administers federal health programs. The National Governors Association represents the interests of state governments. The role of the medical supply industry in health policy decisions is expanding as technology plays a greater role in the provision of health care and comprises a growing percentage of healthcare spending. The pharmaceutical industry, which is represented by the Pharmaceutical Research and Manufacturers of America (PhRMA), is the fastest growing part of this sector. The American healthcare system is known for its technological know-how and the interests of these companies, represented by Advanced Medical Technology Association, must also be taken into account. Closely aligned with provider groups are knowledge producers who advance the science that underpins medical care and its organization and financing and establishes and maintains standards for medical practice. This includes universities and biomedical research organizations. There are also think tanks that produce and disseminate healthcare research, such as the Institute of Medicine, the Kaiser Family Foundation, and the Commonwealth Fund. Last are organizations like the American Association of Medical Colleges and The Joint Commission that work to maintain the standards of medical practice through accreditation, examinations, and licensing.

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Chapter 2 Policy and Politics Explained

Politics of Decision Making In most cases, the social problems addressed by the government have been known and part of the national dialogue for many years. The government, however, does not assume an activist stance on all issues at all times. As a result, there are periods of relative stasis when the government is not called upon to play a highly interventionist role. Rather, it makes incremental changes to improve upon existing policy or advance programs that are limited in scope and whose impacts are understood (Baumgartner, Jones, & Mortensen, 2018). However, the situation can change, and there can be a window of opportunity that brings an issue to the forefront (­Herweg, Zahariadis, & Zohlnhofer, 2018). This can result in large-scale departures from the past. There are different types of events that elevate an issue at a particular point in time (Peterson, 1993). The government is often responsive to the external environment such as a natural disaster like Hurricane Katrina or, more recently, Hurricane Harvey. Many public health issues that had been ignored before the hurricane, such as emergency preparedness, were suddenly perceived as needing immediate action (Fee & Brown, 2002). Interest groups also have the tools to advance their agendas. The series of lawsuits brought against tobacco companies in the 1990s, which led them to seek liability protection in exchange for greater regulation, is an example of the use of the legal system (Pertschuk, 2001). Presidents can also advance a policy issue. Most recently, Presidents Clinton, Obama, and now Trump have made healthcare reform one of the central issues of their presidencies. This overarching concern has dominated health policy making. These triggering events and their ability to shape the political agenda and policy options are heavily influenced by politics of the time (Kingdon, 1995). Obama’s campaign in 2008 was framed by the ideas of hope and change. Given the crash of the financial markets, people were looking for some assurances about the economic well-being of the country. There was a

Democratic majority in the House and the Senate that could assure passage of the ACA with or without partisan support. A similar scenario unfolded concerning repeal. Trump’s campaign to “make America great again” was directed at people who had not benefited from the economic recovery following the recession of 2008. For many middle-income persons, the ACA resulted in higher health costs as a result of rising premiums and deductibles, or their decision to pay the penalty under the individual mandate. With Republicans in control of both Congress and Senate, the executive branch assumed that repeal and replace would not be difficult to achieve. But the consensus on how to proceed was not there (Shabad, 2017).

Identifying the Direction of Policy Change Once a policy issue and its political framing become part of the public agenda, the relevant question becomes which alternative will have the greatest chance of succeeding. Typically, it is argued that the ideas and programs of interest groups with the greatest access to policymakers have the greatest chance of success, while others struggle to be heard (Schnattschneider, 1960; Bachrach & Baratz, 1962). However, the changing parameters of healthcare reform, as supported by the Obama and Trump administrations, demonstrate that the influence of healthcare interest groups is not equal or fixed. Power can become realigned over time, as can the importance of different stakeholders. The changing balance of power must be seen as part of the ongoing nature of the policy process. There is rarely a situation where policymakers start with a clean slate. Rather, they are responding to the conditions resulting from existing policy and programs (Weible, 2018). Sometimes policy implementation achieves its goals and furthers social equity, but at times there can be unintended consequences that worsen the outcomes for many people. It is this tension over who benefits and who is left behind

The Policy-Making Process

that sets up the political conditions for change and the ability of different actors to influence the situation. The passage of Medicare and Medicaid in 1965 marked the first time the federal government provided health insurance for anyone other than federal employees and the military. The legislation garnered widespread support because it was responsive to the dominant healthcare interest groups. The hospitals backed Part A because charges would be determined retrospectively based on actual costs, and they would receive reimbursement for persons who previously had trouble paying for hospital care. Physicians and the AMA, as well as the Republicans, supported Part B because it was voluntary and did not undermine the doctor–patient relationship by creating a broader precedent for the government provision of care. Insurance companies supported Medicare because they would be responsible for claims administration. For Democrats, Medicare was a social insurance program that set a precedent for government-provided universal coverage (Marmor, 1973). These programs were built around the interests of the most influential stakeholders, but they also broke new ground in making health care more widely affordable and, therefore, accessible. What was unforeseen at the time Medicare and Medicaid were passed was that the implementation of these programs would shift the balance of power away from physicians and towards institutions whose interests centered on the financing of health care (Morone, 1995). Following implementation of Medicare and Medicaid, healthcare costs began to rapidly increase due to expanded access to medical care and the ways payments were calculated. Healthcare expenditures almost doubled from 5.6% of the gross domestic product (GDP) in 1965 when the legislation was passed to 10.1% by 1983 when the government implemented a revised hospital payment system from one based on actual costs to one based on fixed costs (Centers for Medicare & Medicaid Services, 2016). The policy issue was recast from one of access to one of cost containment. Physician groups

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who benefited greatly from the expansion of health services were not looked to for the solution. Their medical expertise regarding the organization and delivery of care did not carry the same weight as the managerial expertise of systems administrators, including third-party payers who understood healthcare financing. These groups were in a better position to control costs by creating financial incentives to influence physician practice patterns (Weissert & Weissert, 2012). The government took the lead in controlling hospital costs when it changed Medicare reimbursement and incentivized the growth of managed care. This resulted in the consolidation of health providers under the control of hospitals and large multispecialty group practices and, ultimately, a rebalancing of power between physicians and institutional providers and payers of care in determining how health care would be organized and delivered (Relman, 1980; Starr, 2017). Like Medicare and Medicaid, the ACA can be understood as both an extension and disruption of existing policies and programs. By the time the ACA was passed, the number of uninsured was approaching one-fifth of the population (KFF, 2016). In addition, healthcare spending continued to rise and accounted for over 17% of GDP. The goal of the ACA was to expand access and contain costs. The ACA used private insurance markets to make individual health insurance more widely available by providing subsidies or tax credits to persons with incomes between 138% and 400% of poverty. The fundamental change was the Medicaid expansion. Under the ACA, Medicaid was reconceived as a universal insurance program for all people with incomes below 138% of poverty (Nardin, Zallman, ­McCormick, Woolhandler, & Himmelstein, 2013). Although the Supreme Court made the expansion optional, at this time, over 20% of the population is insured by Medicaid (KFF, 2017). The Republican effort to repeal the ACA is aimed at returning the organization, delivery, and financing of health care to the market (Jost, 2017). Rather than looking to government to provide a public benefit, the Republican bills to repeal and replace the ACA use a system of tax

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Chapter 2 Policy and Politics Explained

credits to ensure the affordability of health insurance. Rather than requiring insurers to provide a basic package of federally defined essential benefits, insurers can offer minimal coverage at lower costs. Rather than mandating that individuals have basic health coverage, Republicans assume that individuals can anticipate the levels of health insurance that would best meet their needs. However, lower costs shift the financial risks and health outcome risks on to patients. This takes us back over four decades. As Kenneth Arrow (1974) pointed out in the early 1970s, the market does not work when there is an unequal distribution of income and the market goods are costly and essential to individual well-being. Health care now accounts for almost one-fifth of the economy (18% of GDP). Given that sizable portion of the economy, major institutional players actively protect their positions when it comes to health policy. This can be seen in the amount of money being spent to influence legislators (OpenSecrets.org, n.d.). In 2016, the pharmaceutical and health product industry spent over one-quarter of a billion dollars ($248,733,749) on lobbying. This was the most of any industry in the country. Pharmaceuticals were followed by insurance companies, which spent almost $153 billion. In eighth place was the hospital and nursing home industry, whose combined spending was just under $100 million. The healthcare industry also donated almost $200 million to parties and candidates in the 2015 to 2016 election cycle—51% to Democrats and 48% to Republicans. These industry groups would not spend such large sums if they were not looking to influence impending health policy decisions in directions that furthered their economic interests but were aligned with the underlying goals of access, cost, and quality.

Policy Adoption and Implementation Policy is enacted through the legislative process. Elected officials decide the broad outlines of policy when they enact laws, but they do not act in a vacuum. They act upon proposals that have

already been negotiated among all of the interested stakeholders during the process of policy formation. These negotiations continue right up until the moment that the proposed legislation comes under review by Congress and is written into law (Weissert & Weissert, 2012). Government seeks to advance broader social interests while being responsive to vested power in the healthcare industry that demands concessions in the programs being advanced. Medicare created a managed care program, Part C, that is controlled by managed care companies to exist alongside traditional Medicare that is controlled by the health providers. Until recently, Part C costs exceeded those of traditional Medicare, but the government subsidized the difference (Biles, Casillas, & Guterman, 2016). Likewise, Medicare Part D, the Prescription Drug Plan, does not allow the government to use its buying power to negotiate pharmaceutical prices. Passage of the ACA also required the support of powerful interest groups, such as the hospital sector, insurance industry, and small businesses. Despite opposition, President Obama moved ahead in a relatively expeditious way. Their support was obtained by making concessions to large stakeholders. The most significant was the elimination of the ­government-sponsored health insurance option (Oberlander, 2010). Legislation provides the broadest possible outline of a program. The specificity of the law determines the flexibility that the administration has in its implementation (Lowi, 1979). There are advantages and disadvantages to both choices. A bill in which the details are clearly specified may encounter difficulty in Congress because groups may oppose the particulars and disregard the overarching goals, which was the case in Clinton’s health reform. A consensus can be more easily built around a law with broad goals and few details (Stone, 2012). In that case, decisions about implementation are left to the administering agencies. How an agency chooses to implement the program can have a tremendous influence on its outcome (Jacobson & Wasserman, 1999;

What Is at Stake for Nurses and Other Health Professionals?

Morone, 1995; Pressman & Wildavsky, 1973). The leadership of the agency must be in accord with the program’s goals so it does not languish, and the personnel must have program expertise to implement it effectively (Peterson, 1993). Organized interests that were instrumental throughout the legislative process play a comparable role during its implementation. They work with the administrative agencies to ensure that the application meets their interests by monitoring the process (Pressman & Wildavsky, 1973). The Obama administration nominated Donald Berwick to serve as Director of the Centers for Medicare and Medicaid Services. He had played a significant role in the development of the ACA. The Trump administration appointed Tom Price as Secretary of HHS. A fierce opponent of the ACA, his administration has begun to weaken enforcement of the individual mandate, impose work requirements on Medicaid recipients, and limit outreach to the uninsured during open enrollment (Park & Sanger-Katz, 2017). Programs do not always achieve their stated goals. There are unintended consequences that result from any legislative act. The cyclical nature of the policy process becomes apparent. The proposed solutions in one period set up the problems that need be addressed in the next. One result of bringing all interested parties into the ACA is that the most recent (2017) efforts to repeal were not successful. Although there is widespread dissatisfaction with the ACA, the Republicans misread its meaning. The public was disappointed that the ACA had not controlled the cost of health care as promised. However, they did not support repeal. They wanted Congress to address the unintended cost consequences of the ACA so the legislation would realize the level of protection it had promised (Jacobs & Mettler, 2017). Also, there was a noticeable absence of support from all interest groups (Leonhardt, 2017). Despite the noticeable lack of support, the Congressional Budget Office’s estimates that as many as 14 million persons might lose health insurance in 2018, and estimates from the insurance industry that individual premiums could

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rise as much as 25%, most Republicans supported repeal of the ACA. They considered the market for health care so distorted by government programs that repeal was the only way to wipe the slate clean and begin again (Ponnuru & Levin, 2013). Whether one agrees or not with the Republican “wipe the slate clean” policy approach, it is up against a powerful real-world coalition of vested interests that are at best inclined towards incremental change in an otherwise working system.

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What Is at Stake for Nurses and Other Health Professionals?

Healthcare professionals and their patients experience the impact of the implementation process on a daily basis. How patients are recruited to programs such as state insurance exchanges is determined by the regulations of these programs. Which companies offer health plans, and the scope of these plans under the exchanges, are the result of program guidelines and the payment rates for physicians participating in accountable care organizations (ACOs). These are examples of how policy developed by federal or state legislatures and implemented by federal and state administering agencies are realized in the ways health care is provided and administered. Although their work is seemingly distant, their impact is immediate regarding access to quality, cost effective care. The work of nurses and other health professionals tends to be highly individualized. By interacting with patients, these individuals see the many problems that result from policy decisions made at a distance. They understand how physicians’ orientation toward care can overrule nurses’ orientation toward care (Glouberman & Mintzberg, 2001). They observe how the loss of healthcare insurance can result in patients deferring care, much to their detriment. They understand that the pursuit of quality patient care

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Chapter 2 Policy and Politics Explained

is dependent on their ability to engage and use nursing resources effectively, which will likely become more challenging as the nursing shortage persists and resources become increasingly limited (Rother & Lavizzo-Mourey, 2009).

© Samuel Perry/Shutterstock

In many cases, these professionals become the patients’ advocates, but historically they have not played a major role in the initial development of the policies that have such a tremendous impact on their work and the lives of their patients. Some have attributed this to heavy workloads. Others have discussed the educational process that socializes nurses to distance themselves from politics. Still others speak about the difficulty nurses have had in asserting their professional authority when they find themselves up against dominant interests, such as physician groups, hospitals, and payers. Regardless of the cause, nurses and other health professionals are asserting a greater voice in the policy-making process (Clarke, Swider, & Bigley, 2013; Needleman & Hassmiller, 2009). Nurses and other health professionals are finding themselves with greater authority and are leading several policy-related discussions. The healthcare labor force, which has been described as a pyramid with physicians at the apex directing all related medical practice, is changing. As the provision of care becomes increasingly complex, team-based care is taking hold. Physicians are working as collaborators with alternative practitioners with differing areas of

expertise (Wynia, Kohorn, & Mitchell, 2012). Nurses and other health professionals who took instruction from doctors for matters related to direct patient care are being recognized for their expertise. They have become strong advocates for interprofessional education and have even begun to seek professional status and the right to independent practice. Professional associations, such as those for physical therapists and nurse practitioners, are lobbying on a state-by-state basis to change licensing laws so these clinicians can practice independently and receive direct reimbursement for their services. Such laws recognize the shifting base of power within the health field through the creation of alternative centers of authority. By understanding the process and how it has shaped the organization and delivery of health care, it is possible to understand the terms of engagement. Since the 1990s, the market was assumed to bring greater efficiency to the organization and delivery of health care. It is the failure of this approach that reinvigorates interest in its politics. We know that the problems of health costs, access, and quality have not been fully resolved. The critical challenge remains one of determining how health care should be organized and delivered to ensure the best possible health outcomes for the population. Determining what will be the trade-offs between access, costs, and quality will impact the situation that nurses and other professionals confront every day. Nurses and other healthcare providers need to become one of the dominant voices in the policy-making and policy-­implementation process for how the healthcare system will best meet the needs of the people it serves.

Discussion Questions 1. 2. 3.

What are the limits of the market in the provision of health services? Why does the federalist system of government result in the fragmentation of healthcare delivery? What makes policy alternatives political in nature?

References

4. 5.

Why has the dominance of physicians given way to corporate interests? Why are nurses and other health professionals beginning to find themselves with greater stature in the health policy arena?

References Anton, T. (1997). New federalism and intergovernmental fiscal relationships: The implications for health policy. Journal of Health Politics Policy and Law, 22(3), 691–720. Arrow, K. J. (1963). Uncertainty and the welfare economics of medical care. The American Economic Review, 53(5), 941–974. Arrow, K. J. (1974). The limits of organization. New York, NY: W. W. Norton. Bachrach, P., & Baratz, M. (1962). Two faces of power. American Political Science Review, 56, 4632–4642. Baumgartner, F. R., Jones, B. D., & Mortensen, P. B. (2018). Punctuated equilibrium theory: Explaining stability and change in public policymaking. In C. M. Weible & P. A. Sabatier (Eds.), Theories of the policy process (4th ed., pp. 55–101). New York, NY: Westview Press. Biles, B., Casillas, G., & Guterman, S. (2016, January). Does Medicare Advantage cost less than traditional Medicare? The Commonwealth Fund Policy Brief. Retrieved from http://www.commonwealthfund.org/publications/issue -briefs/2016/jan/does-medicare-advantage-cost-less Bovbjerg, R., Wiener, J., & Housman, M. (2003). State and federal roles in health care: Rationales for allocating responsibilities. In J. Holahan, A. Weil, & J. Wiener (Eds.), Federalism and health policy (Vol. 3, pp. 25–51). Washington, DC: Urban Institute Press. Brown, L. D., & Sparer, M. S. (2003). Poor program’s progress: The unanticipated politics of Medicaid policy. Health Affairs, 22(1), 31–44. Centers for Medicare & Medicaid Services. (2016, December 6). National health expenditure data: Historical. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems /Statistics-Trends-and-Reports/NationalHealthExpend Data/NationalHealthAccountsHistorical.html Clarke, P. N., Swider, S., & Bigley, M. B. (2013). Nursing leadership and health policy. Nursing Science Quarterly, 26(2), 136–142. Retrieved from https://doi .org/10.1177/0894318413477146 Collins, S. R., Gunja, M. Z., Doty, M. M., & Beutel S. (2017, February 1). How the Affordable Care Act has improved Americans’ ability to buy health insurance on their own. The Commonwealth Fund. Retrieved from http://www .commonwealthfund.org/publications/issue-briefs/2017 /feb/how-the-aca-has-improved-ability-to-buy-insurance Conlan, T. (2006). From cooperative to opportunistic federalism: Reflections on the half-century anniversary of the commission on intergovernmental relations. Public Administration Review, 66, 663–676.

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Conway, P. H., Konetzka, T. R., Zhu, J., Volpp, K. G., & Sochal, J. (2008). Nurse staffing ratios: Trends and policy implications for hospitalists and the safety net. Journal of Hospital Medicine, 3(3), 193–199. Davis, K., & Schoen, C. (1978). Health and the war on poverty: A ten year appraisal. Washington, DC: Brookings Institution. DeCicca, P., Kenkel, D., Mathios, A., Shin, Y. J., & Lim, J. Y. (2008). Youth smoking, cigarette prices, and anti-smoking sentiment. Health Economics, 17, 733–749. Deloitte. (2014). The great consolidation: The potential for rapid consolidation of health systems. Retrieved from https://www2.deloitte.com/content/dam/Deloitte/us /Documents/life-sciences-health-care/us-lshc-great -consolidation-111214.pdf Fee, E., & Brown, T. M. (2002). The unfulfilled promise of public health: Déjà vu all over again. Health Affairs, 21(6), 31–43. Freidson, E. (1970). Profession of medicine: A study of the sociology of applied knowledge. New York, NY: Dodd, Mead. Glouberman, S., & Mintzberg, H. (2001). Managing the care of health and the cure of disease: Part I: Differentiation. Health Care Management Review, 26(1), 56–69. Grumbach, K. (2002). Fighting hand to hand over physician workforce policy: The invisible hand of the market meets the heavy hand of government planning. Health Affairs, 32(5), 13–27. Herweg, N., Zahariadis, N., & Zohlnhofer, R. (2018). The multiple streams framework: Foundations, refinements, and empirical applications. In C. M. Weible & P. A. Sabatier (Eds.), Theories of the policy process (4th ed., pp. 17–53). New York, NY: Westview Press. Huang, C-C, & Van De Water, P. N. (2016, December 15). Millionaires the big winners from repealing the Affordable Care Act, new data show. Center on Budget and Policy Priorities. Published online July 26, 2017. Institute of Medicine. (2014). Graduate medical education that meets the nation’s health needs. Washington, DC: National Academies Press. Jacobs, L. R., & Mettler, S. (2017, July 31). Outside of Washington, there is a new vital center in health care reform. Health Affairs Blog. Retrieved August 1, 2017 from http://healthaffairs.org/blog/2017/07/31/outside -of-washington-there-is-a-new-vital-center-in-health -care-reform/ Jacobson, P., & Wasserman, J. (1999). The implementation and enforcement of tobacco control laws: Policy implications for activists and the industry. Journal of Health Politics Policy and Law, 24, 567–598. Jost, T. S. (2012). The Affordable Care Act largely survives the Supreme Court’s scrutiny—but barely. Health Affairs, 31(8), 1659–1662. Jost, T. S. (2017). First steps of repeal, replace, and repair. Health Affairs, 36(3), 398–399. Kaiser Family Foundation (KFF). (2016, September 29). Key facts about the uninsured population. Menlo Park,

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CA: Henry J. Kaiser Family Foundation. Retrieved from http://www.kff.org/uninsured/fact-sheet /key-facts-about-the-uninsured-population/ Kaiser Family Foundation (KFF). (2017, July 14). Kaiser Health tracking poll: The public’s views on the ACA. Menlo Park, CA: Henry J. Kaiser Family Foundation. Retrieved from http://www.kff.org/interactive/kaiser -health-tracking-poll-the-publics-views-on-the-aca/ Kernell, S., & Jacobson, G. C. (2006). The logic of American politics (3rd ed.). Washington, DC: CQ Press. Kingdon, J. W. (1995). Agendas, alternatives, and public policies. New York, NY: Harper Collins College. Knowles, J. H. (1977). The responsibility of the individual. In J. H. Knowles (Ed.), Doing better and feeling worse: Health in the United States. Cambridge, MA: American Academy of Arts and Sciences. Krugman, P. (2017, July 17). The healthcare debacle: The roles of ignorance and evil. The New York Times. Retrieved August 2, 2017 from https://krugman.blogs.nytimes .com/2017/07/17/the-healthcare-debacle-the-roles-of -ignorance-and-evil/ Leonhardt, D. (2017, July 27). Opinion | ‘Skinny’ cynicism on health care. The New York Times. Retrieved from https://www.nytimes.com/2017/07/27/opinion/skinny -cynicism-on-health-care.html Lowi, T. (1979). The end of liberalism: Ideology, policy, and the crisis of public authority (2nd ed.). New York, NY: W. W. Norton & Company. Lowi, T., & Ginsberg, B. (1998). American government (5th ed.). New York, NY: W. W. Norton & Company. Mariner, W. (1996). State regulation of managed care and the Employee Retirement Income Security Act. New England Journal of Medicine, 335, 1986–1990. Marmor, T. (1973). The politics of Medicare. Chicago, IL: Aldine Press. McCaughan, M. (2017). Pricing orphan drugs. Health Affairs. Retrieved from http://www.healthaffairs.org /healthpolicybriefs/brief.php?brief_id=168 McMorrow, S., & Holahan, J. (2016, June 1). Implications of health spending growth slowdown on the Affordable Care Act. Princeton, NJ: Robert Wood Johnson Foundation. Retrieved from http://www.rwjf.org/en/library /research/2016/06/the-widespread-slowdown-in-health -spending-growth-implications-f.html Midgley, J., & Livermore, M. (Eds.). (2008). The handbook of social policy. Los Angeles, CA: Sage Press. Morone, J. (1995). Elusive community: Democracy, deliberation, and the reconstruction of health policy. In M. Landy & M. Levin (Eds.). The new politics of public policy (pp. 180–204). Baltimore, MD: Johns Hopkins University Press. Nardin, R., Zallman, L., McCormick, D., Woolhandler, S., & Himmelstein, D. (2013). The uninsured after implemen­ tation of the Affordable Care Act: A demographic and geographic analysis. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2013/06/06/the-uninsured

-after-implementation-of-the-affordable-care-act-a -demograhic-and-geographic-analysis/ Needleman, J., & Hassmiller, S. (2009). The role of nurses in improving hospital quality and efficiency: Real-world results. Health Affairs, 28(4), w625–w633. Oberlander, J. (2010). Long time coming: Why health reform finally passed. Health Affairs, 29(6), 1112–1116. OpenSecrets.org. (n.d.). Lobbying spending database. Retrieved August 18, 2017 from https://www.opensecrets .org/lobby/top.php?showYear=2016&indexType=i Park, H., & Sanger-Katz, M. (2017, July 19). 3 things Trump is already doing to ‘Let Obamacare Implode.’ The New York Times. Retrieved from https://www.nytimes.com /interactive/2017/07/19/us/what-trump-can-do-to-let -obamacare-fail.html Pear, Robert. (2017, July 3). Congress moves to stop I.R.S. from enforcing health law mandate. The New York Times. Retrieved from https://www.nytimes.com/2017/07/03 /us/politics/congress-moves-to-stop-irs-from-enforcing -health-law-mandate.html Pertschuk, M. (2001). Smoke in their eyes: Lessons in movement leadership from the tobacco wars. Nashville, TN: Vanderbilt University Press. Peterson Center on Health Care and Kaiser Family Foundation (PCHC-KFF). (2017, July 26). How does health spending in the U.S. compare to other countries? Peterson-Kaiser Health System Tracker. Retrieved from http://www.healthsystemtracker.org/chart-collection /health-spending-u-s-compare-countries/ Peterson, M. A. (1993). Political influence in the 1990s: From iron triangles to policy networks. Journal of Health Politics, Policy and Law, 18, 395–436. Ponnuru, R., & Levin, Y. (2013, November 13). Ponnuru and Levin: A conservative alternative to ObamaCare. The Wall Street Journal. Retrieved from https://www.wsj .com/articles/a-conservative-alternative-to-obamacarea -conservative-alternative-to-obamacare-1384382566?ns =prod/accounts-wsj Pressman, J. L., & Wildavsky, A. (1973). Implementation. Berkeley, CA: University of California Press. Relman, A. S. (1980). The new medical–industrial complex. New England Journal of Medicine, 303, 963–970. Rother, J., & Lavizzo-Mourey, R. (2009). Addressing the nursing workforce: A critical element for health reform. Health Affairs, 28(4), w620–w624. Rothman, D. J. (1971). The discovery of the asylum: Social order and disorder in the New Republic. Boston, MA: Little, Brown. Schnattschneider, E. E. (1960). The semisovereign people: A realist’s view of democracy in America. New York, NY: Holt, Rinehart, and Winston. Schneider, C. E. (1998). The practice of autonomy: Patients, doctors, and medical decisions. New York, NY: Oxford University Press. Shabad, R. (2017, July 28). Why John McCain, Susan Collins and Lisa Murkowski bucked their party. CBS News. Retrieved July 31, 2017 from http://www.cbsnews.

References com/news/why-john-mccain-susan-collins-and-lisamurkowski-bucked-their-party/ Starr, P. (1982 and 2017 edition). The social transformation of American medicine. New York, NY: Basic Books. Steinmo, S., & Watts, J. (1995). It’s the institutions, stupid! Why comprehensive national health insurance always fails in America. Journal of Health Politics, Policy and Law, 20, 329–372. Stevens, R. (1971). American medicine in the public interest. New Haven, CT: Yale University Press. Stone, D. (2012). Policy paradox: The art of political decision making (3rd ed.). New York, NY: W. W. Norton & Company.

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Weible, C. M. (2017). Introduction: The scope and focus of policy process research and theory. In C. M. Weible & P. A. Sabatier (Eds.), Theories of the policy process (4th ed., pp. 1–13). New York, NY: Westview Press. Weissert, W. G., & Weissert, C. S. (2012). Governing health: The politics of health policy (4th ed.). Baltimore, MD: Johns Hopkins University Press. Wynia, M. K., Kohorn, I. V., & Mitchell, P. H. (2012). Challenges at the intersection of team-based and patient-centered health care: Insights from an IOM working group. JAMA, 308(13), 1327–1328. Retrieved from https:// doi.org/10.1001/jama.2012.12601

CHAPTER 3

A Policy Toolkit for Healthcare Providers and Activists Roby Robertson and Donna Middaugh

OVERVIEW What is the role of healthcare professionals in the political process? Given the range of issues, where does the political process begin and end? Healthcare policy is centered around the notion that all healthcare providers require a fundamental understanding of the healthcare system that is not limited to the knowledge required to practice their discipline. No longer can healthcare professionals be prepared solely for clinical practice. They must ready themselves to deal with the economic, political, and policy dimensions of health care because the services they provide are the outcome of these dynamics.

OBJECTIVES ■■ ■■

■■

■■ ■■ ■■

Define the role of healthcare professionals in policy advocacy and politics. Describe processes for becoming a policy advocate within one’s own organization, profession, and community. Recognize the difference between expertise and internal and external advocacy in relation to stakeholders. Describe benefits of using an interdisciplinary collaborative approach in policy advocacy. Apply the concepts of health policy to case study vignettes. Develop one’s own toolkit for becoming a health policy advocate.

© Anthony Krikorian/Shutterstock

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Chapter 3 A Policy Toolkit for Healthcare Providers and Activists

Introduction

Professional nurses and other allied health practitioners must have a seat at the policy table, but they must also understand the perspectives of their colleagues; therefore, we have used contributors from outside of nursing, including allied health professionals, activists, politicians, economists, and policy analysts who understand the forces of health care in the United States. The rationale behind an interdisciplinary approach is that no one person has the right solution to the challenges confronting health care in the U.S. These challenges include high costs, limited access, medical errors, variable quality, administrative inefficiencies, and a lack of care coordination. It is not surprising that the healthcare system is under serious stress and that a host of actors, both within and beyond the system, have myriad solutions to the problem. This chapter offers current and future healthcare practitioners who are committed to reducing health disparities and achieving healthcare equality insight into how clinical practice is derived from regulations and laws that are based on public policy and politics. It is important to note that politics is both necessary and critical to making changes, whether we are discussing system-level reforms (e.g., national health insurance reform) or a local hospital improving health data access (e.g., electronic medical records). This chapter provides healthcare practitioners a toolkit, or a working model, of how to “do” policy advocacy within and beyond our organizational lines. The toolkit is based on the ability to answers these questions: What is the health professional’s role in policy advocacy and politics? How is that role changing in the midst of organizational evolution where strict bureaucratic control is being replaced with more flexible models of collaborative decision making across public, private, and nonprofit arenas? In addition, this chapter examines two broad components of policy change: the influence and power of stakeholders or constituencies, and the

power of expertise. Although these arenas overlap, here we examine them separately to portray their specific roles more accurately. What, then, is the healthcare practitioner’s role in the political process? Where does that process take place? In this chapter we examine the dynamics of the process. Many traditional views define the political process as external only, primarily defined at the policy-making levels of government or boards and commissions; therefore, the argument follows that professionals below senior-level decision makers are primarily reactive—that is, they respond to proposals from up the line and must calculate how to implement changes that others have imposed on them. In public administration this has traditionally been defined as a politics/administration dichotomy; that is, political decisions are made by higher ups, and the administrator finds a way to carry out those decisions. That dichotomy, however, is not reflective of reality because in actual decision making and in the practicalities of day-to-day management, policy shaping and implementation within a given organization are the result of interactions at all levels of the organization. The administrators are trying to influence policy outcomes, like those in the policy arena. It is time that healthcare practitioners do the same. There is another reason why practitioners must develop a political/policy toolkit. Politics and policy making are not a function only of the external environment of the organization. In fact, the most sophisticated and nuanced elements of such a policy/political role can also be found in the internal environment of the organization. Again, practitioners can play a role in influencing these outcomes. Imagine the following scenario: Your senior executive pulls you aside one day and says, “Do you know that proposal you’ve wanted to push forward about how we reallocate the staff here in the organization? Well, why don’t you put together the budget, a time line, and what we need to do to move this forward in the next budget cycle?” You have been anxious to do so

Introduction

for some time, and you stay in the office every evening detailing the proposal (with fancy pie charts, a time line, personnel requirements, etc.), and you turn it in to your executive. A week goes by, and then two, then three. You are getting anxious; to start some of the time line issues you would need to get rolling soon, but you’ve heard nothing. You mention it to the executive and she nods, looks solemn, and asks you back into the office. She sits on the edge of the desk (not behind the desk, not a good sign) and pulls out your proposal. You can see it has lots of red marks throughout. The executive shakes her head and says, “Well it really is a great idea; it really is the way to go in the future, but I ran it up the line, and well, you know, politics got in the way. It’s just not going to fly!” She hands back your proposal. You return to your office and open the file cabinet of other projects that didn’t get off the ground, and you think, politics! Why didn’t it fly? What could have happened? Senior managers did not like the proposal? It competed with other proposed changes that could fly. What kept yours from flying? Perhaps it was because you had not accounted for the politics of your own organization. Politics exist at the organizational level, not just at the policy-making level, and you did not take those considerations into account. Thus, our approach in this chapter suggests that the politics of the environment are both external and internal. In all areas of leadership and management, within the healthcare policy arena and beyond, the shift to managing in a more collaborative arena (vs. a more bureaucratic one) also requires particular attention to utilizing political tools to operate effectively. Instead of perceiving “politics” as a control function (zero sum winning and losing), the effective leader in the policy advocacy world must see the political environment as an ongoing process shaped by short-term collaborative relationships, which may exist for temporary networks and dissolve as the process continues to evolve. In nursing leadership and administration, much of the theoretical and conceptual research

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refers to such models as shared governance models. As early as 1988, research focused on how to better integrate such efforts into effective practice (Allen, Calkin, & Peterson, 1988). Yet, even as late as 2004, a careful review of the literature of shared governance had yielded considerable anecdotal support for its importance, but not much empirical evidence of its effectiveness (Anthony, 2004). The reality is that more and more management functions in health care require greater assimilation of collaborative models to the effective practice of administration. We suggest that the key to gaining more effective use of the policy environment, both inside and outside the organization, is to understand more effectively the power that one has to effect change. Unlike many analyses of power that are often based on the individual, our approach is to examine the organizational power that exists for the ­practitioner/advocate. We examine that power through two broad lenses: the power of stakeholder relationships and the power of expertise. FIGURE 3-1 is a simple heuristic about power. This pyramid has been widely used in political science and policy fields for years. Power can be seen in the levels of the pyramid, with the narrowest (and thus the weakest) type of power at the top of the pyramid. It becomes broader with more effective types of power. Force we all understand. The power to make others do things is obvious, from the actual use of force (including weapons) through the more common use of force in an organization, which is the power of the organization to enforce rules, standards, and practices. Influence is more nuanced, but its role is also obvious. Does the organization have the capacity to convince others that they should support or acquiesce to the organization’s decision? There are many reasons an organization may be able to influence a decision. Possibly the organization has shown the capacity to be successful; maybe the organization has demonstrated knowledge or connections to accomplish the required tasks. Nevertheless, the organization must convince others that its decisions are good. Finally, the broadest and most

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Chapter 3 A Policy Toolkit for Healthcare Providers and Activists

Expertise

Influence

FOCUS

Force

Authority

FIGURE 3-1  The power pyramid

critical part of the pyramid is authority. At the core of a lot of political theory is authority— the acceptance of the organization to decide and the acceptance by others of its decisions without serious question. Expertise is one form of authority. It is clear that in some situations the expertise of the organization, its professionals, and/ or the policy implementation of that expertise is simply accepted—but that is not always true! One example of how all three elements of the power triangle work is when you are driving your car late at night and you stop at a red light with nobody around. There you sit because a light bulb with a red cover is on. Now, that is power! Do you recognize why you stopped? Did you have to be convinced? (Maybe you think for a second that lights regulate traffic, but it is the middle of the night and there are no cars around.) You do not run the light right away because you first look around to see if there is a police car around. Now all three elements are in play. You stopped at the light in the first place because it turned red, and you stop at red lights. Thus, how do we understand our power in organizations? There are multiple elements— from the regulatory environment, the level of federalism, the growth of the state, and so forth.

Stakeholders

LOCUS Internal

External

IS

ES

IE

EE

FIGURE 3-2  Focus and locus of organizational power

Here we summarize two broad elements that undergird the organization’s power: stakeholders and expertise. We are going to distinguish between internal and external power (power within the organization and beyond) (see FIGURE 3-2).

▸▸

Stakeholder Power

For many in the healthcare arena, stakeholder power is the most obvious political tool. A simple “who do you know, who is on our side” model of developing policy change is obvious. Too often, however, our approach is to simply add up the influential players on our side and the other side. The stakeholder list becomes a roster of names rather than the nature of power relationships. If it is just a matter of numbers, any policy that is supported by a greater ­number of individuals or organizations should prevail. Under those conditions, we would suggest that a national health system that is effective for the poor would be the easiest to pass, but we know that organizations representing low-­income groups have less influence than those representing high-income groups. It therefore cannot be just numbers!

Stakeholder Power

Stakeholder analysis is tied to the network of stakeholders and which sets of stakeholders are closer to your organization and which are more distant. This close/distant issue is often defined in terms of natural and face-to-face ­relationships—ideally, which groups deal with your agency or policy arena on a routine, constant basis and which groups deal with your organization on a more limited basis. Thus, the classic stakeholder map often has concentric circles of groups and organizations that are closer and further away from the organization based on the level of interdependence and organizational closeness (Fottler, Blair, Whitehead, Laus, & Savage, 1989). If you represent a veterans’ hospital, for example, members of veterans’ organizations, such as the American Legion or Veterans of Foreign Wars, are more central to your organization, but if you are working at a children’s hospital, that organizational tie is irrelevant. Thus, understanding how central other stakeholders are to the organization may be the first part of a stakeholder analysis (FIGURE 3-3). To understand stakeholder power for an organization, one must define it in terms of organized stakeholders. When working with various healthcare organizations, we often hear stakeholders described in individual terms (e.g., patients or customers), but the key is to recognize

elevant stakehold ers ss r Le

n

O

C

rs

dary stakehold ers con Se e k h a t old es e or z i a n rga or tio gra pro m

FIGURE 3-3  Simplified stakeholder map

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the importance of having stakeholders who are organized and have well-defined structures. For example, veterans is a vague definition for a set of stakeholders, but the American Legion and Veterans of Foreign Wars are two critical organized groups that represent veterans. What if there is no organized set of stakeholders? The first question might be, why is that true? Perhaps the stakeholders in the external environment that your organization deals with are too amorphous to be defined. In James Wilson’s (1989) terminology, you may represent a majoritarian organization that has no discernible set of constituents or stakeholders other than the public. If that is the case, stakeholder power will be more limited for your organization. At the other end of Wilson’s stakeholder organizational model are client agencies whose power is defined heavily through a strong ­relationship with a single client group. In those cases, the organizations must seek to avoid being captured by that single clientele group (Wilson, 1989). However, we have found that many organizations have developed stakeholder groups over time (often for nonpolitical reasons), which generates some level of influence. One of our favorite examples comes from outside the healthcare arena—police departments. If one thinks about natural constituents or stakeholders, a police department’s most obvious stakeholders are those who commit crimes—we are not sure how to build a stakeholder group there! Over time, police departments have developed a host of support organizations, including neighborhood watch groups. The reason they are created is not to influence political decisions about police departments, but strong neighborhood watch groups (organized across a city) can become a critical secondary stakeholder group for a police department. Who organized those neighborhood watches? Generally, police departments took the lead and the neighborhood watch groups typically support what is being proposed by the police department. The example of a children’s hospital is appropriate here. One might argue that on a day-to-day basis, the constituents of such a hospital are the patients. They are children, but maybe we would

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Chapter 3 A Policy Toolkit for Healthcare Providers and Activists

include the parents. What about parent groups? Generally, they have limited interest in being stakeholders of the hospital; in fact, they want their children to get well and leave the hospital. What about children suffering from a chronic illness or a long-term disease such as cancer? Most hospitals have developed parent and children’s groups that get together periodically to support each other (and to provide additional information to the hospital and to other patients and their families about coping with the illness). If the hospital’s outreach department has helped organize the group so that it establishes officers and meeting dates, the group is organized! Is it the same as a veterans’ organization? Clearly not, but it would be wise to include such a group in any efforts to advocate for policy changes (inside and beyond the hospital). If most organizations understand the importance of stakeholder relationships in understanding and utilizing political power, how does the continuing growth of collaborative/shared governance impact that role? At the core of most applications of collaborative models is the need to identify and strengthen all direct and indirect partners in the collaborative process. From a personal toolkit perspective, many have emphasized the importance of creating stakeholder analyses and maps of one’s organizational network. If the relationship will be more dynamic and evolving depending on the particular element of the stakeholders in a collaborative relationship, how much more essential is a continuing in-depth stakeholder analysis? Indeed, in much of the collaborative literature, moving organizations, advocates, and support structures within the policy partnerships (and back out when no longer part of the process) becomes a day-to-day requirement and essential to the ongoing success of the collaborative policy advocacy network. Finally, we suggest that most professional groups have delineated additional ways to develop clear stakeholder relationships because they have a stake in what happens within the day-to-day operations of an organization. In nursing, for example, the American Nurses Association (2013) has created an advocacy network

BOX 3-1  Professional Nursing Membership Associations That Address Policy Advocacy American Academy of Nursing (AAN) – www.aannet.org American Association of Nurse Practitioners (AANP) – www.aanp.org American Association of Colleges of Nursing (AACN) – www.aacn.nche.edu American Nurses Association (ANA) – www.nursingworld.org American Organization of Nurse Executives (AONE) – www.aone.org International Council of Nurses (ICN) – www.icn.ch/ National Council of State Boards of Nursing (NCSBN) – www.ncsbn.org National League for Nursing (NLN) – www.nln.org Sigma Theta Tau International Honor Society of Nursing – www.nursingsociety.org

and has detailed how to expand the relationships with both nurses and other stakeholder groups in the field. Additionally, the National League for Nursing (2013) offers a Public Policy Advocacy Toolkit to guide nurses, nursing students, and nursing faculty through the levels of governmental actions. See BOX 3-1 for a list of professional nursing membership associations that address policy advocacy. To understand the advocacy role, one must see the importance of the professions’ own expertise, to which we now turn.

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Expertise

What is expert power in an organization? Some define it in terms of knowledge acquisition and professionalism. Thus, an expert organization would have a large proportion of highly educated professionals, defined by advanced education, licensure, professional norms and ethical standards, and a lifetime of continuing education. The healthcare arena has a clear advantage here.

Expertise

The various professions within any existing healthcare arena are often complex, and they have specialized education, training, and licensure at virtually every level of professional delivery of services. Such professionalized organizations often begin with a noticeable advantage over other organizations in which there is little or no professionalized work force because of their expertise that lends added weight to their advocacy positions. Thus, any definition of organizational expertise must begin with the nature of the expertise of the organization and whether it is well developed and professionalized and of the highest educational standards; however, one must be careful about defining this power simply as a set of acquired educational or professional standards. In the end, it is a bit like a traffic light—all the diplomas, certificates, and licensures do not necessarily mean the expertise is perceived as powerful. Similar to the number of stakeholders not being as important as the proximity of stakeholders to the decision makers, not all experts carry equal weight when it comes to organizational decisions. What is the key to this expertise? It is the perception of others that the expertise is legitimate. Many healthcare professionals blunder here because they believe a variety of graduate and professional degrees automatically leads to support of their expertise. To put it in simple terms, many occupations (especially in the healthcare arena) are licensed, certified, and with advanced education, but they do not have equal expertise power. Why? Maybe because the public or the broader political and policy environment does not differentiate the various specializations, or the expertise of the profession is recognized strongly only by the profession itself. The public tends to understand expertise hierarchically. The expertise of physicians carries more weight than other professionals within the healthcare system. The best example today is the widespread public agreement about the need for more nurses. How does that translate generally? The public does not differentiate well between licensed practical nurse (LPN), registered nurse (RN), diploma, Associate Degree (AD), Bachelors of Science in nursing (BSN), Master of Science in nursing (MSN),

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advanced practice registered nurse (APRN), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), or other advanced practice nurse. But it does see the difference between a general practitioner in medicine and a specialist in oncology. What is the difference? We suggest that the public is convinced (generally through well-defined efforts by the medical establishment) that there are differences in behavior in the various medical specializations and that some of them have more expertise power because the public perceives them as more expert. Why is that not as true in nursing? We think part of the explanation is that the nursing profession has been reluctant to publically emphasize the differences among the various areas of nursing professionalism. We suggest that this limits the political capacity of the various specializations to garner separate political support. Buresh and Gordon (2000) proclaim that nurses are not recognized as a profession because they do not educate patients and their families, friends, and communities about nursing work. If the voice and viability of nursing were commensurate with the size and importance of nursing in health care, nurses would receive the three Rs: respect, recognition, and reward. These authors expound that if the work of nurses is unknown or misunderstood, then nurses cannot be appreciated or supported and cannot exert appropriate influence in health care. They go on to say that the general public needs to know what nurses do today and why their work is essential. The Institute of Medicine’s The Future of Nursing: Leading Change, Advancing Health report (2011) proclaims, “The nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions” (p. 221). Those in a position to influence legislation, policy making and funding must know that health care environments

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rich in nurses promote high levels of health whereas understaffed settings put patients at risk. They need to be aware of the incipient tragedies awaiting patients when nurses are not available to prevent falls, complications, errors in treatment and care or to rescue patients in need. (Buresh & Gordon, 2000, p. 18) An example of how nurses fail to communicate their expertise can be found in the simple example of dress. Professionals are often recognized by their attire or uniform. The behavior and dress of nurses today tend to downplay professionalism by blurring the identity of nurses and making the place of nursing in health care more ambiguous. In healthcare settings, it is often not easy for patients or families to pick out who is a nurse and who is not. Buresh & Gordon (2000) proclaim that without a protocol to provide clarity, it is up to individual nurses to convey who they are through their appearance, behavior, and language. It has become a common practice for nurses in hospital settings to not tell or show their last name on name tags. Physicians would certainly not do this. When members of the largest healthcare profession (nurses) opt out of the standard professional greeting, they risk communicating that they do not regard themselves as professionals (Buresh & Gordon, 2000). Can you imagine hospitals saying today, as they did 20 to 30 years ago, that they cannot afford to staff with registered or BSN-prepared nurses? What has pushed that bar? The Institute of Medicine’s report on the future of nursing recommends that we “increase the proportion of nurses with a baccalaureate degree to 80 percent and double the number of nurses with a doctorate by 2020” (Institute of Medicine, 2013, p.1). Thus, exerting expert power in an organizational setting must also include addressing some important issues, not the least of which is the belief that the expertise of the particular set of professionals has a valid place in the policy

environment. When policy is being made internally, such as in a hospital, about how practices are implemented, changed, evolved, or reorganized, is the profession you represent at the table in the discussion? If not, why? We all understand how professions develop expertise over time. They have specialized degrees, certifications, accreditations, licensures, state associations, and so forth. For the nursing profession there is no higher recognition than a Magnet designation for a healthcare organization. The American Nurses Credentialing Center’s Magnet Recognition Program recognizes healthcare organizations for quality patient care, nursing excellence, and innovations in professional nursing practice. The organization says, “Consumers rely on Magnet designation as the ultimate credential for high quality nursing” (American Nurses Credentialing Center, 2013, p. 1). It is agreed that it is important for excellent nursing care to be recognized and rewarded, but why don’t all healthcare organizations have Magnet status? Many hospitals have tried and failed; others elect not to go for Magnet status. What does that tell us about this professional issue? It is still desirable but not everyone is doing it; therefore, it is controversial. Many healthcare institutions cannot afford the Magnet journey. For others, they cannot meet the level of nursing education and expertise that is required due to size, location, and so forth. Thus, as we develop the toolkit for expert power, we must ask a critical question: Who believes this expertise of a profession is valued and should be represented in the decision-making process both within and beyond the organization? Let us not lose sight of the increasing reality of expertise within collaborative environments. One of the key components to most analysis of collaborative networks is the need for evolving expertise in accomplishing the tasks within a policy advocacy network. The literature in public administration is rich with two components of expertise in such a network: bringing specific expertise to a short-term involvement in a collaborative network, and expanding all

References

participants’ capacity to expand their own expertise in a shared fashion. Put another way, an effective policy advocacy network needs to share knowledge more effectively, not just add experts to the policy environment.

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Conclusion

Politics and policy require an understanding of how to build support and adapt to change. If we are to be effective advocates, we must be responsive to broader societal needs. Building support is not done simply by presenting the facts. This toolkit is designed to help readers know what it takes in a political environment to build a case and adapt when necessary. A huge mistake in advocacy is to simply believe that the facts are on our side, and if we just continue to list the facts, everyone will believe! In reality, values and political issues are at the core of successful change. Our tasks as political advocates for change are as follows: ■■ ■■ ■■

4.

Believe we can convince others to adapt. Adapt ourselves to handle broader political value issues. Learn to mobilize our expert power as one of the largest groups of stakeholders in the healthcare field.

Discussion Questions 1.

2.

3.

As you read through this chapter, describe the political environment of your own organization, both at the largest level and at a division or office level. Internal and external stakeholders are important to any organization or policy. Describe your view about reliance more on internal stakeholders than on external stakeholders, and vice versa. Why do you think there are differences? Expertise power is often difficult to define in detail, but how do we

5.

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build a stronger perception of the importance of our expertise with those who work with our programs and agencies? Looking at Figure 3-1, how do organizations overutilize the force component in organizational power? What kinds of evidence would you expect to see in an organization that is not using influence or authority well? Given the need for greater collaboration in the health policy arena, how does improving your stakeholder relationships with other organizations and interests become even more important?

References Allen, D., Calkin, J., & Peterson, M. (1988). Making shared governance work: A conceptual model. Journal of Nursing Administration, 18(1), 37–43. American Nurses Association. (2013). Advocacy—becoming more effective. Retrieved from http://www.nursingworld. org/MainMenuCategories/Policy-Advocacy/Advocacy ResourcesTools American Nurses Credentialing Center. (2013). ANCC Magnet Recognition Program. Retrieved from http:// www.nursecredentialing.org/Magnet.aspx Anthony, M., (2004). Shared governance models: The theory, practice, and evidence. Online Journal of Issues in Nursing 9(1), manuscript 4. Buresh, B., & Gordon, S. (2000). From silence to voice: What nurses know and must communicate to the public. Ottawa, Ontario: Canadian Nurses Association. Fottler, M. D., Blair, J. D., Whitehead, C. J., Laus, M. D., & Savage, G. T. (1989). Assessing key stakeholders: Who matters to hospitals and why? Hospitals and Health Services Administration, 34(4), 525–546. Institute of Medicine. (2011). The future of nursing: leading change, advancing health. National Academies Press, Washington, DC. Institute of Medicine. (2013). The future of nursing: leading change, advancing health. Retrieved from http://www .thefutureofnursing.org/recommendations National League for Nursing. (2013). Faculty programs and resources: Public policy advocacy toolkit. Retrieved from http://www.nln.org/facultyprograms/publicpolicytoolkit /publicpolicytoolkit.htm Wilson, J. Q. (1989). Bureaucracy: What government agencies do and why they do it. New York, NY: Basic Books.

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Toolkit Case Studies

The case studies included at the end of this toolkit chapter are designed to aid the reader in understanding the politics of organizational power. They are divided based on four categories: external stakeholder, internal stakeholder, external expertise, and internal expertise. Each of these real-life case studies illustrates how health professionals have applied the tools as highlighted within this chapter. The case study authors have included references when applicable. To guide your comprehension and application of the toolkit, the authors have included several thought-provoking questions at the end of each case study. Readers are encouraged to critically analyze the political methods and power used in each case study, exploring the

CASE STUDY External Stakeholder Power: Margaret Sanger as Nurse and Public Health Advocate Ellen Chesler “No gods, no masters,” the rallying cry of the Industrial Workers of the World, was her personal and political manifesto. Emma Goldman, Bill Haywood, Mabel Dodge, and John Reed were among her earliest mentors and comrades. Allied with labor organizers and bohemians, Margaret Sanger first emerged on the American scene in those halcyon days at the turn of the 20th century when the country seemed wide open with possibility, before world war, revolution, and repression provided a more sober reality. She organized pickets, protests, and pageants in the hope of achieving wholesale economic and social justice. What began as a callow faith in revolution quickly gave way to a more concrete agenda for reform. Working as a visiting nurse on New York City’s Lower East Side, she watched a young patient die from the complications of

stakeholders and type of expertise involved. The questions following each case study are helpful for group discussion and individual analysis. This chapter concludes with one additional case study that has not had any political result to date, and readers are asked to analyze that case in terms of how one might build the necessary political stakeholder and expert power.

External Expert Power The first two cases are doubtless well known to readers, but what may not be well known is the history of policy development in these areas. As you examine these two case studies, remember that their purpose is to show the role of expertise in affecting policy. a then-common illegal abortion, and vowed to abandon palliative work and devote herself to a single-minded pursuit of reproductive autonomy for women. Sanger proudly claimed personal freedom for women. She also insisted that the price women pay for equality should not be at the sacrifice of personal fulfillment. Following in the footsteps of a generation of suffragists and social welfare activists who had forgone marriage to gain professional stature and public influence, she became the standard bearer of a less ascetic breed, intent on balancing work and family obligations. The hardest challenge in writing this history for modern audiences, for whom these claims have become routine, is to explain how absolutely destabilizing they seemed in Sanger’s time. Even with so much lingering animus toward women’s rights today, it is hard to remember that reproduction was once considered a woman’s principal purpose and motherhood was her primary role—women were assumed to have no need for identities or rights independent of those they enjoyed by virtue of their relationships to men. This principle was central to the longenduring opposition women have faced in seeking rights to work, to inheritance and property, to suffrage, and especially to control of their own bodies.

Case Study

contraceptive materials and use the federal mail for transport. The ruling effectively realized years of failed efforts to achieve legislative reform in the U.S. Congress, although it did formally override prohibitions that remained in several states until the historic ruling in Griswold v. Connecticut with its claim of a constitutional doctrine of privacy, later extended so controversially to abortion in Roe v. Wade. With hard work and determination, she was able to mobilize men of influence in business, labor, academia, and the emerging professions. No less critical to her success was her decision to invest in the collective potential of women, many of whom had been oriented to activism by the suffrage movement and were eager for a new cause after finally winning the vote in 1920. She also lobbied the churches, convincing the clerical establishments of the progressive Protestant and Jewish denominations of the virtue of liberating sexuality and reproduction from the shroud of myth and mystery to which traditional faiths had long consigned them. She even won a concession from the hierarchy of the American Catholic Church, which overruled the Vatican and endorsed natural family planning, or the so-called rhythm method, as a way of countering the secular birth control movement and reasserting religious authority over values and behavior. With an uncanny feel for the power of well-communicated ideas in a democracy, Sanger moved beyond women’s rights to put forth powerful public health and social welfare claims for birth control. She proved herself a savvy public relations strategist and an adept grassroots organizer. Through the 1920s and 1930s she wrote best-selling books, published a widely read journal, and crisscrossed the country and circled the globe to give lectures and hold conferences that attracted great interest and drove even more publicity. She built a thriving voluntary movement to conduct national- and state-level legislative lobbying and advocacy and to work in communities on the ground, sustaining affiliate organizations that organized and operated pioneering women’s health clinics. Offering a range of medical and mental health services in reasonably sympathetic environments, many of these facilities became laboratories for her idealism. Yet the birth control movement stalled during the long years of the Great Depression (1929-1939)

CASE STUDIES

Sanger needed broader arguments. By practicing birth control, women would not just serve themselves, she countered. They would also lower birthrates, alter the balance of supply and demand for labor, alleviate poverty, and thereby achieve the aspirations of workers without the social upheaval of class warfare. It would not be the dictates of Karl Marx, but the refusal of women to bear children indiscriminately, that would alter the course of history, a proposition ever resonant today as state socialism becomes an artifact of history, while family planning, although still contested, endures with palpable consequences worldwide. In 1917, Sanger went to jail for distributing contraceptive pessaries to immigrant women from a makeshift clinic in a tenement storefront in the Brownsville section of Brooklyn. Sanger’s contribution was to demand services for the poor that were available to the middle class. Her heresy, if you will, was in bringing the issue of sexual and reproductive freedom out into the open and claiming it as a woman’s right. She staged her arrest deliberately to challenge New York’s already anachronistic obscenity laws—the legacy of the notorious Anthony Comstock, whose evangelical fervor had captured Victorian politics in a manner eerily reminiscent of our time—and it led to the adoption, by the federal government and the states, of broad criminal sanctions on sexual speech and commerce, including all materials related to contraception and abortion. Direct action tactics served Sanger well, but legal appeal of her conviction also established a medical exception to New York’s Comstock Law. Doctors—although not nurses, as she originally intended—were granted the right to prescribe contraception for health purposes; under that constraint she built the modern family planning movement with independent, freestanding facilities as the model for distribution of services, a development that occurred largely in spite of leaders of the medical profession who remained shy of the subject for many years, and did not formally endorse birth control until 1937, well after its scientific and social efficacy was demonstrated. By then, Sanger and Hannah Stone, the medical director of her New York clinic, had also achieved another legal breakthrough. They prevailed in a 1936 federal appellate court decision in New York state that licensed physicians to import

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and World War II (1939-1945), stymied by the increasing cost and complexity of reaching those most in need and overwhelmed by the barrage of opposition it engendered. The issue remained mired in moral and religious controversy, even as its leadership determinedly embraced centrist politics and a sanitized message. When hard times encouraged attention to collective needs over individual rights and when the New Deal legitimized public responsibility for economic and social welfare, Sanger cannily replaced the birth control moniker with the more socially resonant family planning. She invented both terms and popularized them after consulting allies and friends. Having enjoyed Eleanor Roosevelt’s enthusiastic support and personal friendship in New York, Sanger went to Washington, DC in the 1930s, hoping that Congress would overturn the Comstock law and legalize contraceptive practice as a first step to her long-term goal of transferring responsibility and accountability for services from small, privately funded clinics to public health programs with appropriate resources and scale. However, she failed to anticipate that the success of the Roosevelts would depend on a delicate balance of the votes of conservative urban Catholics in the north and rural, fundamentalist Protestants in the south. There would be no invitations to tea at the White House and no government support, at least until Franklin Roosevelt was safely ensconced in a third term. Embittered by these controversies and disenchanted with the country’s increasing pronatalism after World War II, Sanger turned her attentions abroad. In 1952 she founded the International Planned Parenthood Federation, with headquarters in London, as an umbrella for the national family planning associations that remain today in almost every country. By the time of her death in 1966, the cause for which she defiantly broke the law had achieved international stature. Although still a magnet for controversy, she was widely eulogized as one of the great emancipators of her time. She lived to see the U.S. Supreme Court provide constitutional protection for the use of contraceptives in Griswold v. Connecticut. She watched Lyndon Johnson incorporate family planning into America’s social welfare and foreign policy programs, fulfilling her singular vision of how to advance opportunity and prosperity, not to speak of human happiness,

at home and abroad. A team of doctors and scientists she had long encouraged marketed the oral anovulant birth control pill, and a resurgent feminist movement gave new resonance to her original claim that women have a fundamental right to control their own bodies. Hundreds of millions of women and men around the world today freely practice some method of contraception, with increasing reliance on condoms in light of the epidemic spread of HIV/ AIDS and other sexually transmitted infections. This represents a sixfold increase since rates of population growth peaked in the 1960s. Still, half the world’s population today—nearly 3 billion people—are under the age of 25 years. Problems associated with widespread poverty, food insecurity, and environmental degradation are widespread. There remains considerable unmet need for family planning, and there is tragically insufficient funding for research on new methods and for new programming to meet ever-increasing demand. Funding for both population and development programs has slowed dramatically, as other needs compete for funds and as concern now spreads about an aging and shrinking population in many countries where birthrates have sharply declined. The cycles of history repeat themselves.

Case Study Questions 1. Why was the expertise of effective birth control not widely shared, and why did it take the medical establishment so long to endorse policy change in this area? Clearly, the women’s movement was part of the opening of change in this area, but how did it contribute to the creation of knowledge? 2. Have there been changes in recent years in the broader environment that are analogous to the early adoption of birth control programs (e.g., RU-486, or the so-called morning after pill)? 3. Have these changes increased or limited access to birth control? Think through the acceptance of the expertise in this area and the ways in which it has contributed (or limited) the change in policy in this environment and the ways in which it has not been taken into account. 4. Can you illustrate how expertise is still about perception, both within professional fields and in the broader public?

Case Study

CASE STUDY

Claudia J. Beverly The Arkansas State Legislature meets every other year to conduct the business of the state. In the year preceding the legislative session, the Policy Committee of the Arkansas Nurses Association (ArNA) examines the healthcare needs of the state and designs a strategic health policy plan for nursing that will be introduced in the upcoming session. The work is always initiated with a clear understanding of the needs of the state’s citizens. In this rural state, 69 of the 75 counties are medically underserved. The poverty level is one of the worst in the country. The health statistics of Arkansans are in the bottom four states, and several counties do not have a single primary care provider. Given the many healthcare challenges facing the state, nurses are in a key position to address these needs, and society expects them to do so. In the early 1990s the ArNA, which represents all nurses in Arkansas, concluded that advanced practice nurses were best prepared to address the primary healthcare needs of Arkansans. At that time, however, there was no standardization or clear regulation for this level of nurse other than national certification and the registered nurse (RN) license that is basic for all levels of registered nurses. The ArNA’s first attempt to address the primary healthcare needs of the citizens was in 1993. Their attempt to pass legislation that would allow prescriptive authority by advanced practice nurses failed. After this failure, the ArNA, with the assistance of its lobbyist, began to develop legislation for introduction in the 1995 legislative session to provide a mechanism for advanced practice nurses to practice to the extent to which they are academically prepared. Additionally, a mechanism whereby society could be assured of safe practice by all providers needed to be in place. The process began when a legislator from a rural area with the greatest need introduced a study bill. This bill provided an opportunity for the ArNA

to educate legislators about advanced practice nursing and how this type of nurse could address the healthcare needs of Arkansans. The study bill was assigned to the Interim Public Health, Welfare, and Labor Committee of both the state House of Representatives and the Senate. Several public hearings were held by the committee, and various groups and individuals—both in support and in opposition—were given the opportunity to voice their opinions. During the hearings, there were opportunities to provide correct information supported by the literature. Clarification of the proposed legislation was also on the agenda. At one point, concern was raised about the use of the term collaboration with medicine, as some persons preferred to use supervision or a definition that would limit the practice to one being supervised. The task force initiated a process to define the term collaboration. A review of the literature showed that collaboration had already been defined in the 1970s by both medicine and nursing. Armed with that information and definitions given by other sources, the task force reported their findings at the next hearing, and the definition jointly developed by medicine and nursing was incorporated into the proposed legislation.

Process for Success The leadership of the ArNA understood the monumental task and the many challenges and barriers to addressing the healthcare needs of Arkansans. The association decided that appointing a special task force to lead its efforts was the best strategy. This strategy provided a mechanism for focusing on the issue while ensuring that the health policy committee would continue to focus on broader policy issues. The association selected a chair, included the chair in member selection by ArNA leadership, and established the first meeting. As the process evolved, two cochairs, a secretary, and a treasurer were named. The task force was representative of nursing broadly and included members of the Arkansas State Board of Nursing, advanced practice nurses with master’s degrees (e.g., midwives, certified registered nurse anesthetists, nurse practitioners, and clinical nurse specialists), registered nurses, faculty from schools of nursing who prepared advanced practice nurses, and representatives from other nursing organizations. The task force met every other week during the

CASE STUDIES

External Stakeholder Power: Successful Efforts to Pass Advanced Practice Nurse Legislation

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first 6 months of the 2-year preparatory period, then weekly for the remaining year and a half. The first order of business was to develop a strategic plan that included establishing a vision, mission, goals and objectives, strategies, and time line. The vision was critical as a means of keeping task force members focused on the vast needs of Arkansans, particularly those in rural areas. The vision statement also served to keep the broader ArNA membership focused. A literature search on advanced practice nursing and health policy issues was conducted, and articles were distributed to all task force members. The assumption was that all of the members needed information to expand their current knowledge. Subcommittees were developed based on goals and objectives and the operational needs of the task force. Chairs were assigned for each subcommittee, and thus began the 2-year journey. The American Nurses Association (ANA) played a vital role in the process. The legal department was available to assemble and provide information, offer guidance, and identify potential barriers and challenges. The support provided by the ANA was pivotal to our success. The work of the task force focused on external and internal strategies. External strategies focused on stakeholders, which included the Arkansas Medical Society, the Arkansas Medical Board, and the Pharmacy Association. Understanding the views of our colleagues in other disciplines and identifying the opposition to our plans were critical to our success. Many meetings focused on educating those disciplines about the legislation we were seeking. Often this was a balancing act, providing the right information but not too much of our strategy while attempting to keep our enemy close. We valued the process of negotiation and participated in many opportunities to negotiate with colleagues. Throughout this process, the ArNA did have a line in the sand, defined as the point at which there was no negotiation. Our line in the sand included regulations of advanced practice nurses by the Arkansas State Board of Nursing and reimbursement paid directly to the nurses. These two points were never resolved until a vote on the legislation occurred. The good news is that the advanced practice nurse legislation passed successfully in 1995. The legislation was successful in that the criteria for an advanced practice nurse to be licensed in the State of Arkansas were written by nursing, advanced

practice nurses were to be regulated by nursing, and the legislation acknowledged national certification and educational requirements. Prescriptive authority was granted, and selected scheduled drugs could be ordered by an advanced practice nurse. Reimbursement to advanced practice nurses was lost at the last minute. For advanced practice nurses in the field of geriatrics, Medicare passed reimbursement regulations in 1997. Medicaid reimburses geriatric nurse practitioners according to national guidelines. Reimbursement is critical to meeting the needs of Arkansas citizens and is a topic that is still being discussed. Many individuals participated in this successful campaign. A clear vision, legislation based on evidence and current literature, a comprehensive strategic plan, education of all parties (including those in opposition and those in support), and well-informed legislators were critical to success. Probably the most critical message in health policy legislation is to focus on the needs of the citizenry and what nursing needs to contribute.

Case Study Questions 1. We suspect that most nursing professionals can expand on this case; however, the key question is: What was the nature of building a stakeholder network? 2. Who were the critical first players in this movement, and why was their involvement critical? 3. As the network expanded, which other professional groups were involved? Why were those groups, and not others, involved? 4. Do you see why some professions were the logical next parts of the coalition for adopting change? 5. Who was most likely to oppose advanced practice nursing? Obviously, you do not include likely opponents in the initial development of the network of stakeholders, but why? 6. How did the coalition eventually succeed through this inclusive network? 7. What would you have done differently in a different practice arena? 8. What does this case study tell you about building stakeholders for advancing practice? 9. What would you need to do to apply this policy to advancing roles in your healthcare setting?

Case Study

CASE STUDY

Ralph Vogel Strides in technology have created great advances in how we can provide services to families and their children. A prime example is the expansion of newborn screening, which has dramatically increased the number and type of genetic conditions that can be detected immediately after birth. Historically, most states have screened for hemoglobinopathies (like sickle cell anemia), thyroid disorders, phenylketonuria, and galactosemia. These conditions, along with newborn hearing screening, were relatively easy to administer at a cost-effective rate. With advanced laboratory and computer technology, we can now add multiple genetic conditions that are identified during a single run. In 2004 the March of Dimes proposed expanding the genetic conditions for which newborns are screened to their List of 29, including several enzyme deficiencies and cystic fibrosis. The cost of the limited newborn screening had been approximately $15 per newborn, and it would increase to about $90 with the expanded list. Insurance companies would cover the cost of adding the additional conditions. The value of newborn screening is in identifying genetic conditions early and implementing treatment plans from birth. Over a life span, this greatly reduces the morbidity and mortality associated with later diagnosis. With some conditions, the care can be as simple as a dietary change that is implemented from birth. Early diagnosis also allows for genetic counseling with families about the risk that additional children will have the condition. Many states adopted this recommendation quickly, although the process has been slower in others. In Arkansas a committee, titled the Arkansas Genetics Health Advisory Committee (formerly Service), has existed for several years. Its mission is to monitor health care related to genetics in the state. This diverse committee includes several

members of the Arkansas Department of Health (ADH) who are involved in the newborn screening program administration and laboratory testing, physicians from Arkansas Children’s Hospital genetic clinic, and interested parties that either work in the area of genetics or are parents of children with genetic conditions. The main purpose of the committee has been to coordinate care and to try to educate the public about genetic conditions and screening for newborns. The ADH receives samples from about 95% of the newborns in the state and does screening at their central location in Little Rock. When an infant is identified with a newborn genetic condition, the ADH notifies the community hospital and the assigned pediatrician, who counsels the family and develops a plan for care and follow-up. Expanding the screening program to the existing March of Dimes List of 29 created several problems. The committee, however, felt strongly that it should take an advocacy role to address these concerns. The first problem was the cost of increased screening. Although most of the individual cost for each child could be absorbed by insurance or Medicaid reimbursement, as in other states, the initial financial support would need to be provided by the state. The ADH had no provision for increasing funding but estimated that the increased cost would be as follows: ■■

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Two million dollars for equipment and supplies The addition of at least two more laboratory technicians to do the increased testing The addition of at least one more public health nurse to coordinate the increased number of identified genetic cases Training for new and current personnel on the new equipment Personnel time to develop and coordinate the expansion of the program Development of an education program to make parents and professionals aware of the changes.

Overall the estimated cost for start-up was approximately $3 million, some of which could be recouped after billing for the tests was established. The committee and ADH decided that we would outline a plan for expansion with

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Internal Expertise Power: Expanding Newborn Screening in Arkansas

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estimated costs and submit it to the director of the ADH, Dr. Faye Bozeman. With his approval, we would then approach legislators and ask for the needed funding to be included in the upcoming budget. Because the Arkansas state legislature convened only every 2 years, it would be critical to move forward over the next 6 months. We prepared a letter to Dr. Bozeman that the committee approved on a Friday with the intention of mailing it on the following Monday. The next day, Saturday, Dr. Bozeman was killed in an accident on his farm; therefore, we were in a quandary about who should receive the letter and whose approval would be needed in the ADH. During the next 6 months there was an interim head, who was thrust into the position and did not want to approve anything at this level of expense. We were on hold until a permanent director was named. After about 3 months, we decided to take another tack and develop a plan to seek legislative approval for funding and then approach the new ADH director after the person was named. We developed a list of legislators to contact and identified members of the committee who had worked with the legislators in the past and could approach them. By this time, we were 2 months from the legislature convening and knew that after it convened nothing new would be introduced; therefore, we had to get support ahead of time. We approached some legislators and received tacit support, but none were willing to introduce a new bill or request funding without a permanent head of ADH. We had lost the opportunity for funding until the next legislative session in 2 years. The committee decided to continue to seek support from the legislators and ADH with the idea of gaining funding in 2 years. Meanwhile, we began to look at other states and what newborn screenings they were currently doing to make sure that politicians were aware of national standards. We had identified that Arkansas was one of the last five states to not expand newborn screening, and all of the surrounding states in the region had incorporated all or a large part of the March of Dimes List of 29. Making legislators aware of this became one of our goals; once they realized that the states surrounding Arkansas were already

doing expanded screening of newborns, they were more receptive to our plan. After we started to discuss funding with legislators during the legislative session, they seemed willing to support newborn screening. But we had a surprise: They said it did not require any special legislation or special funding; the ADH could expand newborn screening without their approval because this was already within their realm of responsibility. Funding could be obtained by submitting a budget request to cover the cost of expansion. The interim head of ADH was willing to support this because the head of the newborn screening section was on our committee. By fall we had the budget expansion approved and support for newborn screening expansion. The decision was then made to target July 1, 2008 as the date to start the expanded program. After we knew the finances and political support were confirmed, we developed a time line that involved equipment acquisition, training for ADH staff, an education program for the public, and a plan for making community hospitals and professional healthcare providers aware of the expansion. At this point the ADH contacted members of the media with whom it had worked in the past and developed a plan for public information advertisements to be run on television and radio. These began running in early May, 2 months before the July 1 start date. Because the media members had worked with ADH in the past, it was much easier to develop the advertisements. Print media advertisements were also started, and the local chapter of the March of Dimes provided funding and brochures that were distributed to OB/GYN physicians in the state to make expectant mothers aware of the testing to be done on their newborns. One of the members of the committee also wrote an article that appeared in the March issue of the Arkansas State Board of Nursing Update magazine, which is distributed to 40,000 healthcare providers in the state. In July the expanded screening began, and it has been continued with a relatively smooth transition, largely because of the preparation of the ADH staff in the laboratory and the outreach nurses. Because of the public awareness campaign, there has been little voiced concern from parents, and there seems to be an awareness of the value of the expanded screening.

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Although the entire process took more than 2 years, in the end the transition has been very smooth, and few problems have been identified at any level. Having a diverse group on the committee was a strength, because different members had different perspectives. This gave us much greater ability to anticipate problems and coordinate care, and in the end the program will benefit newborns in Arkansas for years to come.

Case Study Questions 1. This case is a good example of how the stakeholders adapted as the intended policy change moved from internal adoption of policy to legislation back to internal adoption of policy within an existing organization. Can you see how the nature of the stakeholders defined for a legislative change is different from stakeholders for adaptation of existing policy? 2. The initial group involved in this process was established primarily as an informational group, but it was modified to advocate change. How did the group evolve to influence policy differently? If the initial group had been more broadly defined at the start, would it have made the same mistake about requiring legislative change to adopt the policy? Why or why not?

Final Case Study This final case study is presented to stimulate the reader’s political thinking. We encourage you to read the case carefully and then consider how you would go about creating an environment for policy change.

CASE STUDY Workplace Violence Steven L. Baumann and Eileen Levy In the wake of the terrorist attack of September 11, 2001 and a series of tragic school shootings, workplace violence has gained national attention in the United States. Although nurses and other healthcare workers are generally well educated and regularly reminded to practice good handwashing and infection control, there is little attention given to the potential for violence in hospitals and other healthcare settings, even though it is common and can have devastating long-term consequences (U.S. Department of Health and Human Services, 2002; U.S. Department of Labor, 2004). According to Love and Morrison (2003), nurses who sustain injuries from patient assaults, in addition to suffering psychological trauma, are often out of work for periods of time, have financial problems, show decreased work productivity, make more errors at work, and report a decreased desire to remain a nurse. In addition to these problems, nurses who have been assaulted report feeling less able to provide appropriate care to their patients (Farrell, Bobrowski, & Bobrowski, 2006) and are reluctant to make formal complaints (Love & Morrison, 2003). As was the case with needlestick injuries in the past, many organizations do not openly discuss problems that increase the risk for violence, nor do they adequately prepare for episodes of violence, leaving nurses more likely to blame themselves for its occurrence. The National Institute for Occupational Safety and Health (NIOSH), the same organization that requires hospitals to be attentive to infection

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Preparation is the key to a smooth transition. Know exactly what is required to proceed and who needs to approve new or expanded plans of action. If we had approached the legislature first to find out what they wanted, we could have saved time. Plan for the unexpected. We could not have anticipated Dr. Bozeman’s death, but it did cause about a 6-month delay. Educate everyone who is going to be involved. This includes administrators, healthcare providers, laboratory staff, parents, and professionals in the impacted communities. Discuss with the media exactly what they need and use their expertise in terms of length of announcements and the best ways to distribute information.

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CASE STUDIES

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Chapter 3 A Policy Toolkit for Healthcare Providers and Activists

control strategies and proper handling of hazardous materials, also provides clear definitions and guidelines to reduce the potential for violence in the workplace. According to NIOSH, workplace violence includes acts of physical violence or threats of violence directed toward people on duty or at work (U.S. Department of Health and Human Services, 2002). NIOSH has recognized employer responsibilities in mitigating workplace violence and assisting employees who are victims (Love & Morrison, 2003). The U.S. government has required employers to provide safe workplaces since 1970 (U.S. Department of Labor, 2004). These federal guidelines call for hospitals and other organizations to incorporate written programs to assure job safety and security into the overall safety and health program for their facilities. Violence prevention, they suggest, needs to have administrative commitment and employee involvement. This case study is of a moderate-sized, nonprofit community hospital in the New York metropolitan area. As in many parts of the United States, this hospital and the communities it serves are becoming increasingly crowded and diverse. In this environment of change and tension, the hospital is a meeting place of people, many not by choice but in crisis, bringing together dramatically different histories, backgrounds, educational attainment, and cultures. The hospital and its clinics have become increasingly stressful, unpredictable, and at times hostile places. For example, the use of hospitals as holding tanks for acutely disturbed and violent individuals, the release of mentally ill persons from public hospitals without adequate outpatient programs and follow-up services, and the accessibility of handguns and drugs in communities all contribute to hospital and community violence. A failure of leadership at various levels, as well as inadequate reimbursement from payers, has contributed to violence that can occur on its premises. The case study hospital, like most in the United States, has dramatically reduced the number of public psychiatric beds. Many of these former psychiatric patients have to rely on outpatient mental health services supported by community hospitals with a limited number of beds on one or two psychiatric units. In addition,

the case study hospital reduced inpatient and outpatient addiction services. New research suggests that actively psychotic patients with schizophrenia and patients with schizophrenia who had a premorbid conduct problem or exposure to violence are more likely to be violent than less acutely ill patients and those without substance abuse or antisocial personality comorbidity (Swanson et al., 2008). Nevertheless, it is a mistake to consider persons with mental illness or substance abuse as the only individuals who can become agitated or violent in healthcare settings. It is also shortsighted to solely blame any single policy, such as the deinstitutionalization of the chronically mentally ill, for workplace violence in the United States. At the same time that the case study hospital has cut beds and programs for persons in distress, it has a clear mission/vision/value statement that puts professional nurses in leadership positions and has taken steps to address workplace violence. It has made efforts to reduce violence in high-risk areas, such as the emergency department and psychiatric unit, by restricting access to these areas, using surveillance equipment and panic buttons, and strictly requiring all staff to wear identification, as other hospitals have. Community hospitals, like the one in this case study, however, often do not provide the kind of ongoing self-defense and violence prevention education and training that many psychiatric hospitals provide. In addition, all hospitals should have a task force and regularly meeting committee consisting of management, human resources/employee relations, employee assistance program staff, security, and the office of chief counsel with the sole purpose of developing policies and procedures to prevent and address workplace violence. Following The Joint Commission’s (2008) lead, the case study hospital and nursing administration have hospital-wide discussions and training on behaviors that undermine a culture of safety. In addition, the hospital requires workplace violence risk assessment, hazard prevention and control, and safety and health training, as well as careful record keeping and program evaluation (U.S. Department of Labor, 2004). Hospitals need to keep in mind the malpractice crisis in this country. The move to put patients first does not turn over control of the hospital to patients or their families. Indeed,

Case Study

Case Study Conclusion A community hospital in the New York metropolitan area is presented as a case study of an organization struggling to carry out its mission in a way that facilitates the growth and well-being of its employees. The hospital is experiencing different pulls. On one hand, it has had to cut back on essential programs. On the other hand, the nurses and the central leadership in the hospital need to work together to avoid quick-fix solutions and suffer the failure of nerve that Friedman (2007) talked about. The busy hospital environment in a changing society is stressful and, at times, hostile and violent. Nurses need to be effective leaders to help protect the integrity of the hospital as an organization—to maintain its self-definition. They can best do this by becoming as self-defined as possible and by consistently implementing federal guidelines to prevent and manage workplace violence.

Case Study Questions In this case there is a need for policy change—the need for workplace violence policies. Here is our challenge to the reader. Can you take our two components, both an internal and external role, and define what needs to be done to accomplish this policy change? We suggest that you define the work in terms of your most likely environment, whether it is a psychiatric facility or a hospital or clinic. How would you go about creating an environment for policy change here? Some core questions should guide you. First, what key stakeholders are in the initial stakeholder group (i.e., those most likely to feel the strongest need for the policy)? Remember, it is essential that stakeholders are identifiable and represent a clear position on this topic. Can you identify both internal and external stakeholders? Are they organized around various professional lines within your organization? How do you begin to create a shared view among these stakeholders? As you begin to broaden the network—an increasingly collaborative one—which groups should be brought into the discussion? Let us give you an example: The human resource specialists in your organization will need to be involved at some point in creating a policy about the elimination and reduction of workplace violence. Should they, however, be in your initial set of stakeholders? Why or why not?

CASE STUDIES

to understand Friedman (2007) correctly, to put patients’ health and satisfaction first, the hospital needs effective leadership at the top and from its professional nurses. To prevent violence in the workplace, nurses need to strive to be as authentic in their patient contact as possible and to avoid detached impersonal interactions (Carlsson, Dahlberg, Ekcbergh, & Dahlberg, 2006). The case study hospital provides considerable avenues of reward for individual nurses and other staff members to advance themselves and stand out as innovative, which helps mitigate the tendency for workers to herd, that is, to avoid developing themselves and improving the institution for the sake of togetherness with selected coworkers (Friedman, 2007). The case study hospital does provide a psychiatric nurse practitioner on staff and onsite one day per week as an employee assistance provider. Having this person onsite provides an opportunity for hospital staff to be counseled on becoming less reactive to emotionally intense environments, as recommended by Friedman (2007). Healthcare organizations also need to provide referral information, such as to employee assistance programs or clinicians experienced in trauma care, for employees who may exhibit more serious and persistent reactions to perceived violence and aggression (Bernstein & Saladino, 2007). Nurses and nursing organizations should become more familiar with national guidelines and recommendations and persuade their hospitals to adopt and implement them. The process for nurses is to focus more on taking responsibility for their own condition, practice self-regulation, and have a wide repertoire of responses to stressful situations. Although this does not guarantee that violence will be avoided, it does make it less likely to happen and makes nurses better able to keep it in perspective. Friedman (2007) described this as being able to turn down the dial or volume. Nurses need to be just as effective in managing toxic emotional environments as in handling toxic chemicals and infections. Nurses’ interpersonal effectiveness is increased when they look for and support strengths in others. Postincident debriefing helps transform the experience into a team building and learning opportunity. Leaders should involve all staff and review events, including what precedes and follows an incident.

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Chapter 3 A Policy Toolkit for Healthcare Providers and Activists Now are the more difficult questions: ■■

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What expertise is needed to make such a policy change? What kinds of facts (someone has to gather the data in a systematic way) need to be gathered? Are we discussing violence between patients and those providing medical services, or violence among fellow professionals within the organization? What kind of violence and danger are we discussing here—physical or verbal violence, or both? What about safety issues (including other types of danger to employees and patients)? Would you agree that an emergency room might see these questions a bit differently from those handling financial claims (although both have real needs)? How do you build expert power? Who shares it, and who might be expert in defining these issues over time?

As you create the case, think about developing it in two stages: the initial definition of the issues (expertise), and who needs a seat at the table (stakeholders) both inside and outside the organization. The second stage is writing and defining the policy. If the issue is defined well by all the stakeholders, the delineation of the necessary expertise of workforce violence will become a shared view among the stakeholders. Then, and only then, can one move to the writing of a policy about dealing with workplace violence. Do all the stakeholders need to be involved in writing that policy? We suggest that is not necessary for those

involved to reach a broad agreement about the issues that define the policy itself.

Case Study References Bernstein, K. S., & Saladino, J. P. (2007). Clinical assessment and management of psychiatric patients’ violent and aggressive behaviors in general hospital. Medsurg Nursing, 16, 301–309. Carlsson, G., Dahlberg, K., Ekcbergh, M., & Dahlberg, H. (2006). Patients longing for authentic personal care: A phenomenological study of violent encounters in psychiatric settings. Issues in Mental Health Nursing, 27, 287–305. Farrell, G. A., Bobrowski, C., & Bobrowski, P. (2006). Scoping workplace aggression in nursing: Findings from an Australian study. Journal of Advanced Nursing, 55, 778–787. Friedman, E. H. (2007). A failure of nerve: Leadership in the age of the quick fix. New York, NY: Seabury. Love, C. C., & Morrison, E. (2003). American Academy of Nursing expert panel on violence policy recommendation on workplace violence (adopted 2002). Issues in Mental Health Nursing, 24, 599–604. Swanson, J. W., Van Dorn, R. A., Swartz, M. S., Smith, M., Elbogen, E. B., & Monahan, J. (2008). Alternative pathways to violence in persons with schizophrenia. The Role of Childhood Antisocial Behavior, 32(3), 228–240. The Joint Commission. (2008, July). Behaviors that undermine a culture of safety. Retrieved from http://www.joint commission.org/assets/1/18/SEA_40.pdf U.S. Department of Health and Human Services. (2002). Violence: Occupational hazards in hospitals (Document #2002-101). Cincinnati, OH: National Institute for Occupational Safety and Health. U.S. Department of Labor. (2004). Guidelines for preventing workplace violence for health care & social service workers (OSHA 3148-01R). Washington, DC: Occupational Safety and Health Administration.

SECTION 2

Population Health CHAPTER 4

Population Health Care: Access, Cost, and Quality

CHAPTER 5

Global Health: A Vision for Action

CHAPTER 6

Mental and Behavioral Health

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CHAPTER 4

Population Health Care: Access, Cost, and Quality Marie Truglio-Londrigan and Sandra B. Lewenson

OVERVIEW Vulnerability and living in a state of vulnerability have been experienced by individuals, families, communities, and populations over time. The strategies developed to improve the health of vulnerable populations, such as political advocacy and legislation, have evolved. To illustrate this unfolding evolution, this chapter has been developed from a historical to a contemporary perspective. The historical perspective highlights the work of nurses with vulnerable populations as these nurses engaged in political advocacy. It shows the work of one local rural community in upstate New York during the late 19th and early 20th centuries that joined forces to provide healthcare access, specifically nursing care, to those who typically lacked services. The more contemporary aspect of this chapter introduces vulnerability and its complexity as it is understood today, including what factors facilitate and sustain these vulnerabilities that lead to disparities. It also addresses the political advocacy required to assure and ensure access to care, as well as improve quality and limit cost. An interview with a contemporary public health nurse illustrates how public policy initiatives influence care delivered at the local level. This interview demonstrates how politics and policy play a role in how programs are developed, negotiated, and delivered, and, in turn, it addresses the health needs of vulnerable populations.

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Understand nursing’s historical role in primary health care and care of vulnerable populations. Discuss factors that have the potential to facilitate vulnerability. Examine the relationship between vulnerability and disparity. (continues)

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Explore the relationships among ethical norms, ideas, values, and beliefs related to the public policy agenda. Describe how nursing ideas, values, and beliefs play a role in setting the policy agenda. Consider the role that politics, policy, and law have in protecting the rights of vulnerable populations.

Lessons from Nursing History on Vulnerability, Disparities, and Political Advocacy

In 1922, noted nursing leaders and public health nursing activists Lavinia Dock and Fannie Clement described how a pioneer rural nursing association was started by a Johns Hopkins nursing school graduate, Ellen M. Wood, in the northern region of Westchester County, just north of New York City. This new service that began in 1898 provided families living in the northern reaches of the county, which is now considered a suburb but then was a rural setting, access to muchneeded healthcare services. These services were not readily available because of geographic isolation and economic circumstances. The founding of the District Nursing Association of Northern Westchester County (DNA) pre-dated the start of the American Red Cross Rural Nursing ­Service, which began in 1912 and would later bring public health nursing to the far reaches of A ­ merican life, where access to care was at a minimum and vulnerability was at a premium.

Wald’s Work This was not an entirely new concept, but it is a good example for understanding the relationship between the lack of access and the politics of health. Noted public health leader Lillian

Wald had already established primary healthcare ­services in 1893 on New York City’s Lower East Side at the Henry Street Settlement, bringing vital nursing services to immigrant ­populations who came to New York seeking a better way of life (Keeling & Lewenson, 2013). It was Wald who recognized that all citizens, whether in the crowded urban environment or in ­isolated rural areas, required healthcare services. She started the visionary American Red Cross R ­ ural Nursing Service in 1912 and called for additional educational training for public health nurses, in both urban and rural communities ­(Keeling & Lewenson, 2013). Wald also was a leader in advocating for healthcare reforms in New York City, effecting local laws to include placing school nurses in public schools, establishing playgrounds where children in crowded urban settings could play, and supporting tenement laws to protect the health of people who lived in unhealthy conditions. In addition, Wald and many of her colleagues at the Henry Street Settlement, including Lavinia Dock, advocated for women’s suffrage to protect the health of the public (­ Lewenson, 1996). Dock called for nursing p ­ rofessionals “to look at social and political problems and include social reform among their professional obligations” ­(Lewenson, 1996, p. 144). For many nurses during this ­period of social activism, “nurses’ concerns with injustices in the world rendered their political involvement unavoidable” ­(Lewenson, 1996, p. 150). The late 19th and early 20th centuries were a time of professional advancement, political advocacy, and local commitment to bettering health care for populations. The women in northern Westchester County were part of this

Lessons from Nursing History on Vulnerability, Disparities, and Political Advocacy

progressive movement and led healthcare reform efforts in their community.

Ellen Wood and the Use of Political Advocacy The Wood family had a long history of caring for their rural neighbors prior to Ellen Wood’s entrance into nurses’ training at Johns ­Hopkins Training School for Nurses. Her brother, Hollingsworth Wood, wrote about his sister, “she d­ ecided to experience the training then given to nurses in order to take the best possible care of her neighbors” (District Nursing Association of Northern Westchester County [DNA], 1948, p. 13). When Ellen Wood graduated in 1896* she returned home and brought the nursing skills she learned at Johns Hopkins to her neighbors. Her brother wrote, “At first her daily rounds were made on foot, but soon her circle widened as cases of sickness in the remoter county districts came to her knowledge, until presently a horse and buggy were needed to take her to her patients” (DNA, 1948, p. 14). In these early years, Wood provided skilled nursing care and taught families how to care for themselves in her absence. Her work was considered ­“instructive, preventive, and social service work” (DNA, 1948, p. 14). When the Spanish-American War broke out in 1898, Wood volunteered to serve and was assigned as superintendent of nurses at the Fort Hamilton Army base located in Brooklyn, New York. The Spanish-American War lasted less than a year, starting on April 25, 1898, and ending with the signing of Treaty of Paris on December 10, 1898. Wood’s work in the American Red Cross continued following the war. She served on a committee to establish an Army Nurse Corps, something that professional nursing leaders also advocated. Wood worked alongside nursing leaders like Mary Adelaide Nutting, Anna Maxwell, Irene H. Sutliffe, and Isabel Hampton Robb in

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their efforts to have nursing recognized in the military. These leaders found support from several social-minded women who supported nursing’s efforts in this area, including Mrs. Winthrop Cowdin, who later helped Wood establish the rural nursing service in their upstate community (Dock & Clement, 1922). With the support of her family and friends, Wood went on to begin the DNA following the war. The women began the DNA with $250, which were the funds that remained after their short-lived Red Cross Auxiliary that they started to support the local men who fought in the Spanish-American War. Four committees gathered the needed equipment either through loans or purchases to support this new endeavor. They collected items such as hot water bags, rubber sheets, sheets, towels, diapers, ice caps, thermometers, soap, Vaseline, bandages, and other items that were needed for care in the home. They provided instruction for home care to practical nurses and arranged for a “special nurse” from New York City to come to their community when needed (DNA, 1948, p. 15). The ­organizers of the DNA also asked community members to join by paying a $1 annual membership fee. These dues, along with other fundraising activities, donations, and fees charged for nurses’ visits, financed the growth of the organization. In addition, money from two insurance ­companies— Metropolitan Life ­Insurance Company and John Hancock Insurance Company—paid for nursing services for their ­policyholders. For those who could not pay, the DNA provided services free of charge. The DNA organizers believed that trained nurses needed to bring health care to their rural communities and spoke highly of their pioneering effort. They acknowledged the challenges they faced when starting the association and recognized that although district nursing existed already in cities like Boston, New York,

* In an email dated February 28, 2013, archivist Marjorie Kehoe at Johns Hopkins University wrote that Ellen Wood graduated in 1895 and received postgraduate training in obstetrical nursing in 1896.

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Buffalo, and Baltimore, none yet existed in rural communities. These women believed, like other reformers of that period, that health care must be learned and that nurses in the community could implement the ideas of sanitary reform by teaching the women in the community. Convincing the community of the need for public health nurses also meant winning the support of local physicians. Stories about the need to gain support from physicians, who often refused to accept their professional nursing colleagues, include the following from one of the early pioneers, Miss Luquer: I remember sending the nurse to a patient who lived near me. I begged the doctor for his permission. He finally consented. I got the nurse and took her to the neighbor. She made the patient so comfortable that when the doctor called, she thanked him again and again for sending the nurse. He never said a word, but neither did he ever call the nurse again. (DNA, 1948, pp. 20–21) Although it was not always successful in the beginning, the writers of the DNA’s history noted that physicians ultimately became the organization’s “mainstay” (DNA, 1948, p. 21). Without calling the rural communities vulnerable, the late 19th- and early 20th-century community activists, mostly women, joined forces with early public health nurses to provide care to those in need and to those living in rural northern Westchester County. Like in other rural settings, the lack of adequate ­roadways, hospitals, health departments, and healthcare facilities contributed to the vulnerability of the families in this community. The women who joined forces with Wood advocated for the start of the visiting nurses services that Wood and other nurses could provide. These women believed that joining people together was key to meeting the needs of those who required care. People must just “go ahead and do it” (DNA, 1948, p. 47). They were used to working together, as demonstrated in their earlier work in establishing a Red Cross

Auxiliary during the Spanish-American War in 1899, and then again when they lobbied in Washington, DC for the ­establishment of an Army Nurses’ Corps (­ Sarnecky, 1999). They were accustomed to ­working toward providing access to care, whether on the battlefield or in the civilian community, and sought support from organized nursing, local boards of health, other healthcare professionals, and insurance companies. The history of the DNA shows how nurses in the past responded to primary healthcare needs, collaborated intra- and interprofessionally, and recognized the value of political advocacy for that care. This narrative about the 1920s era captures how nurses have responded to the needs of vulnerable populations on a local level and perhaps can help us shape how we consider the advocacy role that nurses continue to have in the 21st century. It also shows the collaborative nature of nurse advocates as they joined the work of rural and urban efforts (DNA and Henry Street Settlement, respectively). When a nurse was needed to care for a young camper at Henry Street’s camp in the rural Westchester County, the urban settlement house contacted the DNA in Katonah for aid: Late one summer evening a call came from Henry Street Settlement asking if it were possible to send a nurse to their camp at Secor’s Lake where a boy had been taken very ill. There was no nurse, the camp doctor had gone to New York, and there was no night train. The need was urgent and Katonah was the only point of contact because there was a visiting nurse there. It took some time to locate the camp, but at last the livery man was awakened and the willing nurse set off with the livery team in a violent thunder storm. The picture she found was a gloomy one. The boy had been removed to a vacant barn for fear of contagion. The nurse stayed for hours doing all she could for his comfort, but the next day he was

The Face of Vulnerability Today

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REFLECTION AND DISCUSSION Before you continue reading this chapter, consider the work of these past nursing leaders and engage in the following reflection and discussions: 1. Describe the communities and the population living within these communities that Lillian Wald and Ellen Wood served. 2. What were the major needs of the population during that time? Is there evidence of their vulnerability and disparities? 3. Were services available and accessible? 4. What were the reasons for the limited availability and access to these needed services? 5. What role did geography and economics play at the time? 6. What skills did these past nursing leaders possess and what can we learn from them for our contemporary practice? 7. What questions do you suppose these nursing leaders ask during periods of quiet self-reflection? 8. How do you suppose these past nursing leaders engaged others in their quest to develop services that were both available and accessible? 9. How did they develop and expand opportunities for those they served? 10. How is this related to social activism and social justice? 11. Considering the stories from the past, what were the core factors that facilitated these nurses in these transformational endeavors?

removed to a New York hospital where he died. Miss Wald’s letter received later spoke with appreciation of the “link of co-operation” which brought help to the boy, and relief to the Henry Street Settlement from the Nursing Association of Northern Westchester. (DNA, 1948, p. 52) Vulnerability can happen in any population living in urban or rural settings, and it is often compounded by race, class, and gender. As this historical example shows, nursing attempted to provide care to vulnerable populations in rural settings and urban settings. The DNA, the American Red Cross Rural Nursing Service, and the Henry Street Settlement on the Lower East Side of New York City are just a few exemplars of how nurses cared for the populations living in the community. Nurses in each of these ­community-based organizations offered primary healthcare services, such as well-baby classes for new mothers, bedside care in the home for those in need, coordination of care with other healthcare providers, and

collaboration with local governmental agencies like health d ­ epartments, school boards, and local Chambers of Commerce to provide such care. The ability of the activists and the families in the northern Westchester community during the late 19th and early 20th centuries to work together and address the needs of the community offers insight into today’s need for strong community partnerships, political advocacy for those who need healthcare services, and the ­recognition of nursing’s role in providing primary health care in rural settings.

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The Face of Vulnerability Today

Nursing’s history and historical leaders give us pause as we think about how nurses have ­always played a role in consideration of those most vulnerable. Contemplating that which was documented in the first part of this chapter illustrates some of these leaders and their pioneer work. The iconic image of the nurse climbing

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Chapter 4 Population Health Care: Access, Cost, and Quality

over rooftops in New York City is a visual image to which all nurses have been introduced throughout their education and professional experience. Ensuring and assuring that vulnerable populations have access to the care they need was not only at the forefront of nursing practice in years gone by; it continues to play an important part of the professional responsibility of nurses today. In contemporary practice the responsibility of providers to assure and ensure access is even more crucial along with quality and cost as the trifecta of the “overriding goals of change” (Cox, 2009, p. 217). Vulnerability and vulnerable populations have been defined as “those at greater risk for poor health status and health care access” (Shi & Stevens, 2005, p. 148). There are certain factors that place these individual and populations at risk. These risk factors are varied and many. A scoping review of the literature by Grabovshi, Loignon, and Fortin (2013) provided evidence that there is the coexistence of multiple risks, frequently noted as multivulnerability, including: poverty, especially in relation to a specific racial/ethnic minority group; chronic physical or mental illness; lack of insurance; older age; incarceration; immigrant status; limited formal education; living in underserved areas; unemployment; widowed; and homelessness (p. 7). Given the possibility of the multiple risks, Shi, Stevens, Lebrun, Faed, and Tsai (2008) introduced the idea of “risk profiles” (p. 846). These authors noted that the ability to identify risk profiles enables the healthcare system and providers to explore the influence of these multiple risks in certain populations in terms of ­access to care and use of that care. For e­ xample, risk profiles may ­facilitate an understanding of the presence of a “dose–­response relationship,” with increasing number of risk factors increasing the likelihood of delaying care (p. 851). In addition, risk profiles allow for vulnerability and disparities to be viewed as the complex constructs that they are, and to consider strategies of a more complex nature inclusive of advocacy and policy.

Taking a Closer Look at Vulnerable Populations Public health initiatives throughout the 20th century made strides in addressing vulnerability. Yet, despite these strides, there are still “vulnerable populations left behind” (Institute for Alternative Futures, n.d., p. 8). Some of these identified populations are as follows: high-risk mothers and infants; people who are chronically malnourished, homeless, ill, or disabled; people who are living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (including pediatric AIDS cases); people who abuse alcohol and drugs (including fetal alcohol syndrome and crack babies); ­people with health problems caused by chemical exposures; people who are mentally ill; veterans who suffer from posttraumatic stress disorder (PTSD); abusive families and relationships; gays and lesbians who suffer from discrimination; foster youth who are aging out of the foster care system; prisoners; and American Indians (Institute for Alternative Futures, n.d. pp. 8–9). Discussions pertaining to vulnerability focus on individuals, families, and communities—but, the greater focus is on the population perspective. It is important to recognize, however, that individuals make up populations. An individual who is a member of a vulnerable population may not experience vulnerability; conversely, an individual who is a member of a nonvulnerable population may be vulnerable due to personal life events (de Chesnay, 2011). Changes in social, economic, and political contexts may create a state of vulnerability for an individual, such as an illness, a loss of a job, a move to an unfamiliar environment, or the loss of a loved one (Benatar, 2013; de Chesnay, 2011; Rogers, 1997). Vulnerability is a complex concept involving life experience that requires understanding of the vagaries of life; an understanding of this complexity can help avoid stereotyping individuals and populations. Conversations about who vulnerable people are and the risk factors that precipitate the openness or exposure leading to vulnerability

Case Study

is crucial yet difficult. The tendency is to speak of each factor in isolation—such as age, economic status, lack of education, loss of a job, and so forth—but they coexist and there is an interplay between and among the risks, enhancing the complexity of being vulnerable. This highlights the multifactorial nature of vulnerability (Flaskerud & Winslow, 2010). Stevens, Shi, and Faed (2008) further explain this phenomenon as being “vulnerable in more than one way” (p. 902). Aday (2003) furthered this conversation by illustrating how vulnerability may be considered from community and individual perspectives and examines the relationships among concepts such as ethical norms and values and policy (social and economic policy, community-oriented health policy, and medical care and public health policy). We, the authors of this chapter, suggest that Aday’s use of the term medical care does not adequately represent the expansiveness of the needs of any population, and we propose that a broader term, such as health care and public policy, would be more useful. In addition, we also suggest that family perspectives are important to consider in any model pertaining to vulnerability. An example of the complexity of vulnerability is noted in the case study about Rose located below.

CASE STUDY Rose is a 42-year-old Hispanic female who immigrated to the United States; she is educated at the master’s level and employed as an office worker. Rose had a stroke that left her with left-sided hemiplegia. She finds herself socially and physically isolated from family and friends as a result of living in a rural setting. Rose loses custody of her two children to her ex-husband and finds that her new live-in fiancé of less than 1 year (and her sole caretaker following the stroke) no longer wants to marry her. The economic vulnerability affecting her physical and mental recovery is compounded when she learns that the remaining disability payments from her job, which she can no longer perform, will be gone within a year. Being

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ineligible to enroll in Medicaid creates long-term economic concerns that add to her stress and ability to recover. Rose’s inability to drive, lack of funds, emotional and physical loss, geographic isolation, and limited social supports and networks pertaining to family and community, as well as the lack of local physical therapy compound her increasing vulnerability and thus her health outcomes. As we will see later in this chapter, Healthy People 2020 considers health services to be one of the determinants of health; it supports the increasingly untoward experience of Rose and the need to advocate for better health services to achieve the desired health outcomes and is concerned with the other factors that compound her increasingly vulnerable state (U.S. Department of Health and Human Services [USDHHS], 2010b). While this case study is about one individual, this one case is representative of a population in need of care and the risks associated with vulnerability.

Case Study Questions 1. Who is the population that Rose represents? 2. What risks are present that foster Rose’s vulnerability? 3. What disparities can you identify that are evident in health care and health outcomes? 4. What is the potential role for a political advocacy initiative?

Mechanic and Tanner (2007) also identified that vulnerability results from “developmental problems, personal incapacities, disadvantaged social status, inadequacy of interpersonal networks and supports, degraded neighborhoods and environments, and the complex interactions of these factors over the life course” (p. 1200) and may arise from challenges evidenced not only in populations but in individuals and communities (de Chesnay, 2011; Mechanic & Tanner, 2007). The following case study depicts how an older adult, experiencing aging changes, is at greater risk for vulnerability and disparities. It is interesting to note that this individual is representative of other older adults and raises the real possibility that the population of older adults may be at risk for similar vulnerabilities and disparities.

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Chapter 4 Population Health Care: Access, Cost, and Quality 3. What disparities can you identify that are evident in health care and health outcomes? 4. What is the potential role for a political advocacy initiative?

CASE STUDY

Differences in Health and Health Care

A 75-year-old active man named Joe has been living independently in his chosen community for the past 6 months after the death of his wife. He has been experiencing normal aging changes; as a result, his family notes a difference in his ability to engage in activities of daily living and instrumental activities of daily living. In particular, Joe has not been able to go to follow-up appointments with his primary healthcare provider, attend lunch outings with his friends, or make needed trips to the pharmacy and grocery store. In addition, he has experienced several minor car accidents during his outings that frightened him and caused him to abandon these once enjoyable trips. These aging changes have introduced vulnerability into Joe’s life. This new vulnerability places Joe at risk for negative health outcomes. Furthermore, Joe’s family has been negotiating the health and social networks of Joe’s community to look for social support since he has expressed great sadness over the loss of his wife. They have noted that there is a limited network of support that would permit him to age successfully and safely in place; thus, Joe is vulnerable and at risk.

Case Study Questions 1. Who is the population that Joe represents? 2. What risks are present that foster Joe’s vulnerability?

The relationship between vulnerability and healthcare disparities is correlational in that “the people with the greatest health care needs receive the least health care services” (Grabovschi, Loignon, & Fortin, 2013, p. 2). Furthermore, these authors suggest that “people who accumulate more vulnerability factors are more likely to face health care disparities” (p. 7). Disparities are referred to as “. . . differences in health and health care between population groups” (Ubri & Artiga, 2016, p. 1). The Agency for Healthcare Research and Quality (AHRQ) has reported on healthcare quality and disparities since 2003. The National Healthcare Quality and Disparities Report (QDR) is published annually and provides an overview of the quality of health care received by the U.S. population as well as the disparities in care experienced by different racial, ethnic, and socioeconomic groups. The National Healthcare Disparities Report (2011) highlighted that Americans who experience disparities have the following characteristics: ■■ ■■ ■■ ■■

They do not receive care they need, and/or The care they received causes harm, and/or The care was delivered without consideration of the patient’s preferences. The care was distributed in a way that was inefficient and uneven across populations.

It appears, therefore, that there are certain situations that place certain populations at risk, making them vulnerable to disparities in terms of access to care, quality care, and cost of care that ultimately affects disease outcomes, leading to disparities not only in terms of differences in health status between and within populations, but the type of care received by different populations. For example, just because a healthcare service is available to an individual, family, or

Vulnerability and Disparities from a Population-Based Perspective

population does not mean that these potential end users will make use of the service. Therefore, just because a healthcare service is technically available, if it is not accessed and used is it really available? In other words, building it does not mean that they will come. There may be multiple barriers to accessing that health service such as: geography, limited or no transportation, cost of transportation, limited physical or mental health in terms of the individuals’ ability to travel to the service, lack of awareness of the service, fear due to immigration status, limited literacy, and care deemed not acceptable, satisfactory, or culturally congruent by the intended user. There are examples of population-specific disparities. Black and Hispanic populations are less likely than whites to have a usual place to go for health care—thus limited access (AHRQ, 2015). Children with only Medicaid or Children’s Health Insurance Program (CHIP) are less likely to get care when needed compared with children with other forms of insurance (AHRQ, 2014). Ultimately, delays in care access result in poor outcomes as evidenced by increases in morbidity and mortality (Ubri & Artiga, 2016). There is also evidence to suggest that barriers to quality care are significant in households of limited income (AHRQ, 2014, 2015). Certain populations will present with higher rates of certain diseases and health conditions along with poor outcomes. For example, chronic diseases such as heart disease, diabetes, stroke, and cancer are more common for specific populations such as non-Hispanic blacks, Hispanics, American Indians, Alaska Natives, Asians, Native Hawaiians, and Pacific Islanders (Centers for Disease Control [CDC], 2016). Non-Hispanic blacks are also 40% more likely than non-Hispanic whites to have high blood pressure and the rate of diagnosed diabetes is 77% higher among non-­ Hispanic blacks, 66% higher among Hispanics, and 18% higher among Asians than among nonHispanic whites (CDC, 2016). Additional ­examples of health disparities in other populations include infant m ­ ortality rates that identify infants born to black women as being 1.5 to 3 times more likely

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to die than infants born to women of other races/ ethnicities; higher rates of new HIV in racial and ethnic minorities are noted, except for Asians/ Pacific Islanders (CDC, 2011). Despite the fact that there have been some improvements in the existence of disparities in our nation, there is still work that needs to be done. It is clear that racial and ethnic minority populations often receive poorer quality care and face more barriers in seeking care than do non-Hispanic whites. These disparities can lead to poor health outcomes as well as higher healthcare costs. Vulnerability and disparities must be addressed along with attention to quality, as well as the direct and indirect costs. The direct ­expenses are affiliated with the provision care once accessed and the indirect costs from outcomes such as lost productivity and lost wages (LaVeist, Gaskin, & Richard, 2009).

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Vulnerability and Disparities from a Population-Based Perspective

As previously noted, progress has been made, but more still needs to be done. A recent N ­ ational Healthcare Quality and Disparities Report (2015) identifies three aims. These aims act as a guide to improve national disparities and include: 1.

2.

3.

Improve overall quality, by making care patient centered, reliable, accessible, safe, and focused on achieving meaningful health outcomes. Improve the health of the U.S. population by supporting proven interventions that are based in evidence to address behavioral, social, and, environmental determinants of health. Reduce the cost of quality health care for individuals, families, communities, populations, employers, and the government.

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Chapter 4 Population Health Care: Access, Cost, and Quality

The question remains: How? How do we as a nation address these challenges in a systematic way that utilizes the best evidence of the time? Derose, Gresenz, and Ringel (2011) propose that application of our public health framework as a means to address vulnerability and disparities enhances access of services.

Public Health Framework The Institute of Medicine (IOM) (1988) defined public health as “what we, as a society,

do collectively to assure the conditions in which people can be healthy” (p. 1). How we as a society assure the health of our public is through the application of a comprehensive public health framework that begins with the three core functions of public health: assessment, policy development, and assurance (IOM, 1988) along with the 10 essential public health services determined by the USDHHS and CDC. A visual image depicting these core functions and essential public health services is seen in FIGURE 4-1.

Three core functions of public health

Assessment

Policy development and planning

Assurance

Monitor health status to identify community health problems.

Inform, educate, and empower people about health issues.

Enforce laws and regulations that protect health and ensure safety.

Diagnose and investigate health problems and health hazards in the community.

Mobilize community partnerships to identify and solve health problems.

Link people to needed personal health services and ensure the provision of health care when otherwise unavailable.

Develop policies and plans that support individual and community efforts.

Ensure a competent public health and personal healthcare workforce. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Research new insights and innovative solutions to health problems.

FIGURE 4-1  Three core functions of public health Data from Institute of Medicine. (1988). The future of public health. Washington, DC: National Academies Press; U.S. Department of Health and Human Services. (1994). The public health workforce: An agenda for the 21st century. Washington, DC: U.S. Government Printing Office; Centers for Disease Control and Prevention. (2015). Core functions of public health and how they relate to the 10 essential services. Retrieved from http://www.cdc.gov/nceh/ehs/ephli/core_ess.htm

Vulnerability and Disparities from a Population-Based Perspective

Carrying out an assessment is a systematic process that includes the gathering of information about individuals, families, communities, systems, and the population. Information is gathered by interview and observations; information can also be retrieved from large databases about the population of interest. These large databases offer a wide variety of information such as vital statistics, as well as morbidity, mortality, incidence, and prevalence rates, just to name a few. Those working with populations may analyze this information over a period of years searching for trends in specific populations. This analysis will offer information about which populations are exposed to risks, vulnerability, and disparities. In addition, assessment includes details about the history of the community, geography, and environmental hazards and benefits (Truglio-Londrigan & Lewenson, 2017).

Factors and Precipitators Leading to Potential Vulnerability An important part of this population-based assessment is the gathering of information about the determinants of health that include those factors or precipitators that can place individuals and the population at risk for being vulnerable and thus determine their health—as well as their part of the vulnerable risk profile. These categories, as identified in Healthy People 2020, include social factors, health services, individual behavior, biology and genetics, and policy making (USDHHS, 2010a). Social factors, as determinants of health, are subdivided into social determinants and physical determinants. Some examples of social determinants include the following: availability of resources; social norms and attitudes, such as discrimination; crime and violence; social support; social networks and social interactions; socioeconomic conditions; transportation; and safety. Examples of physical determinants include the following: the built environment, housing, and environmental exposure to toxic substances (USDHHS, 2010b).

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Social Factors Social factors are not all-inclusive but offer some evidence as to the strong influence of social determinants on vulnerability. Shi, Stevens, Faed, and Tsai (2008) stated that the healthcare ­professions are now understanding the impact that “social position and social class, racism and discrimination, social networks, and other more relational community factors have on population health” (p. 43). And, Carthon (2017) stated that “racial and ethnic minorities in the United States have endured long-standing health disparities” (p. 3). Furthermore, factors that have the potential to facilitate vulnerability—such as education, income, occupation, social networks, and social support—correlate with health outcomes. These social determinants of health have been positively associated with employment and higher paying jobs with benefits that result in favorable health outcomes (Moscou, 2017). This has been seen over time. One example can be found in the work of Carthon (2011) in which the author presented a historical study of the physical and social environments of blacks in early 20th-century Philadelphia. In what would fit under the description of today’s Healthy People 2020 social determinants of health, the black community was faced with economic hardships, housing shortages, insufficient toileting, lack of clean water, lack of educational opportunities, and limited social relief. This community banded together to address these issues through community activism. They organized the Little Mother Club, which offered health education to childbearing women as a means to reduce infant mortality in the city.

Health Services Health services, as a determinant of health, refers to both access to and quality of healthcare services (USDHHS, 2010c). Vulnerable populations include those who are “not well integrated into the health care system because of ethnic, cultural, economic, geographic, or health characteristics” (Urban Institute, 2010, para. 1). Because of this

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Chapter 4 Population Health Care: Access, Cost, and Quality

lack of integration, they are put at further risk. This lack of access may mean that the population, and the individuals who are part of that population, may not be aware of needed resources or how to navigate the complex healthcare system. As a result, they are not able to avail themselves of services, further facilitating their vulnerability (Gallagher & Truglio-Londrigan, 2004; Krout, 1986, 1994; USDHHS, 2010d; Williams, Ebrite, & Redford, 1991). As a result, they never were integrated into the system and thus were left behind. An individual who does not have access to needed healthcare services due to barriers such as cost, lack of availability, geographic location, or language may be at risk for being vulnerable and present with negative health outcomes (USDHHS, 2010d).

Individual Behavior Individual behavior, as a determinant of health, refers to personal choices regarding diet, physical activity, or the use of substances. The choices a person makes may have a direct implication on health (USDHHS, 2010e). Note that even though public health is generally about care to populations, individuals make up the population; therefore, individual behavior along with collective behaviors of families and even communities are part of a public health framework.

Biology and Genetics Biology and genetics, as a determinant of health, refer to factors such as age, gender, and genetic predisposition (USDHHS, 2010f), which are not under an individual’s control. There may be situations when these specific factors place an individual or population at risk, thus facilitating vulnerability with potential negative health outcomes. Age, for example, may have an impact on whether an individual is vulnerable, as evidenced in the case study about Joe and his increasing vulnerability and potential for adverse health outcomes. Yet in the case study of Rose, who is only 42 years of age and not typically part of a vulnerable population for the kind of illness

she is experiencing, age plays a factor because she is a mother of two young children and is no longer able to care for them due to her disability. As a result, she faces a change in custody. ­According to Aday (2003), “People are more or less ­vulnerable at different states of their lives” (p. 54). For example, older adults experience normal aging changes (Smith & Cotta, 2012) and an increase in the incidence of chronic illness (Federal ­Interagency Forum on Aging-Related Statistics, 2012). These alterations in health may precipitate vulnerability along with the potential for negative health outcomes.

Policy Making Finally, policy making, as a determinant of health, may have an impact on health outcomes. For example, increasing taxes on tobacco sales may correlate with decreased sales of cigarettes, or laws may facilitate greater safety and a decrease in injury rates (USDHHS, 2010g). Another example shows how changes in political leadership in government can affect advocacy and the health of the vulnerable. The 2017 budget proposed by the Trump administration threatens to cut funding for specific programs. Meals on Wheels, a program that provides food to the elderly in their homes; Supplemental Nutrition Assistance Program (SNAP), a program that provides food for children; and Planned Parenthood, a program that provides women’s health care are just a few examples of how policy on the national and state level can potentially affect the most vulnerable in our society (Paletta & Costa, 2017). The importance of health determinants as risks or precipitators of vulnerability in individuals or populations cannot be underestimated as nurses and other healthcare providers seek to address disparities with the goal of improving health outcomes and in achieving equity. According to the American Nurses Association (ANA) (2015), the integration of social justice is a responsibility of the profession and individual nurses who “. . . must be v­ igilant and take action to influence leaders, legislators, governmental agencies, non-governmental

Political Advocacy toward Health Equity

organizations, and international bodies in all related health affairs to address the social determinants of health” (p. 36).

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Political Advocacy toward Health Equity

Nurses engage in reflection individually and collectively as a professional group as they work with populations towards the elimination of disparities and achieving equity via policy development and assurance. They ask questions such as: Where do we stand, and where does the nation stand? It is important to ask these questions to clarify and answer them. Courtwright (2008) says, “If we take the social determinants of health seriously, we need to look beyond asking whether the conditions that create them are just or unjust and start with the more fundamental questions of whether it is right that some people have worse health care than others” (p. 17). Over the decades, there has been a progressive movement in the work of Healthy People to address this issue, as noted in the evolution of its overall goals, where there has been a shift of emphasis concerning disparities. Initially, the focus was on the reduction of health disparities, then the focus shifted to the elimination of health disparities. More recently, Healthy People 2020 introduced the concept of health equity, which is defined as “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities” (National Partnership for Action, 2011, para. 1).

Social Justice and Responsibility Flaskerud and Winslow (2010) invite readers to reflect on and answer the following question: “Who has the ultimate responsibility for the well-being of the most vulnerable among us?” (p. 298). Given the issues we face as a nation

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with regard to economics and the never-ending debate regarding the health of our people, it is a question that warrants a courageous and crucial conversation (Patterson, Grenny, ­McMillan, &­ Switzler, 2012). Fairman and D’Antonio (2013) speak about this national conversation throughout U.S. history, as seen in debates triggered by Social Security legislation in the 1930s, Medicaid and Medicare in the 1960s, and now the ­Affordable Care Act (ACA) of 2010 and its proposed repeal. Rogers (1997) discussed how certain factors that lead to vulnerability are nonmodifiable, such as age and gender, and how others, such as ­poverty, education, and social support, are modifiable. Nurses, for example, with their knowledge base, are in a prime position to ­develop strategies to address these modifiable and nonmodifiable factors that may lead to vulnerability and disparity. According to Benatar (2013), the common response in terms of protecting the health and rights of vulnerable people is through the law. There is, however, conflicting discourse about this very notion of responsibility and accountability. Some say the responsibility rests solely with the individual, and others say it is a collective responsibility. This directly impacts politics and the policy agenda. Even if there were agreement that health is a collective responsibility, as argued by Benatar (2013), and if responsibility were carried out through law, the laws themselves do not guarantee social justices. This is further explicated by Mechanic and Tanner (2007): Federal and state government are more likely to provide assistance to those who are not seen as responsible for their vulnerability, such as children, the blind, disabled veterans, and the elderly. When people are seen as responsible for their life circumstance, such as in the case of substance abusers . . . There is less public compassion and often stigma. (p. 1222) This idea is further supported by Truglio (2017) who put forth the idea that governments

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Chapter 4 Population Health Care: Access, Cost, and Quality

are not always “altruistic” or “value neutral” with regard to different populations who may be “cast out” and “treated prejudicially” (p. 434). This author further states, “. . . if it is the objective of public health providers to safeguard access to healthcare services for all members of society, it is crucial to be attentive to public policy and the powers behind policies creation” (p. 434). As evidenced by the government in power today, questions about the notion of “health for all,” an attribute of primary health care that supports the care of the most vulnerable in society, is now gravely challenged. Do we, as a nation, a profession, and a people, recognize and see a problem? Do we see and understand the issues experienced by vulnerable people as a priority, or do we neglect, ignore, or become bogged down in the dogma that reflects the diverse and wide variety of ideas pertaining to social and moral values (Mechanic & Tanner, 2007)? To talk about the policy necessary to address the needs of vulnerable people in this way implies an approach that is paternalistic without regard to the strengths of the vulnerable population in question. Purdy (2004) conducted a concept analysis of the term vulnerable and identified several positive consequences. One had to do with the term open and exposed. Purdy indicated that being open and exposed, with regard to vulnerability, may lead to positive opportunities. Dorsen (2010) took this a step further in a concept analysis of vulnerability in homeless adolescents and noted positive consequences of vulnerability as the homeless adolescents demonstrated increased resilience, self-­reliance, resourcefulness, and innovation. In addition, the providers demonstrated a decrease in negative judgmental behavior and also illustrated a greater understanding of the struggles of this specific population. The possibility exists, therefore, to view vulnerability in a different way, where healthcare providers and policymakers see those who are vulnerable as valuable partners working

together to address the determinants that facilitate vulnerability and disparities. This new way emulates practice from a primary healthcare perspective. Truglio-Londrigan, Singleton, and Lewenson (2017) view primary health care as a philosophical belief about social justice and health equity that nurses and the profession must consider in their work. They base their beliefs on the 1978 saying “Health for All” that was coined by the World Health Organization (WHO) and led to the idea of primary health care as the means of achieving this goal. So strong was this belief that at the International Conference on Primary Health Care, the Declaration of Alma-Ata was developed and expressed a call to action by all governments and world communities to promote and protect all ­people (WHO, 1978). This declaration contains 10 points. The fifth point speaks specifically to the idea of primary health care. The declaration formally ­defined primary health care as follows: Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. (WHO, 1978, para. 6)

Case Study

The notion of full participation in this definition is further defined in the following statement: Requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate. (WHO, 1978, point 6, section 5) Could this engagement for full participation by vulnerable people be another way of working with our elected officials in the policy arena? As individuals and populations who are living in vulnerable states partner with organizations in the development of strategies to address factors, precipitators, or determinants of health that facilitate these vulnerabilities, which may lead to negative health outcomes, is it possible to apply the insights of those considered vulnerable in the identification of priority policy agenda items and how these policies are implemented at local levels? The ability to fully operationalize partnering with all other parties in a community, while perhaps the goal, is difficult to achieve but not impossible. Using an example from the recent past allows us to view the way a public health nurse operationalized the idea of engaging vulnerable people in political advocacy for better healthcare outcomes by establishing beginning connections necessary for partnership development with the population being served. The following case study is from an interview with a public health nurse and illustrates the intersection of nursing social responsibility, laws to protect vulnerable people, and concern for the population in general, and how standards of care were executed with policies and procedures.

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CASE STUDY A Public Health Nurse’s Story: Responding to a Local Need This case study is based on the work of a public health nurse, Amanda, who served in the role of director of public health nursing in a county department of health services during the 1990s and early 2000s. While public health nursing focuses on populations, it also works with individuals, families, and communities. By virtue of their practice, public health nurses are connected with governments at local, county, state, and federal levels. This case illustrates how public health nursing practice is often based on legislation that must be enacted at the local level. “It is because federal, state, and local laws require enforcement, that public health nursing can be described as a combination of nursing practice and public health science, including the enforcement of all applicable, local health laws” (anonymous personal communication, August, 7, 2013). Amanda further explained that the U.S. Department of Health and Human Services (USDHHS) and the Centers for Disease Control and Prevention (CDC) guide public health practice, whereas the state commissioner of health and each state’s legislated Standards of Performance for Local Boards of Health guide practice at a local level. The delivery of care at a local level to a vulnerable population of adults who are diagnosed with tuberculosis (TB) highlights the core functions of public health: assessment, policy development, and assurance.

Population at Risk The population at risk is any resident within the county who had been diagnosed with TB or was at risk for TB. Physicians at the County TB Chest Clinic and the public health nurses related to this specific County Department of Health Services (CDHS) were the main providers of TB care in the community.

The Problem For a long time, Amanda reported, Chest Clinic physicians and the involved public health nurses

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Chapter 4 Population Health Care: Access, Cost, and Quality

were able to deliver the required care and meet standards of practice. Over time, however, there was a change in the population served; this was not recognized by the public health nurses and other professionals, resulting in diminished treatment compliance, reduced numbers of optimal outcomes, and increased risk of multidrug-resistant tuberculosis (MDR-TB). Demographic trends showed the county was changing due to increased migration from Korea, China, South America, and Central America. This created a shift from a mostly white, English-speaking population to a more culturally diverse population, with English as a second language or no English at all. This was compounded by the fact that these diverse populations often had a different cultural understanding of TB and its treatment. In addition, if a particular person was undocumented, he or she saw the public health nurse as a government person and wanted to avoid contact. Although the population had changed, Amanda reported, the available public health nurses were still primarily white and English speaking. They sensed these shifts in demographics, but it had happened gradually, so its significance was not apparent. They were not culturally aware of what these shifts meant in terms of how TB care delivery needed to be changed. Strategies for the delivery of culturally competent and congruent care would be needed if positive health outcomes were going to be sustained. Instead, the nurses recognized only how increasingly difficult it was to meet client needs, obtain compliance, achieve standards of care, and reach positive outcomes. Simultaneously, additional standards of care had been developed by the State Department of Health—Standards of Care for Tuberculosis Disease and Latent TB Infection—that stressed the use of directly observed therapy (DOT) for all pulmonary and laryngeal TB cases. DOT means that a public health nurse, or a delegate, would meet with each TB patient to observe the self-administration of prescribed medications. As this standard was incorporated, each TB program throughout the state did its best to meet the DOT standard; however, it became apparent that provider agencies with a significant number of TB cases needed additional CDC funding or additional

staff to meet the DOT standard, particularly in this county, where there was a significant shift in demographics. This issue spurred an internal assessment to find out what was happening. Conducting the assessment was difficult because the CDHS system was not fully supported by technology, and data mining was impossible. What ensued was a massive chart audit that helped everyone see the changing demographics and created the context for collective reflection. Based on this audit, policies and staffing needed to change, as did the competencies of the staff and the involvement of key individuals living in the communities that were reflected in the vulnerable population being served.

Solution Amanda, in concert with the CDHS health officer, applied for a grant that the CDC made available to state departments with demonstrated need. The previous audit outcomes allowed her to be successful in demonstrating need; the grant was awarded, and monies to enhance the department’s abilities were received. This financial resource permitted the CDHS to hire additional staff, purchase necessary equipment, and provide the public health nurses with culturally accurate educational materials for the target population of TB cases and their contacts. Amanda reported that these grant monies allowed the CDHS Office of Public Health Nursing to add bilingual nursing or outreach staff to meet the language needs of the population, have a designated car for DOT home visits, provide annual updated and culturally sensitive TB Standards of Care education to all involved public health personnel, and enhance involvement of the communities and populations being served.

Outcome As a result of these population-based interventions, the treatment policies changed. DOT was provided daily by culturally sensitive staff, community understanding and involvement increased, TB treatment compliance increased, and the incidence of MDR-TB conversions decreased. These positive outcomes resulted in continued grant funding from the state, thus ensuring continuance of care. The cycle of public health assessment, policy development, and assurance had come full circle.

References

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Conclusion

There is a danger when making a list of vulnerable populations. Such a list gives the impression that the list is complete. The list presented earlier in this chapter is not complete and is provided as a demonstration of the breadth of this issue. There is also a danger in accepting the status quo, and believing the government accepts the responsibility to support the vulnerable populations among us. Yet, this is not always true, and even knowing the scientific evidence that supports a more socially just practice, nurses and healthcare providers must become clearer on who these populations are and what needs to be done—socially, economically, and politically— to ensure and assure that the care is provided. Vulnerability can be assigned to populations, and it can occur in individuals. There is a relationship among factors that lead to vulnerabilities. Using various examples from history and contemporary times, we see an evolving overarching public health framework in which we can explore the ideas surrounding vulnerability, disparity, quality, cost, advocacy, and policy. Nurses have responsibly acted upon the needs of vulnerable people over the past 100 years. From Wald’s leadership in both urban and rural settings to nurses’ responses today as they meet the needs of vulnerable people, this commitment continues. This chapter illustrates how nurses have served and must continue to serve the public in addressing vulnerabilities and disparities through political advocacy while addressing cost and quality. In this way, it is hoped that the Declaration of Alma-Ata phrase “Health for All” can be realized.

Discussion Questions 1.

As a group, discuss a vulnerable population and the disparities this population experiences. After the group develops a common understanding, delve into nursing databases, such as CINAHL or nursing history databases. Identify an article from the past that depicts the work of nurses

2.

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as they engaged in the role of political advocacy for this vulnerable population. a. Identify the time in history and describe what the presiding issue was and what the population was experiencing with regard to the issue. b. How did the nurses of that time exemplify the role of a political advocate for the population? c. How did the nurses of the time engage in political advocacy? As a group, discuss the various vulnerable populations that you have encountered in your practice. a. Identify the population. b. Gather information about the population and the risks that make them vulnerable and the specific disparities they experience. c. What are the specific issues that this population presently face? d. How would you describe their access to care, quality of care, and the economic burden of that care? e. How can you advocate politically for this particular population with regard to the issue? f. How can you engage and partner with the population in political advocacy, working together to address their vulnerability and disparities? Provide specific examples. g. How does partisan politics affect the care society provides to vulnerable populations?

References Aday, L. A. (2003). At risk in America: The health and health care needs of vulnerable populations in the United States (2nd ed.). San Francisco, CA: Jossey-Bass. Agency for Healthcare Research and Quality. (2011). 2011 national healthcare quality and disparities report. Retrieved from https://archive.ahrq.gov/research/findings/nhqrdr /nhdr11/key.html Agency for Healthcare Research and Quality. (2014). 2014 national healthcare quality and disparities report. Retrieved from https://www.ahrq.gov/research/findings/nhqrdr /nhqdr14/index.html

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Agency for Healthcare Research and Quality. (2015). 2015 national healthcare quality and disparities report; 5th anniversary update on the national quality strategy. Retrieved from https://www.ahrq.gov/research/findings /nhqrdr/nhqdr15/aims.html American Nurses Association (ANA). (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author. Anonymous. (2006). Vulnerable populations: Who are they? The American Journal of Managed Care. 12(13 Suppl). S348–S352. Benatar, S. R. (2013). Global health, vulnerable populations, and law. Journal of Law, Medicine & Ethics, 41(1), 42–47. Carthon, J. M. B. (2011). Bridging the gaps: Collaborative health work in the city of brotherly love, 1900–1920. In P. D’Antonio & S. B. Lewenson (Eds.), Nursing interventions through time: History as evidence (pp. 75–87). New York, NY: Springer Publishing Company. Carthon, J. M. B. (2017). Minority nurses in diverse communities: Mary Elizabeth Tyler and the Whittier Centre in early 20th-century Philadelphia. In S. B. Lewenson, A. McAllister, & K. M. Smith (Eds), Nursing history for contemporary role development (pp. 3–18). New York: Springer Publishing Company. Centers for Disease Control and Prevention. (2011). CDC health disparities and inequalities report—United States, 2011. Morbidity and Mortality Weekly Report, 60, 1–113. Centers for Disease Control and Prevention. (2016). Race and ethnic approaches to community health (REACH): Finding solutions to health disparities at a glance 2016. Retrieved from https://www.cdc.gov/chronicdisease /resources/publications/aag/reach.htm Courtwright, A. (2008). The social determinants of health: Moving beyond justice. The American Journal of Bioethics, 8(10), 16–17. Cox, J. V. (2009). From the editor’s desk: Access, quality, and cost. Journal of Oncology Practice. 5(5), p. 217. de Chesnay, M. (2011). Vulnerable populations: Vulnerable people. In M. de Chesnay & B. A. Anderson (Eds.), Caring for the vulnerable: Perspectives in nursing theory, practice and research (3rd ed., pp. 3–15). Sudbury, MA: Jones & Bartlett Learning. Derose, K. P., Gresenz, C. R., & Ringel, J. S. (2011). Understanding disparities in health care access—and reducing them—through a focus on public health. Health Affairs, 30(10), 1844–1851. District Nursing Association of Northern Westchester County. (1948). The District Nursing Association Northern Westchester County, 1898–1948, Mount Kisco, NY. Found in the Pace University Lienhard School of Historical Nursing Archives of Westchester/Rockland Counties, Birnbaum Library, Pleasantville, NY, HNAWRC, RT 97, D61. Dock, L. L., & Clement, F. (1922). From rural nursing to the public health nursing service. In L. L. Dock, C. D. Noyes, F. F. Clement, E. G. Fox, & A. R. VanMeter (Eds.), History

of the American Red Cross nursing (pp. 1211–1292). New York, NY: Macmillan. Dorsen, C. (2010). Vulnerability in homeless adolescents: Concept analysis. Journal of Advanced Nursing, 66(12), 2819–2827. Fairman, J., & D’Antonio, P. (2013). History counts: How history can shape our understanding of health policy. Nursing Outlook, 61(5), 346–352. Federal Interagency Forum on Aging-Related Statistics. (2012). Older Americans 2012: Key indicators of well-being. Washington, DC: Author. Flaskerud, J., & Winslow, B. W. (2010). Vulnerable populations and ultimate responsibility. Issues in Mental Health Nursing, 31, 298–299. Gallagher, L. P., & Truglio-Londrigan, M. (2004). Using the “Seven A’s” assessment tool for developing competency in case management. Journal of the New York State Nurses Association, 35(1), 26–32. Grabovschi, C., Loignon, C., & Fortin, M. (2013). Mapping the concept of vulnerability related to health care disparities: A scoping review. BMC Health Services Research, 13(1), 1–11. Institute for Alternative Futures. (n.d.). The history of vulnerability in the United States. Retrieved from http:// altfutures.org/pubs/vuln2030/history.pdf Institute of Medicine. (1988). The future of public health. Washington, DC: National Academies Press. Keeling, A., & Lewenson, S. B. (2013). A nursing historical perspective on the medical home: Impact on health care policy. Nursing Outlook, 61(5), 360–366. Krout, J. A. (1986). The aged in rural America. Westport, CT: Greenwood Press. Krout, J. A. (Ed.). (1994). Providing community-based services to the rural elderly. Thousand Oaks, CA: Sage Publications. LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States. Washington, DC: Joint Center for Political and Economic Studies. Lewenson, S. B. (1996). Taking charge: Nursing, suffrage, and feminism, 1873–1930. New York, NY: NLN Press. Mechanic, D., & Tanner, J. (2007). Vulnerable people, groups, and populations: Societal view. Health Affairs, 26(5), 1220–1230. Moscou, S. (2017). Fundamentals of epidemiology and social epidemiology. In M. Truglio-Londrigan, & S. B. Lewenson (2017), Public health nursing: Practicing population-based care (3rd ed., pp. 91–117). Burlington, MA: Jones & Bartlett Learning. National Partnership for Action. (2011). Health equity and disparities. Retrieved from http://www.minorityhealth. hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34 Paletta, D., & Costa, R. (2017, May 22). Trump’s budget proposal slashes spending by $3.6 trillion over 10 years. The Washington Post, p. NP. Retrieved from https://www.washingtonpost.com/business/economy

References /trumps-budget-proposal-slashes-spending-by-36-trillion -over-10-years/2017/05/22/69dbdb5e-3f1c-11e7-adba -394ee67a7582_story.html?utm_term=.3c2541be839c Patterson, K., Grenny, J., McMillan, R., & Switzler, Al. (2012). Crucial conversations: Tools for talking when stakes are high. New York, NY: McGraw-Hill. Purdy, I. B. (2004). Vulnerable: A concept analysis. Nursing Forum, 39(4), 25–33. Rogers, A. C. (1997). Vulnerability, health and health care. Journal of Advanced Nursing, 26, 65–72. Sarnecky, M. T. (1999). A History of the U.S. Army Nurse Corps. Philadelphia, PA: University of Pennsylvania Press. Shi, L., & Stevens, G. D., (2005). Vulnerability and unmet health care needs: The influence of multiple risk factors. Journal of General Internal Medicine, 20(2), 148–154. Shi, L., Stevens, G., Faed, P., & Tsai, J. (2008). Rethinking vulnerable populations in the US. Harvard Health Policy Review, 9(1), 43–48. Shi, L., Stevens, G. D., Lebrun, L. A., Faed, P., & Tsai, J. (2008). Enhancing the measurement of health disparities for vulnerable populations. Journal of Public Health Management & Practice. 14(6), S45–S52. Smith, C. M., & Cotta, V. T. (2012). Normal aging changes: Nursing standard of practice protocol: Age related changes in health. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence based geriatric nursing protocols for best practice (4th ed., pp. 23–47). New York, NY: Springer Publishing Company. Stevens, G., Shi, L., & Faed, P. (2008). Vulnerable in more than one way. Health Affairs, 27(3), 894–902. Truglio, P. (2017). Case study—public policy and populations: Are we safeguarding the vulnerable? In M. Truglio-Londrigan & S. B. Lewenson (Eds.), Public health nursing: Practicing population-based care (3rd ed., p. 435). Burlington, MA: Jones & Bartlett Learning. Truglio-Londrigan, M., & Lewenson, S. B (2017). What is public health and public health nursing? In M. Truglio-Londrigan & S. B. Lewenson (Eds.), Public health nursing: Practicing population-based care (3rd ed., pp. 3–21). Burlington, MA: Jones & Bartlett Learning. Truglio-Londrigan, M., Singleton, J., & Lewenson, S. B. (2017). Conversation about primary health care. In M. Truglio-Londrigan & S. B. Lewenson (Eds.), Public health nursing: Practicing population-based care (3rd ed., pp. 423–441). Burlington, MA: Jones & Bartlett Learning. Ubri, P., & Artiga, S. (2016). Disparities in health and health care: Five key questions and answers. San Francisco, CA: The Henry J. Kaiser Family Foundation. Retrieved from http://kff.org/disparities-policy/issue-brief/disparities-in -health-and-health-care-five-key-questions-and-answers/

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Urban Institute. (2010). Health policy center: Vulnerable populations. Retrieved from http://www.urban.org /health_policy/vulnerable_populations/ U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2011). National healthcare disparities report 2011. Rockville, MD: Author. U.S. Department of Health and Human Services, Office of Minority Health. National Partnership for Action to End Health Disparities. The National Plan for Action. (2011). Health equity and disparities. Retrieved from http://www.minorityhealth.hhs.gov/npa/templates /browse.aspx?lvl=1&lvlid=34 U.S. Department of Health and Human Services/Healthy People 2020. (2010a). Determinants of health. Retrieved from http://www.healthypeople.gov/2020/about /DOHAbout.aspx U.S. Department of Health and Human Services/Healthy People 2020. (2010b). Social factors. Retrieved from http://www.healthypeople.gov/2020/about/DOHAbout .aspx#socialfactors U.S. Department of Health and Human Services/Healthy People 2020. (2010c) Health services. Retrieved from http://www.healthypeople.gov/2020/about/DOHAbout .aspx#healthservices U.S. Department of Health and Human Services/Healthy People 2020. (2010d). Access to health care. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020 /overview.aspx?topicid=1 U.S. Department of Health and Human Services/Healthy People 2020. (2010e). Individual behavior. Retrieved from http://www.healthypeople.gov/2020/about/DOHAbout .aspx#individual U.S. Department of Health and Human Services/Healthy People 2020. (2010f). Biology and genetics. Retrieved from http://www.healthypeople.gov/2020/about /DOHAbout.aspx#biology U.S. Department of Health and Human Services/Healthy People 2020. (2010g). Policymaking. Retrieved from http://www.healthypeople.gov/2020/about/DOHAbout .aspx#policymaking U.S. Department of Health and Human Services/Healthy People 2020. (2010a). Disparities. Retrieved from http:// www.healthypeople.gov/2020/about/DisparitiesAbout.aspx Williams, M., Ebrite, F., & Redford, L. (1991). In-home services for the elders in rural America. Kansas City, MO: National Resource Center for Rural Elderly. World Health Organization. (1978). Declaration of Alma-Ata. Geneva, Switzerland: Author. Retrieved from http:// www.who.int/publications/almaata_declaration_en.pdf

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CASE STUDIES

CASE STUDY A Multidisciplinary Effort to Improve the Detection of Elder Abuse Among Adult Protective Service Workers in New York City Anh Phuong Tran

Purpose To develop a training for Adult Protective Service (APS) workers of New York City (NYC) that focuses on the physical signs or markers of elder abuse, so that APS workers will be better equipped to identify these signs in alleged victims and make referrals for these victims to needed services.

Body Elder abuse victims have a lower quality of life and higher healthcare resource utilization, such as emergency department visits and nursing home admissions, when compared to elders who are not experiencing abuse (Dong & Simon, 2013; Dong, 2015; LoFaso & Rosen, 2014). For the protection of older adults, all 50 states and Washington, DC are mandated to have an APS program under Title XX of the Social Security Act (Connell-Carrick & Scannapieco, 2008; Jackson, 2017; Nerenberg, 2006). The national prevalence of elder abuse is estimated to be 11.4%, but is likely to be higher due to low reporting rates (Acierno et al., 2010) and will likely continue to increase as the aging population rises. APS workers investigate allegations of the abuse of vulnerable adults (i.e., physically or mentally disabled and/or elderly) and make referrals for services when needed (Jackson, 2017; Nerenberg, 2006). The investigative skills of APS workers and their knowledge of elder abuse are pivotal to identifying a vulnerable adult in need of assistance; however, their skills and knowledge differ from state to state due to varying requirements for minimal education and differences among APS training programs (Connell-Carrick & Scannapieco, 2008; Dyer et al., 2006; Jackson, 2017). Additionally, as the older adult population grows, APS workers also face the

demands of an increasing caseload (O’Brien, 2015; S. Plichta, personal communication, November 17, 2015; Zou & Savchuk, 2015), further requiring that their skills in identifying elder abuse be strengthened. A focus group of experienced APS workers was conducted prior to the pilot study to better understand APS workers’ baseline knowledge. Participants discussed that the NYC APS employed a professional registered nurse (RN) in the past who would, at times, attend client visits with workers. The nurse’s official role was to “conduct thorough healthcare assessments of clients and support APS caseworkers and supervisors on complex cases” (NYC Human Resource Administration, n. d.). In addition to assessing clients for signs of abuse, duties included making referrals for medical and mental health care, participating in multidisciplinary team conferences, assisting clients with setting and meeting healthcare goals, and providing training to APS workers and supervisors on “healthcare issues” (HRA, n. d.). Focus group participants stated that they felt the nurse helped them with medically complicated cases, especially when clients were in denial of their health status. One worker stated, “You just never know if the story that they are telling is true. It [sexual abuse] may have happened to them when they were younger and they are remembering it now because of their dementia.” The nurse also helped workers to better differentiate signs of abuse from medication side effects. For example, one worker stated that she learned that a client’s bruises were due to her taking blood thinners, not because she was being abused (Tran, 2016). The often confusing nature of aging and the impact of abuse on the client’s mind and body required the help of a healthcare expert to assist in investigative efforts. There was a consensus that the RN was an important member of the APS team. However, at the time of this project, the RN position remains vacant. A multidisciplinary group project was conducted to help improve the training for NYC APS workers on the identification of the physical signs of elder abuse through collaboration between Hunter-Bellevue School of Nursing (HBSON)/City University of New York (CUNY), Brookdale Center for Healthy Aging at Hunter College, and the Human Resources Administration (HRA) of NYC. The multidisciplinary team, comprising nurses, physicians, social workers,

Case Study

nursing in the aging process, physical assessment, and education of lay persons contributed to the development of a focused training for APS workers. The project demonstrated that a focused educational program developed by a multidisciplinary team of elder abuse experts, including lay APS workers, can help to improve the knowledge, confidence, and skills of those who investigate elder abuse. Ultimately, the goal of this educational program is to positively impact the lives of elder abuse victims in the community.

Summary The HBSON, Brookdale Center for Healthy Aging at Hunter College, HRA of NYC, and APS of NYC collaborated on a multidisciplinary project to develop a training to help APS workers improve their ability to identify physical signs of elder abuse, escalate potentially life-threatening situations, and communicate their findings. After conducting a focus group with APS workers, the curriculum, associated training, and evaluation materials were reviewed by experienced APS workers, physicians, nurses, social workers, and training experts. The half-day pilot training included 16 APS workers with field investigation experience. The pilot showed that focused training increased workers’ knowledge of the signs of elder abuse and escalation of potentially dangerous situations, improved self-efficacy in identifying elder abuse and the communication of findings, and provided recommendations to improve the training.

Case Study Questions 1. Should the federal government have a more active role in providing oversight for APS and/or provide financial support in an effort to improve the identification of elder abuse through: a. Standardize training? b. Increasing the number of APS workers in the workforce? c. Expanding the role of the professional RN in APS? 2. The caseload of APS workers varies from state to state. Should there be a maximum number of cases per worker like the RN to patient ratio in hospitals? 3. Should the minimum education and field of study for APS workers be standardized

CASE STUDIES

training and education experts, and APS workers, was led by a Doctor of Nursing Practice (DNP) student from the HBSON. The training was developed using medical and nursing literature on the physical signs of abuse, and adapted from existing elder abuse training modules. The Diffusion of Innovations Model was used to guide the project in order to include the population of focus (APS workers) in the training development, piloting, and revision of the curriculum in hopes that APS workers would ultimately adopt the “innovation” (the knowledge and skills gained through the training). Once the curriculum was finalized by the interdisciplinary team, it was piloted with a group of 16 experienced APS workers. The pilot training was facilitated by the project lead, a DNP student with a concentration as an adult/geronotological nurse practitioner, and the Director of Training and Learning at Brookdale. APS workers participated in a half-day training, which consisted of group discussions; case studies activities; and a lecture on the physical signs of abuse, potentially life-threatening situations that required escalation (i.e., notifying a supervisor or calling 911), and communication. Participants filled out a survey to give feedback on the training to improve future trainings for their colleagues. Participants in the pilot training demonstrated an increase in both their knowledge and confidence in being able to identify the physical signs of elder abuse and communication of these findings. Additionally, most of the participants believed that the training will help to increase their abilities to detect the signs of elder abuse when investigating allegations, and boost their communication skills. The participants also provided feedback on methods to improve the training. APS workers are dedicated to the protection of vulnerable adults. However, due to a national variation in training, specific information regarding the physical indicators of elder abuse, in some APS programs, may not be provided. Further, the demands from having an increased caseload may lead to APS workers overlooking some signs of abuse, leaving some older adult victims unidentified. Although NYC APS did not have a professional RN on staff, the collaboration between the HRA of NYC, HBSON, and Brookdale has allowed nursing to impact APS through training development. The knowledge and skills of

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Chapter 4 Population Health Care: Access, Cost, and Quality like the effort for nursing to have RNs with a bachelor’s degree minimum? 4. This case study demonstrates the ability of the RN to assist in the care and advocacy of a vulnerable population. What other opportunities are there for RNs in improving elder abuse detection in the community?

References Acierno, R., Hernandez, M. A., Amstadter, A. B., Resick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The national elder mistreatment study. American Journal of Public Health, 10(2), 292–297. doi: 10.2105 /AJPH.2009.163089 Connell-Carrick, K., & Scannapieco, M. (2008). Adult Protective Services: State of the workforce and worker development. Gerontology & Geriatrics Education, (29)2, 189–206. doi:10.1080/02701960802223290 Dong, X. (2015). Screening for elder abuse in healthcare settings: Why should we care, and is it a missed quality indicator. Journal of the American Geriatrics Society, 63(8), 1686–1692. doi: 10.1111/jgs.13538 Dong, X., & Simon, M. A. (2013). Elder abuse as a risk factor for hospitalization in older persons. JAMA Internal Medicine, 173(10), 91–97. doi: 10.1001/jamainternmed.2013.238 Dyer, C. B., Toranjo, C., Cunningham, M., Festa, N. A., Pavlik, V. N., Hyman, D. J. Paythress, E. L., & Searle, S. (2006). The key elements of elder neglect: A survey of Adult Protective

Service workers. Journal of Elder Abuse & Neglect, (17)4, 1–10. doi: 10.1300/j08v17n01_01 Jackson, S. L. (2017, January). Adult protective services and victim services: A review of the literature to increase understanding between these two fields. Aggression and Violent Behavior, 1–14. doi.org/10.1016/j.avb.2017.01.010 Lofaso, V. M., & Rosen, T. (2014). Medical and laboratory indicators of elder abuse and neglect. Clinics in Geriatric Medicine, 30(4), 713–728. doi: 10.1016/j.cger.2014.08.003 Nerenberg, L. (2006). Communities respond to elder abuse. Journal of Gerontological Social Work, 46(3–4), 5–34. doi:10.1300/J083v46n03 02 NYC Human Resource Administration (n.d.). Staff nurse job description [Word document]. Retrieved from https:// outlook.office.com/owa/?realm=myhunter.cuny .edu &exsvurl=1&ll-cc=1033&modurl=0&path= /attachmentlightbox O’Brien, C. (2015). Working with domestic violence: A clinician’s guide to ethical and competent practice. InPsych, 37(5). Retrieved from https://www.psychology .org.au/inpsych/2015/october/obrien. Personal communication: Stacey Beth Plichta. (November 17, 2015). Tran, A. P. (2016). Enhancing adult protective service workers’ abilities to detect the physical signs of elder abuse: focus group (Unpublished report). New York, NY: Hunter-Bellevue School of Nursing. Zou, J. J., & Savchuk, K. (2015, July 22). City struggles to protect New Yorkers in need. The New York World. Retrieved from http://www.thenewyorkworld.com/2015/07/22 /city-struggles-protect-new-yorkers-need-2/

CHAPTER 5

Global Health: A Vision for Action Stephanie L. Ferguson

OVERVIEW Global health and its challenges remain a top priority for world leaders and health professionals. The Millennium Development Goals (MDGs) developed by the United Nations (UN) showed us that the world can set a vision for global health and action, yielding “unprecedented efforts and profound achievements” (UN, 2015, p.4). Ban Ki-moon, former Secretary General of the United Nations, wrote it best in the Millennium Development Goals Report 2015 when he proclaimed that, “The MDGs helped to lift more than one billion people out of extreme poverty, to make inroads against hunger, to enable more girls to attend school than ever before and to protect our planet. They generated new and innovative partnerships, galvanized public opinion and showed the immense value of setting ambitious goals. By putting people and their immediate needs at the forefront, the MDGs reshaped decisionmaking in developed and developing countries alike” (UN, 2015, p. 3.). However, despite progress achieved with the MDGs, as an example, the goals of reducing child mortality and improving maternal health were not realized. Today, we anticipate with new hope the global health goals, indicators, strategies, and actions set forth in the vision of the Sustainable Development Goals (SDGs) (UN, 2016). The effects of globalization have been both positive and negative. From a positive perspective, globalization has increased travel, trade, productivity, and economic growth in many nations. Globalization has allowed populations to rapidly exchange information and share solutions to common problems worldwide. However, the negative effects of globalization have led to an increase in global health security threats such as outbreaks of pandemic influenza, Ebola, Zika, and Middle East Respiratory Syndrome coronavirus (MERS-CoV). Nations have struggled to meet the challenges of these outbreaks due to of a lack of public health infrastructure and preparedness capabilities. The global health challenges faced today are daunting and range from communicable diseases, such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis (TB), and malaria, to noncommunicable diseases (NCDs), such as cardiovascular disease (continues) © Anthony Krikorian/Shutterstock

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OVERVIEW

(continued)

(CVD) and cancer. There are numerous factors that influence health, such as the environment, mental health, substance abuse, and antimicrobial resistance, to name a few. In the 2015 Global Burden of Disease Study, Forouzanfar and team (2016) found that there are 315 conditions that contributed to the most global disability-adjusted life years (DALYs). DALYs represent the total number of years lost to illness, disability, or premature death within a given population (National Institutes of Mental Health [NIMH], 2017). Other challenges for the world include increases in population growth, which has a direct impact on climate, food supply, health systems and health workforce, and more. For instance, by 2035, the World Health Organization (WHO) estimates that there will be a shortage of 12.9 million health workers (WHO, 2013). Without enough health workers fit to serve in the right place at the right time to care for the world’s population, the global quest for Health for All, Universal Health Coverage and Access, and the realization of the SDGs will not be achieved by 2030. To learn more about global health challenges and issues facing the world, refer to the latest health topics, data, publications, country statistics, programs, and global governance structures provided by the World Health Organization. The WHO is the premier United Nations organization responsible for all policies and governance activities related to public health worldwide. The WHO website (www. who.int) provides a wealth of information on health. To learn more about the mission and vision of the WHO, visit their website at www.who.int/about/en/. The United States has been a champion and global leader in health at the WHO headquarters in Geneva, Switzerland and at all the WHO’s regional offices. To follow the work of the U.S. in global health, visit the Office of Global Health Affairs (OGA) at the U.S. Department of Health and Human Services (USDHHS) website (www.hhs.gov/about/agencies/ oga/index.html). The Office of Global Affairs is the diplomatic voice of the USDHHS. OGA fosters critical global relationships, coordinates international engagement across USDHHS and the U.S. government, and provides leadership and expertise in global health diplomacy and policy to contribute to a safer, healthier world. This chapter overview is a snapshot of some of the global health challenges and issues facing the world today and tomorrow. This chapter is a call to action for all nations to commit to investing in global health, and for nurses and health professionals to advocate for the investment in global health. Investing in global health over the next 20 years can save the lives of millions of children and adults, and result in positive returns on investments for people living and working in lower-middle income countries (LMICs) (National Academies of Sciences, Engineering, and Medicine [NAS], 2017). The author of this chapter was selected to participate in the consensus study to determine global health and the future role of the United States (see the press release: www8.nationalacademies.org/onpinews /newsitem.aspx?RecordID=24737). To learn more about Global Health and the Future Role of the United States, read the latest report from the National Academies of Sciences, Engineering, and Medicine (2017).

OBJECTIVES ■■

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Define the politics of global health in the context of the latest National Academies of Science’s report, Global Health and the Future Role of the United States (2017). Provide examples of current global health initiatives important for nurses and other health professionals. Identify roles nurses and other health professionals can play in global health policy and advocacy, including ways to get involved and get a seat at the table.

The Politics of Global Health in the United States of America

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The Politics of Global Health in the United States of America

Global health, as a field of study, research, and policy, has grown tremendously over the last few decades. The United States has achieved a proven track record and legacy of leadership in providing foreign assistance, excellence in determining global health policies, and funding global health initiatives to care for populations worldwide. As a nation, the U.S. has been a champion in the fight against HIV/AIDS, malaria, and TB. For instance, global U.S. investments include the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 and the President’s Malaria Initiative (PMI) in 2005. The U.S. has also been a key partner in leading and funding the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Vaccine Alliance (GAVI). Likewise, the National Academies of Sciences, Engineering, and Medicine have been front and center studying the United States’s work in global health and, in general, the science in the field of global health, as well as global health risk assessment and security worldwide. The National Academies of Sciences, Engineering, and Medicine, also known as The National Academies (NAS), are the private, nonprofit institutions that provide independent, objective analysis and advice to the U.S. to solve complex problems and inform public policy decisions related to science, technology, and medicine. The Health and Medicine Division of the NAS helps those in government and the private sector make informed health-related decisions by providing reliable and objective evidence. To learn more about the National Academies of Sciences, Engineering, and Medicine, visit their website at www.nationalacademies.org/. In 1997, the Institute of Medicine’s (IOM) Board on International Health was commissioned to produce the first report to address the United States’ interest in and commitment to improving human health worldwide. The r­ eport,

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­entitled America’s Vital Interest in Global Health: Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests, defined global health issues as “health problems, issues, and concerns that transcend national boundaries, and are best addressed by cooperative actions” (IOM, 1997). Similarly, in 2009, an independent committee was constituted by the IOM Board on Global Health to prepare a report for then-President Barack Obama and his new administration, entitled The U.S. C ­ ommitment to Global Health: Recommendations for the New Administration (IOM, 2009). Like the IOM 1997 Global Health report, it was concluded in the 2009 IOM Global Health report that the direct interest of the citizens of the United States are best served when the U.S. acts decisively to promote health around the world. That 2009 report on global health also included a call for better structuring of market incentives to develop medical products. Much has been achieved since the two IOM reports (1997, 2009). For instance, the U.S. Office of the Assistant Secretary for Preparedness and Response established the Biomedical Advanced Research and Development ­Authority (BARDA) through the 2006 Pandemic and All-Hazards Act (Public Law. No. 109-417, 42 US 201). Another example is the U.S. Food and Drug Administration (FDA)’s priority review voucher program, established in 2007, which provides our government with the ability to expedite the FDA’s review of new drugs, particularly those needed in an emergency crisis like the 2014 outbreaks of Ebola in parts of West Africa. A great case in point was the expedited review of products to treat Ebola, which became eligible in 2014. Despite these initiatives and achievements, there remains a need for drug and vaccine development worldwide to tackle some of the persistent and emerging infectious disease and other global threats today and tomorrow. Since the 2009 IOM global health report, much progress has been made in research development in low and middle-income countries (LMICs) through country-led workforce development and the creation of national health

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plans. In addition, the formation of the Nursing Education Partnership Initiative (NEPI) and the Medical Education Partnership Initiative (MEPI) was developed through the President’s Emergency Plan for AIDS Relief (PEPFAR) at the Department of State to address the shortage of health workers in high-burden HIV/AIDS countries. NEPI and MEPI program efforts improved workforce capacity in these LMICs. The other most notable recommendation that came out of the 2009 IOM Global Health report was the recommendation to create a White House Interagency Committee on Global Health. The proposed new agency would be chaired by a U.S. government senior official designated by the U.S. President. The job of the chair of the new global health agency was to lead, plan, prioritize, and coordinate the budget for major U.S. government global health initiatives. President Obama agreed with this IOM 2009 Global Health report recommendation and he created the U.S. Global Health Initiative (GHI). During this time frame, under the leadership of President Obama and through the GHI, the author of this chapter had the great opportunity to work with the GHI and the State Department, the U.S. Human Resources for Health Administration (HRSA), the National Institute of Nursing Research (NINR) at the National ­Institutes of Health (NIH), and the Centers for ­Disease Control and Prevention (CDC) to provide health diplomacy services to strengthen the research capacity of nurses and other health professionals in countries like Bangladesh. In addition to the author of this chapter, Dr. Afaf Meleis, former Dean of the University of Pennsylvania, elected member of N ­ ational Academy of Medicine (NAM, formerly IOM), member of the IOM Global Health Report Committee in 2009; and Dr. Mary Kerr, former Deputy Director of the National Institute of Nursing Research at the National Institutes of Health and Dean of the Frances Payne Bolton School of Nursing at Case Western Reserve, were a part of the delegation that worked to strengthen the nursing capacity in research on behalf of the GHI. Unfortunately, as time moved forward, the GHI was not successful. There was a lack

of authority and budget given to the GHI and its leadership; as a result, the only thing left to show progress was an internet presence showing some coordinating priority area of global health programs. Despite the failure of GHI, there was much progress made through PEPFAR, the President’s Malaria Initiative (PMI), and the U.S. Global Health Security Agenda. With the hope of continued change post– President Obama and “making America Great Again,” global health continued to be in the forefront of the presidential debates of 2016 behind the scenes. Questions were being asked about what the U.S. should do with PEPFAR. Should PEPFAR’s mission and global health mandate remain the same or should it be reformed? Better yet, should the U.S. declare success and move forward with another government global health initiative? Other key stakeholders and citizens questioned what the U.S. should be doing to protect our nation and the world from persistent and/or emerging global epidemics and pandemics, outbreaks, and global health challenges like noncommunicable diseases (NCDs). Moreover, what should the U.S do to address the unfinished business in the Millennium Development Goals (MDGs) and the new business of the Sustainable Development Goals (SDGs), particularly in the context of women and children? Essentially, citizens, government officials, academics, private and public partners, foundations, businesses, other nations, and global health policy organizations such as the United Nations (UN), the World Bank, the World Health Organization (WHO), the Global Fund, and the Global Vaccine Alliance (GAVI) wanted to know what the next presidential administration and the U.S. government should be investing in related to global health. Thus, because of the upcoming presidential elections in the United States in 2016, the timing was right to ask the National Academies of Sciences, Engineering, and Medicine to conduct a new consensus study on Global Health and the Future Role of the United States. The 2017 NAS report on global health, the third of its kind (IOM, 1997, 2009; NAS, 2017a), was launched in May 2017. The NAS global health consensus

The Politics of Global Health in the United States of America

report was commissioned to advise the new U.S. president and administration, whether it be Hillary Clinton or Donald Trump. In August 2016, the author of this chapter was selected and appointed by the National Academies of Sciences, Engineering, and Medicine (NAS) to serve as a member of the Committee on Global Health and the Future of the United States (CGH) (NAS, 2017b). This author is an elected member of the National Academy of Medicine (NAM), formerly known as the Institute of Medicine (IOM). The author was fit for purpose because of her expertise, which ranges from global health security, interprofessional workforce, and leadership development to health systems strengthening, universal health coverage and access implementation and evaluation strategies, HIV/AIDS, and women and children’s health. This author has worked in more than 100 nations over 20 years on behalf of the U.S. government, WHO, and the ­International Council of Nurses. The National Academies’ CGH was charged to conduct a consensus study to identify global health priorities in light of emerging global health threats and challenges and provide recommendations to the U.S. government and other stakeholders for increasing responsiveness, coordination, and efficiency in addressing these threats and challenges by establishing priorities and mobilizing resources. The NAS received ­financial and expert support from a variety of federal agencies, foundations, and private partners such as the U.S. Agency for International Development (USAID), U.S. Department of Health and Human Services (USDHHS), Centers for Disease Control and Prevention (CDC), U.S. Food and Drug Administration (FDA), National Institutes of Health (NIH), President’s Emergency Plan for AIDS Relief (PEPFAR), Rockefeller Foundation, Merck Foundation, Becton, Dickinson, and Company (BD), and Medtronic. Like domestic U.S. healthcare policy and reform, funding and reforming global health care and initiatives are highly political. In general, “foreign assistance is often considered a type of charity, or support for the less fortunate. Although this can be true for the poorest and most

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vulnerable populations, most such aid, especially when directed toward health, is an investment in the health of the recipient country, as well as the United States and the world at large” (NAS, 2017a, p. S-2). The CGH agreed that asking the United States for more money alone to invest in global health challenges was not the answer. Moreover, realizing that there were many global health challenges on which to focus, such as mental health and substance abuse, environmental health (including climate change, food safety, air pollution, and water and sanitation issues), refugee health, and health workforce, to name a few, the CGH focused on priorities with the potential for catastrophic loss of life and impact on society, such as pandemics, persistent communicable diseases (HIV/AIDS, TB, and malaria), and noncommunicable diseases (NCDs), specifically cardiovascular health and select cancers. As well, the CGH focused on areas where significant U.S. funds had been invested and determined what needed to be achieved with the gains and how these investments should be consolidated and sustained in the current presidential administration. The CGH further agreed to focus the report on promoting women and children’s health, building capacity, and global health innovation and implementation. The Committee identified two over­arching themes: 1. Securing against global threats; and, 2. Enhancing productivity and economic growth. The Committee proposed 14 recommendations in the context of these two themes. As well, four priority areas for action were identified to ensure the greatest positive effect on health. The CGH felt that these two themes with the 14 recommendations and four priority areas set the strategy forward to position and maintain the United States as a global health leader worldwide. The four priority areas recommended include:

1.

Achieve global health security. The Committee urged the administration to create a coordinating body within the U.S. government with the

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2.

3.

authority and budget to develop a proactive, cost-effective, and comprehensive approach to preparedness for and response to international public health emergencies. To learn more about the global health security priority, read Chapter 3 in the NAS Global Health report (2017a). Maintain a sustained response to the continuous treats of communicable diseases. The Committee urged the administration to maintain a sustained focus on HIV/AIDS and malaria, as well as a re-evaluate the commitment to fight TB. The progress achieved to combat these communicable diseases needs to be sustained to prevent reversal of the gains achieved in the past decades and avoid the further spread of resistant strains in all three diseases. To learn more about this priority area regarding maintaining and sustaining response to the continuous treats of communicable diseases, see Recommendation 4 (Envision the next generation of the President’s Emergency Plan for AIDS Relief) and read more about this in NAS, 2017a, Chapter 4. Save and improve the lives of women and children. The U.S. commitment to the current survival agenda should be continued but also expanded to incorporate early childhood development as a key component. The Committee noted that adding a multisectoral focus on childhood development to the current survival-focused programs can contribute to resilient societies and growing economies. To learn more about Recommendations 7 and 8, which address the improvement of survival in women and children and ensuring health and productive lives for women and children, you can read more about this priority and these recommendations in NAS, 2017a, Chapter 5.



4.

Promote cardiovascular health and prevent cancer. NCDs, cardiovascular diseases (CVD), and cancer are rising in countries around the world. The committee urged improved mobilization and coordination of private partners at the country level and across the U.S. interagency community to implement strategies to ensure that CVD risk factors are targeted for early detection and treatment, and that strategies are implemented to target hypertension, cervical cancer, and immunization against vaccine-preventable cancers. See Recommendation 9 (Promote cardiovascular health and prevent cancer), and read NAS, 2017a, Chapters 6 and 8, for more information.

Finally, the report followed three cross-cutting areas for action to maximize the returns on U.S. investments to achieve better health outcomes and use funding more effectively. These three cross-cutting areas for action included: 1.

2. 3.

Catalyze innovation through both the accelerated development of medical products and development of integrated digital health infrastructure. Employ flexible financing mechanisms to leverage new partners and funders in global health. Maintain U.S. status and influence as a world leader in evidence-based science, economics, measurement, and accountability. To learn more about the cross-cutting themes, review Recommendations 10 through 14 and NAS, 2017a, Chapters 7, 8, and 9.

An overview of the Committee’s recommendations is provided in TABLE 5-1 with actions for nurses and other health professionals to consider they advocate for and participate in the development of global health policies. To read the full text of the NAS 2017 Global Health report recommendations, please see the Recommendations document available at www.nationalacademies.org/hmd/reports/2017/

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TABLE 5-1  NAS Global Health Report 2017 Recommendations and Actions for Nurses and Other Health Professionals Recommendations

Actions

Improve international emergency response coordination.

Write letters and meet with your local U.S. Congress members and write letters to the current presidential administration to support the creation of an International Response Framework to guide U.S. response in an international health emergency. In your letter, advocate for three separate funding streams dedicated to investments in preparedness, emergency response, and critical medical product development. Examples of opportunities to serve in international emergencies: International Federation of the Red Cross: media.ifrc.org/ifrc/what-we-do/volunteers/ American Red Cross: www.redcross.org/volunteer/volunteer-opportunities /volunteer-internationally Doctors Without Borders: www.doctorswithoutborders.org/ Peace Corps: www.peacecorps.gov/resources/media/press/2146/

Combat antimicrobial resistance.

Consider a job in the U.S. Department of Health and Human Services (USDHHS), the U.S. Department of Defense (DoD), the U.S. Department of Agriculture (USDA), and the U.S. Agency for International Development (USAID). These agencies are responsible for investing in national capabilities to accelerate the development of international capabilities to detect, monitor, report, and combat antibiotic resistance. For career opportunities in the agencies above to help fight antimicrobial resistance, check out the official website for jobs in the U.S. government: www.usajobs.gov/ To learn more about antimicrobial resistance, review WHO resources at: www.who.int/antimicrobial-resistance/en/

Build public health capacity in low and middle-income countries.

Advocate for the CDC, NIH, DoD, and USAID to expand training and information exchange efforts to increase the capacity of low and middleincome countries to respond to both public health emergencies and acute mass casualty disasters. Examples of opportunities to serve are like those mentioned in Recommendation 1. To learn more about strategies to help build the public health capacity of low and middle-income countries, see the following WHO consultation paper on health workforce and service for the Global Framework for Public Health: www.who.int/workforcealliance/media/news/2014/RefA_PublicHealthpaper.pdf Review the WHO Framework for a Public Health Emergency Operations Centre at: www.who.int/ihr/publications/9789241565134_eng/en/ (continues)

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TABLE 5-1  NAS Global Health Report 2017 Recommendations and Actions for Nurses and Other Health Professionals

(continued)

Recommendations

Actions

Envision the next generation of PEPFAR.

Review the next generation of PEPFAR Indicators at: www.nationalacademies.org/hmd/~/media /CCCCE5C1068F44A19DFAB5CF2CD914F6.ashx What role can you play to advocate for the continued funding of the Global Fund to Fight AIDS, Tuberculosis and Malaria? Check out the Global Fund and notice the job and volunteer opportunities worldwide at: www.theglobalfund.org/en/

Confront the threat of tuberculosis.

Consider the recommendations above. In the U.S. we need to advocate for a plan of action to improve the current governance structure and priority activities and investments in new diagnostics, drugs, vaccines, and delivery systems. The CDC, NIH/National Institute for Allergy and Infectious Disease (NIAID), and USAID should conduct a thorough global threat assessment of the rising TB levels and multidrug-resistant TB levels. Learn more about TB from the WHO at: www.who.int/tb/en/

Sustain progress toward malaria elimination.

Consider advocating to keep the funding for the President’s Malaria Initiative (PMI). To learn more about this important effort and how to participate in eliminating malaria, read: www.pmi.gov/

Improve survival in women and children.

The U.S. Congress should increase funding for USAID to augment the agency’s investments in ending preventable maternal and child mortality, defined as global maternal mortality rates of fewer than 70 deaths per 100,000 live births by 2020 and fewer children deaths per 1,000 live births by 2030. Encourage your Congress members to invest in the most effective interventions and support monitoring and evaluation in: ■■ ■■ ■■ ■■ ■■

Immunizations Integrated management of child illness Nutrition (pregnant women, newborns, infants, and children) Prenatal care and safe deliveries Access to contraceptives and family planning

Think about joining and financially supporting Women Deliver at: www.womendeliver.org/. Women Deliver is the lead global organization advocating for the health, rights, and well-being of girls and women. Women Deliver catalyzes action by bringing together diverse voices and interests to drive progress for gender equality, with a focus on maternal, sexual, and ­reproductive health and rights.

The Politics of Global Health in the United States of America

Recommendations

Actions

Ensure healthy and productive lives for women and children.

USAID, PEPFAR and their implementing partners, and other funders should support the integration of principles of country ownership, domestic financing, and community engagement to: ■■

■■ ■■

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Promote cardiovascular health and prevent cancer.

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Provide adequate nutrition for optimal infant and child cognitive development. Reduce childhood exposure to domestic and other violence. Detect and manage postpartum depression and other maternal mental health issues. Support and promote early education and cognitive stimulation in young children.

To learn more about these recommendations read The Lancet Series on M ­ aternal and Child Health: Black, M. M., Walker, S. P., Fernald, L. C., Andersen, C. T., DiGirolamo, A. M., & Lu, C . . . Grantham-McGregor, S. (2017). Early childhood development coming of age: Science through the life course. Lancet 389(10064):77–90. Also, check out the Every Woman Every Child Strategy (2015) at: ­globalstrategy.everywomaneverychild.org/. Advocate for USAID, the State Department, and CDC to provide seed funding through their country offices to mobilize and involve the private sector in addressing cardiovascular disease and cancer at the country level. Strategies should include: ■■

■■ ■■ ■■

Target and manage risk factors (e.g., smoking, alcohol use, and obesity) for major NCDs and adopt fiscal policies to regulate tobacco control and healthy diets. Detect and treat hypertension early. Detect and treat early cervical cancer. Immunize for vaccine-preventable cancers (e.g., human papilloma virus [HPV] and hepatitis B vaccines).

To learn more about how to advocate and fund NCD prevention strategies, join the NCD Alliance: www.ncdalliance.org/ Accelerate the development of medical products.

Advocate for U.S. government agencies to invest in reducing the costs and risks of developing, licensing, and introducing vaccines, therapeutics, diagnostics, and devices needed to address global health priorities. The approaches need to enable innovations in trial design, streamline regulations, ensure production capacity, create market incentives, and build the capacity for international capacity for research and development. The CDC, NIH, and DoD should increase the number of people and institutions in partner countries capable of conducting clinical trials for global health priorities and build the skills of principal investigators. To learn more about the development of medical products, read: www.ncbi.nlm.nih.gov/books/NBK234438/ (continues)

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TABLE 5-1  NAS Global Health Report 2017 Recommendations and Actions for Nurses and Other Health Professionals

(continued)

Recommendations

Actions

Improve digital health infrastructure.

USAID and the State Department should incentivize and support countries in building interoperable digital health platforms. USAID should provide technical assistance to countries in the development and implementation of interoperable digital health platforms. U.S. agencies should expand upon the “build-once” principle of the Digital Global Access Policy Act and align U.S. funding in digital health by multiple agencies to reduce fragmentation and duplication. For more information, read: www.who.int/bulletin/volumes/90 /5/11-099820/en/ Review NAM’s recent workshop documents on the use of technology to advance global health: www.nationalacademies.org/hmd/Activities/Global/PublicPrivatePartnershipsForum/2017-MAY-11.aspx

Transition investments toward global public goods.

USAID, the State Department, and USDHHS should, together, systematically assess their approach to global health funding to ensure long-term investments in high-impact, country level programs. As advocates, keep your eye on what the U.S. is investing in globally and why and what is the impact of the goods provided for the global public?

Optimize resources through smart financing.

USAID and PEPFAR should structure their financing to promote greater country ownership and domestic financing. Ministries in countries should be engaged to design and finance the plan, model refinement, and expansion of the return on investment analysis for financial execution. Simply put, USAID and the State Department should motivate the World Bank, GAVI, the International Monetary Fund, and the Global Fund to Fight AIDS, Tuberculosis and Malaria to promote transitioning to domestic financing, assist countries in creating fiscal space for health, leverage fiscal policies to improve health, and attract alternative financing sources. Actions to take: When writing your advocacy letters, never forget to discuss your arguments in a policy framework to include cost, access, and quality. As global health threats, challenges, and issues continue, money will matter and how nations, including the U.S., pay for the money matters. No national government will be able to pay for this alone. Private and public partnerships will need to be forged and new financing mechanisms that are smart will need to be created.

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Recommendations

Actions

Commit to continued global health leadership.

The United States should commit to maintaining its leadership in global health and actively participate in global health governance, coordination, and collaboration. The U.S. needs to be at the table to influence and improve the performance of key United Nations agencies such as the World Health Organization (WHO). WHO needs greater resources to address the health challenges of the 21st century, and many of its priorities align with those of the U.S. government. However, U.S government financial contributions to WHO should come with a requirement that the organization adopt and implement the much-needed management and operational reforms. The U.S. also needs to remain partners in financing GAVI, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as new entities such as the Global Health Security Agenda and the Global Financing Facility. The U.S. needs a more strategic approach implemented to achieve global health goals. The State Department should create a global health career track and seek congressional action to ­enable the establishment of a cadre of global health experts within the U.S. D ­ epartment of Health and Human Services through an amendment of the Foreign Service Act. This would create the environment necessary to expand the health attaché program, particularly in lower and middle-income countries (LMICs). As nurses and health professionals, you should advocate for nurses and health workers to be at the tables in all WHO and other UN agency global health policy and evaluation works. By 2030, the health workforce shortages will be enormous and there will not be enough health workforce to meet the global health needs of the world’s population. Without adequate health workers, there will be no progress achieving global health outcomes. Know what is happening in your nation and at the WHO from a health workforce perspective. Keep up with the latest global policy strategies and initiatives on ­human resources for health at: World Health Organization Strategy on Human Resources for Health: www.who.int/hrh/resources/globstrathrh-2030/en/ World Health Organization Strategic Direction for Nursing and Midwifery 2016–2020: www.who.int/hrh/nursing_midwifery/global-strategic-midwifery2016-2020.pdf Join the Global Health Workforce Alliance: www.who.int/hrh/network/en/

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global-health-and-the-future-role-of-the-unitedstates.aspx. There is also a Blueprint for Action in Table 10-1 of the NAS Global Health report (2017a), which outlines the recommendations pertinent to each national entity with actions to achieve global health security and enhance productivity and economic growth worldwide.

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Conclusion

Global health, and its challenges and threats, remain a top priority for world leaders and health professionals. This chapter focuses on the politics, the policies, and the advocacy strategies that nurses and health professionals need to engage in to improve health services and ensure positive health outcomes for our world’s populations. It is a call to action for the United States and other nations to commit to investing in global health, and for nurses and health professionals to advocate for investment in global health. To learn more, read the latest report from the ­National Academies of Sciences, Engineering, and Medicine, Global Health and the Future Role of the United States (NAS, 2017).

Discussion Questions 1.

2. 3.

What are politics of global health in the context of the latest National Academies of Science’s report, Global Health and the Future Role of the United States (NAS, 2017)? Identify global health initiatives important for nurses and other health professionals. Describe specific actions nurses and other health professionals can take to become advocates for global health policy and advocacy.

References Forouzanfar, M. H., Afshin. A., Alexander, L. T., Anderson, H. R., Bhutta, Z. A., & Biryukov, S . . . Murray, C. J. (2016). Global, regional, and national comparative

risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1659–1724. Institute of Medicine (IOM). (1997). America’s vital interest in global health: Protecting our people, enhancing our economy, and advancing our international interests. Washington, DC: National Academies Press. Institute of Medicine (IOM). (2009). The U.S. commitment to global health: Recommendations for the new administration. Washington, DC: National Academies Press. National Academies of Sciences, Engineering, and Medicine (NAS). (2017a). Global health and the future role of the United States. Washington, DC: National Academies Press. Retrieved from https://www.nap.edu/catalog/24737 /global-health-and-the-future-role-of-the-united -states National Academies of Sciences, Engineering, and Medicine (NAS). (2017b). New report recommends priority actions to achieve global health security, protect U.S. position as global health leader, and safeguard billions of dollars in health investments. Retrieved from http:// www8.nationalacademies.org/onpinews/newsitem .aspx?RecordID=24737 National Institutes of Mental Health (2017). Health statistics: Global index—DALYs. Retrieved from https://www.nimh .nih.gov/health/statistics/global/index.shtml Pandemic and All Hazards Preparedness Act (2006). Public Law 109–417. Retrieved from https://www.phe.gov /preparedness/legal/pahpa/pages/default.aspx United Nations. (2015). The Millennium Development Goals report: 2015. Retrieved from http://www.un.org /millenniumgoals/2015_MDG_Report/pdf/MDG%20 2015%20rev%20(July%201).pdf United Nations (2016). Sustainable Development Goals: 2016. Retrieved from http://www.un.org/sustainable development/sustainable-development-goals/ World Health Organization. (2013). Global health workforce shortage to reach 12.9 million in coming decades. Retrieved from http://www.who.int/mediacentre/news /releases/2013/health-workforce-shortage/en/ World Health Organization (2015a). WHO progress report on nursing and midwifery: 2013–2015. Retrieved from http://www.who.int/hrh/nursing_midwifery /nursing-midwifery_report_13-15.pdf?ua=1 World Health Organization (2015b). Options analysis report on strategic directions for nursing and midwifery: 2016–2020. Retrieved from http://www.who.int/hrh /nursing_midwifery/options_analysis_report/en/ World Health Organization (2016). Global strategic directions for strengthening nursing and midwifery: 2016–2020. Retrieved from http://www.who.int/hrh/nursing _midwifery/global-strategic-midwifery2016-2020.pdf

Case Study

CASE STUDY

Valerie Gruhn

Background Overnight, the people of northwestern Iraq were suddenly stripped of all forms of human rights. In October 2016, Iraqi military forces, along with an international coalition, launched an operation to defeat the Islamic State in the governorate of Nineveh. International humanitarian groups boosted all efforts to install trauma stabilization posts, as well as field hospitals in and around Mosul, to provide lifesaving care. In March 2017, I had been deployed to West Mosul by the humanitarian organization Médecins Sans Frontières (MSF), also known as Doctors Without Borders (Doctors Without Borders, n.d.), to open a hospital and assist with the escalating humanitarian crisis. At that time, 400,000 civilians were still trapped in the Old City alone (United Nations, 2017). In their attempts to escape, civilians were often targeted by snipers or used as human shields. Women and children were exploited and turned into sex slaves. Civilian men, if captured, were tortured and/or executed. The battle for Mosul became a complicated urban war that created immense suffering and countless casualties. The use of massive firepower and aggressive military tactics by the Iraqi Forces, the International Coalition Forces, as well as the Islamic State were responsible for the innumerable loss of life that occurred since the beginning of the battle. The BBC stated, “The mission is now regarded as the single largest urban battle since World War II” (Rodgers, Stylianou, & Dunford, 2017).

It Is Personal I was no longer a third party. For years, I had watched sensational 3-second videos of parents carrying bodies of their children dangling in their arms as

they ran through the streets of some unknown war torn city. Then, on my first day, I saw a father holding his lifeless boy with a despairing look on his face just like I had seen countless times on media channels. Only this time, he was running towards me. On my first day working in the field hospital, I bore witness to the horrors I had seen on their faces and to the true meaning of inhumanity. Ambulances packed with dismembered people came crashing in in waves. Once the ambulance doors opened, with every person I triaged, I was struck by the absurdity of the words I was dictating: “toddler with a mortar injury,” “man with a left leg amputation,” “woman with an abdominal wound from a sniper attack,” “child with a blast injury from a landmine.” I ran back to a small area within the emergency room designated for stabilizing the most critical patients, the red zone, to direct the local nurses towards different tasks. I then proceeded to finding the woman who’s disembodied leg I had picked up along the way. We never found the person this leg belonged to. Reflecting back upon this, I realize that in the midst of all the chaos of stabilizing patients, I did not notice how unhinged some of the things we did and witnessed were at the time they happened. Not far off, loud explosions followed by black smoke and white mushroom clouds painted the sky. I could hear the sound of whistling bullets flying overhead, and just down the street from the field hospital, a military point shelling into the old city. The conditions were horrendous and at times I found myself questioning my presence there. MSF local staff had been living under the Islamic State of Iraq and the Levant (ISIS), and were victims of war themselves. They chose to take the risk to work with us, and were motivated to help these victims within their own community. Most of the staff worked and slept at the hospital for one week, then travelled hours to return to where their families had relocated for their week off. However, some members of their own family were still trapped inside the Old City. Their anxiety was palpable; the next patient could potentially be one of them. It was all very surreal. The war that was at first happening to strangers in a distant country in the Middle East was now happening to people I call my friends and my family. Working in global health

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Restoring Humanity in a War Zone: One Nurse’s Experience Mosul Case Study

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makes every crisis, every war, every bit of injustice, bigotry, or inequality, personal. What many often fail to understand is how fragile basic human rights are and how easily they can be taken away. Ultimately, the one and only factor that makes us different from any of these victims or stories is simply the luck of where and when we were born.

Restoring Dignity Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world, Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind . . . (United Nations, 1948, p. 10) One month after my arrival, I was asked to open a hospital in West Mosul close to the frontline. The road towards West Mosul reflects the skeletons of what once used to be a bustling city. Empty streets, abandoned homes, collapsed buildings, and old car bombs are overturned on the roads. Additionally, truckloads of people who fled months prior were forced to come back and reinstall themselves to the rubble that once was their home, in order to make room for newly liberated people in the camps. “By the beginning of August, more than 800,000 were still regarded as displaced by the International Organization for Migration (IOM), more than half of those housed in camps or emergency sites” (Rodgers, Stylianou, & Dunford, 2017), only to face conditions in the camps that are an amalgam for the spread of infectious diseases. When opening a project, you have the chance to watch it evolve and bring in ideas and protocols that will immediately affect your patient population. However, it does not come without frustration, especially in such a complex context. Finding a stable structure to open an emergency project so close to the frontline, without putting everyone at risk is near impossible. Yet, we were able to find one of the last standing buildings to provide emergency lifesaving care with surgical capacity near the frontline. We hired newly liberated staff and provided them with opportunities they did not have in years. I remember a conversation I had with a local staff

doctor who told me how he managed to flee: “My wife and I, we ran from building to building and hid with my son. We took a boat to get to the other side of the Tigris River. It only took thirteen minutes, but it felt like days. I thought we were going to die! When I heard about an organization that was helping my people, I immediately applied to work for MSF. We were afraid that you would think that we were all ISIS, but you didn’t. You gave us work, you gave us life, and you made us human again.” Towards the final phases of the battle, when the city of Zanjili was liberated, in an effort to escape, many people had been wounded. The exodus meant that hospitals were activating their mass casualty plan, and were planning to receive an influx of wounded patients within the hour. Among them was a 4-year-old girl, with an open head injury, who arrived to our hospital separated from her family while escaping. I was hopeful that they had been brought to other facilities, yet the alternative had not bypassed my thoughts. When she woke up, she cried for her mother until I took her in my arms in order to comfort her, and slept by her side to keep a much-needed close eye on her. The local nurses circulated her picture on Facebook, which would get shared by others. Many families were reunited in this manner, including our little fighter. Within 2 days, the mother appeared with her two siblings, injured, but relieved that her baby was still alive. Their father had been killed in their attempt to escape. I take comfort in these abstruse survival stories.

The Politics of Caring These are the stories of the people of Mosul. Those who survived now have an uncertain future; limbless and malnourished, people are starting over by finding the remains of their families to give them a decent burial. The children only know the sounds of war, and many are orphans who suffer from posttraumatic stress disorder. The general infrastructure of Mosul is crippled; homes, health facilities, and schools are in ruins, and there is no electricity or access to clean water or food. It will take years to rebuild and cost millions of dollars the country does not have. Moreover, vaccination schedules were interrupted, and noncommunicable diseases were neglected, which is sure to cause meaningless disease and suffering for years to come.

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Case Study Questions 1. What do you think motivated the author to help this particular patient population? What motivated the local nurses? 2. Do you think the benefits of working in such a context outweighs the risks? Could she have been more effective helping a local population at home? 3. What were the most significant challenges you think the author faced in her initial days? 4. Using the American Nurses’ Association Code of Ethics as a guide, describe what you see as the most significant challenges you might face in respecting the professional boundaries of nursing vs. caring on a more emotional level? Does this change with a pediatric patient population? 5. Do you think the exposure to a life-threatening environment affected the author’s ability to perform her duties? 6. Referencing Maslow’s Hierarchy of Needs, describe how the author fulfilled each tier for her patients. What about for herself? How do you think your experience would differ, if at all?

References Doctors without Borders. (n.d.). Charter. Médecins Sans Frontières (MSF) USA. Retrieved from http://www .doctorswithoutborders.org/about-us/history-principles /charter (accessed August 16, 2017). Rodgers, L., Stylianou, N., & Dunford, D. (2017, August 9). What’s left of Mosul? BBC News. Retrieved from

http://www.bbc.co.uk/news/resources/idt-9d41ef6c -97c9-4953-ba43-284cc62ffdd0 United Nations. (1948). Universal declaration of human rights. New York, NY: UN. Retrieved from http://www .un.org/en/universal-declaration-human-rights/ United Nations. (2017, March 24). Hundreds of thousands trapped in Mosul with ‘worst yet to come’- UN agency. UN News. Retrieved from http://www.un.org/apps/news /story.asp?NewsID=56423#.WZOcrtPyveR

CASE STUDY NCDs: Nursing’s Opportunity? Christine Hancock Founder and Director C3 Collaborating for Health

Background Six years before noncommunicable diseases (NCDs) and prevention were included in the United Nations Sustainable Development Goals, C3 Collaborating for Health, a small London-based not-for-profit agency, was working internationally to address this escalating public-health crisis. Christine Hancock, then President of the International Council of Nurses, attended a conference that changed her life. After a career in nursing, specializing in cardiac care, working as a ward sister in London’s National Heart Hospital, Christine followed a career in nursing management, culminating in 12 years as CEO of the Royal College of Nursing where she was able to influence UK health policy, working closely with health ministers and probably visiting more hospitals and community facilities across the UK than anyone else. Christine next had a full term as President of the International Council of Nurses, when over 4 years she visited 50 countries and was able to see health care in action, and meet nurses and health ministers. Towards the end of that time, she learned of the growing epidemic of NCDs not, as once thought, diseases that only affected rich, elderly, fat Americans closely followed by the British, and she learned two startling facts: First that this epidemic was disproportionately affecting low and middle-income countries (LMICs), and second, it was happening at an earlier age than in western countries.

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No matter how much I feared the rockets and airstrikes, I was driven by the resilience of the survivors and the local nurses, who revealed to me what my obligation as a nurse truly is. By simply stepping out of my living room, I was no longer a passive bystander. Once you become the person a pleading father runs towards to hand his wounded child to, you are never the same again. Iraq will continue to bleed for many years to come. The truth is the politics of caring on a global scale is difficult, yet it has the power to restore humanity. In the words of Martin Luther King Jr. “Our lives begin to end the day we become silent about things that matter.” Nursing gives us the ability to go beyond our own borders and use our voice to speak out about what we witness. “The choice of where or how we care is ours” (D. Nickitas, personal communication, August 15, 2017).

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There are 40 million deaths from NCDs occurring each year: 70% of the total. Most of these are caused by four diseases: cardiovascular disease (CVD), cancer, chronic obstructive pulmonary disorder (COPD), and diabetes. Eighty percent of these preventable deaths occur in LMICs and 48% NCD deaths in LMICs occur in people under 70 years old. The Word Health Organization (WHO) estimates that 80% of heart disease, type 2 diabetes, and stroke, and 35% of cancers are preventable by focusing on just four risk factors: smoking tobacco, increasing physical activity, reducing harmful alcohol use, and eating a healthy diet with less salt, sugar, and fats and more fruit, vegetables, whole grains, and nuts. There has been increasing global recognition that prevention and the risk factors of NCDs are critical issues. However, our work has become more urgent as the NCD epidemic escalates and health systems buckle under enormous financial demands. Using their extensive connections to bring together organizations, C3 Collaborating for Health began to imagine a world where there are no premature or preventable deaths from NCDs, by working towards a world where: ■■ ■■

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It is easier to live healthy lives. Fewer fathers and mothers, brothers and sisters, and daughters and sons are dying at young ages from largely preventable diseases. Prevention, health, and well-being are core to proper health care. The focus is on not just on individual behavior change, but also on changing our environment.

C3 is unusual as it is global (not national or local), it is not disease focused like most charities, and it uses multisector collaboration to focus on the unhealthy behaviors that lead to NCDs: tobacco use, unhealthy eating and drinking, and physical inactivity. While C3 does not work with the tobacco industry, a fundamental principle is to engage the business world, and that includes the food industry; many of these companies have played a part in our unhealthy lives, and C3 believes they need to be part of the solution. Although NCD prevention frequently focuses on individual behavior change, C3 knows that

the environment in which we all live very much dictates our behavior. It can be difficult, if not near impossible, to adopt healthy behavior if your surroundings make being unhealthy the cheaper, easier option. That is why C3 uses a partnership approach to bring together different groups—individuals, communities, organizations, businesses, and policymakers—to collaborate on societal solutions that make it easier for people to live healthy lives. C3’s main work areas include businesses, including the workplace, professionals who can influence others, and local communities. Why would businesses care about NCDs? It is estimated that NCDs will cost the world’s economy about £30trillion over the next 20 years. The World Economic Forum has stressed that the NCD epidemic is one of the most important global risks in terms both of likelihood and severity. Health starts where you live, learn, work, and play, says Sir Michael Marmot, President of the World Medical Association. The place where you are born, grow up, and live is critical to your health throughout your life. Too often, governments and well-meaning people focus on convincing (they often say “educating”) individuals to change their unhealthy lifestyle, but fail to recognize the importance the environment has on our ability to choose healthy options: fresh or fast food? Green space or concrete? Walking and cycling or driving? Social networks or isolation? All of these can influence the risks to our health. This is particularly true for disadvantaged communities, where healthy food options and opportunities for physical activity can be nonexistent, expensive, and/or unrealistic. The best way to break down the barriers to living a healthy life and creating sustainable change is to work with community members who are the experts in their environment and their health; the empowerment of people is essential to address the NCD epidemic. Health professionals are among those best placed to give the trusted, accurate advice needed to prevent and treat NCDs. C3 wants to stimulate a global movement to raise awareness, motivate, stimulate, educate, and support the global health workforce in promoting healthy behavior to combat the NCD epidemic. C3’s Healthy Nursing Collaborative is a network of nurses, nursing organizations, and other stakeholders, which aims

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Conclusion There are more than 20 million nurses across the world; in some parts of the world they are the only health professionals people meet. Imagine the progress that could be made if all those nurses were supported with the knowledge, skills, and opportunities to promote healthy lifestyles and prevent NCDs. C3’s NCD nursing model does just that: ■■

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Help and support nurses to understand and improve their health. Educate and promote health among their patients, families, and communities. Disseminate knowledge and promote skills development with their colleagues. Advocate for NCD prevention locally, nationally, and internationally.

Are you interested in making it easier for people to be more active, eat and drink better, and stop smoking tobacco?

Case Study Questions 1. To what extent do health professionals have a responsibility to role model healthy behaviors? 2. What changes are needed in the work environment to ensure that health professionals are enabled to lead healthy lives at work? 3. How can initiatives such as C3’s Healthy Nursing Collaborative and ANA’s Healthy Nurse: Healthy Nation help build a culture of health in nursing? 4. What changes are needed to ensure that healthcare professionals receive appropriate education input and appreciation of public health issues to ensure a skilled workforce knowledgable in preventive health care, well-being, and public health?

References C3 Collaborating for Health. (n.d.) Welcome to the Healthy Nursing Collaborative. Retrieved from https://www .c3health.org/our-projects/health-professionals /healthy-nursing-collaborative/ Marmot, M., Sir. (2015, November 3). The health gap: The challenge of an unequal world. London, UK: Bloomsbury Press. World Health Organization. (2009). 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases. Retrieved from http://www .who.int/nmh/publications/9789241597418/en/

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to encourage sharing of evidence, resources, materials, and experiences to support nurses in leading healthier lives so they can better lead and help their colleagues, family, friends, and communities to live more healthily. C3 is interested in sharing evidence and good practice from around the world.

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CHAPTER 6

Mental and Behavioral Health Barbara Cohen

OVERVIEW Mental health rights, resources, and policies that provide or limit mental health services are in the public spotlight on a daily basis. Mental health needs of Americans affect tens of millions of individuals. The Substance Abuse and Mental Health Services Administration (SAMHSA) has reported that treatment of the sequelae of mental illness, including illnesses such as cardiac disease and diabetes, was in the $600 billion range (SAMHSA, 2014a). A brief overview of the 2016 SAMHSA report on the nation’s mental health (SAMHSA, 2017, pp. 1, 27) set out stark figures for Americans affected in 2015 by substance abuse and/or mental illness for individuals age 12 and older (TABLE 6-1). The face of mental health has changed over the decades. Consumers of mental health services expect to be active partners in their treatment rather than passive recipients of others’ planning as in days gone by. Services to address bullying (in person and cyberbullying), suicide attempts, and the mental health needs of the lesbian, gay, bisexual, transgendered, and queer (LGBT-Q) population are growing. Cities are taking a more assertive approach to providing mental health care to citizens, advertising such services on public transportation and through television and other social media. The struggle for parity of mental health services with other medical services is ongoing, particularly in light of repeated efforts in the U.S. Congress to repeal and replace the Affordable Care Act provisions. This chapter provides an overview of the policies that have shaped and continue to shape the provision of mental health and behavioral health care services in the United States. The chapter explores resources available on national, state, and local levels throughout the United States. A discussion of policies that support expansion of mental health and behavioral health services to include active participation of consumers as partners in care is had. Policies aimed at promotion or limitation of mental health and behavioral health options for specific vulnerable groups are described. The chapter concludes with an overview of the future possibilities of care in the mental health and behavioral health arenas.

© Anthony Krikorian/Shutterstock

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OBJECTIVES ■■

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Describe the recent past and current status of the provision of mental health and behavioral health services on federal, state, and local levels. Discuss trends in mental health and behavioral health policies that have fostered greater consumer participation. Analyze policies allowing the provision or denial of mental health and/or behavioral health care to specific groups of patients.

TABLE 6-1  Number of Americans Affected by Substance Abuse and/or Mental Illness in 2015—Age 12 or Older Category of Substance Abuse

Numbers of Americans Affected

Illicit drug use in past 30 days

27.1 million (10.1% of all Americans)

Cigarette smoking

52.0 million

Current use of alcohol

138.3 million

Category of Mental Illness

Numbers of Americans Affected

Adults receiving mental health care

34.2 million

Adults with AMI

43.4 million (17.9% of all adults)

Adults with AMI and SUD

8.1 million (3.3% of all adults)

Adolescents with MDE

3.0 million (12.5% of all adolescents)

Adolescents with SUD and MDE

350,000 (1.5% of all adolescents)

AMI 5 any mental illness; SUD 5 substance use disorder; MDE 5 major depressive disorder. Source: Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from https://www.samhsa.gov/data/sites /default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf

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Introduction to Mental and Behavioral Health

In order to understand policies related to mental health and behavioral health, nurses must first appreciate how mental health and behavioral

health are defined, regulated, and legislated by our government. The U.S. Department of Health and ­Human Services (USDHHS) defines mental health as: “our emotional, psychological, and social well-­being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices” (USDHHS, 2017).

Federal Government and Presidential Efforts to Improve the Nation’s Mental Health

The World Health Organization (WHO) ­ efines mental health as: “a state of well-­being d in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO, 2014). The Substance Abuse and Mental Health Services Administration (SAMSHA) (2014b) defines behavioral health as “mental/emotional well-being and/or actions that affect wellness. Behavioral health problems include substance use disorders; alcohol and drug addiction; and serious psychological distress, suicide, and mental disorders. Problems that range from unhealthy stress or subclinical conditions to diagnosable and treatable diseases such as serious mental illnesses and substance use disorders are included.” “Behavioral health” has also been used as a “phrase to describe service systems that encompass prevention and promotion of emotional health; prevention of mental and substance use disorders, substance use, and related problems; treatments and services for mental and substance use disorders; and recovery support” (SAMHSA, 2014b). With the definitional frameworks in mind, a view of past and current federal, state, and local policies regarding mental health will be explored, beginning with the federal government level.

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Federal Government and Presidential Efforts to Improve the Nation’s Mental Health

President Harry Truman signed the National Mental Health Act in 1946 (Public Law 79-487) calling for the establishment of the National Institute of Mental Health (NIMH). The NIMH, established in 1949, provides legislative policy guidance for important federal initiatives. Exploration of the mental health needs of Americans expanded in the 1950s and 1960s.

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The Mental Health Study Act of 1955 (Public Law 84-182) focused upon analyzing and re-­ evaluating the impact of mental health issues in the United States. Congress passed the Mental Retardation Facilities and Community Mental Health Centers Construction Act (Public Law 88-164) and the NIMH’s duties were to monitor the nation’s community mental health center (CMHC) programs. National action was recommended for child mental health in the mid-1960s. President Jimmy Carter established the President’s Commission on Mental Health in 1977. The repeal of the Mental Health Systems Act in 1981 created opportunities to enable each state to administer its own funds through block grants. In the 1990s, focus was placed on basic and clinical neuroscience research, services and intervention research, mental disorders, behavioral research, and acquired immunodeficiency syndrome (AIDS). The Substance Abuse and Mental Health Services Administration (SAMHSA) was created in 1992. In looking at the panoply of mental health challenges, the U.S. Surgeon General has focused on suicide prevention; SAMHSA and the NIMH have expanded services focusing not only on suicide, but also on eating disorders, panic disorders, and anxiety disorders. NIMH Depression Awareness, Recognition and Treatment (DART) programs were expanded to address the needs of men suffering from depression and survivors of mass violence in the 2000s. Outreach to Native American and Hispanic populations increased in light of rising incidences of substance abuse and mental health issues. Additional emphasis was placed upon treatment for severe persistent mental illnesses such as schizophrenia and bipolar disorder. Research into support for veterans as well as for those suffering from autism was expanded in the late 2000s through the Children’s Health Act of 2000 (Public Law 106-310), and again in 2006 through the Combating Autism Act of 2006 (Public Law 109-416). In 2011, the NIMH funded the Grand Challenges in Global Mental Health with 400 participants conducting research in 60 countries concerning mental, neurological, and

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substance use disorders. Prevention of suicide and preventing mass shootings and managing survivors gained support through executive orders signed by President Barack Obama in 2012 (Obama, 2012) and 2013, recognizing issues surrounding posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), and furthering our understanding of the functions of the brain (NIMH, 2017). The NIMH works in conjunction with the Centers for Medicare & Medicaid Services (CMS), Children’s Health Insurance Program (CHIP), and SAMSHA. NIMH provided a 2015 informational bulletin to state Medicaid directors concerning coverage of treatment for first episode psychosis, providing support for coordinated specialty care (CSC), an evidence-based treatment approach that had been explored in the NIMH’s RAISE (Recovery After an Initial Schizophrenia Episode) project (NIMH, 2017). In addition to the NIMH, SAMHSA provides additional support and guidance on a federal level in the area of behavioral health. SAMHSA (2016) provides national policies improving services to meet the behavioral healthcare needs of individuals, communities, and service providers. SAMSHA’s 2014 to 2018 initiatives include: (1) the prevention of substance abuse and mental illness, (2) healthcare and health systems integration, (3) trauma and justice, (4) recovery support, (5) health information technology, and (6) workforce development (SAMHSA, 2014a). The first initiative, the prevention of substance abuse and mental illness, focuses on high-risk populations including “college students and transition-age youth; American Indian/ Alaska Natives; ethnic minorities experiencing health and behavioral health disparities; service members, veterans and their families; and lesbian, gay, bisexual, and transgender (LGBT) individuals” (SAMHSA, 2014a, p. 10). The second initiative, healthcare and systems integration, focuses in part on “reducing the disparities between availability of services for mental illness and substance abuse compared to the availability of services for other medical conditions

and also focuses on support of coordination of care and services across systems” (SAMHSA, 2014a, p. 14). The third strategic initiative aims to reduce harmful effects of trauma and violence on children and youth, adults, families, and communities. The criminal and juvenile justice system has received special attention as individuals with mental illness are frequently routed through these systems without the provision of appropriate healthcare alternatives. These efforts include treatment for survivors of mass trauma (SAMHSA, 2014a, p. 19). This is particularly important given the uptick in mass shootings such as the Aurora Theater in Colorado in 2012; the 2012 Sandy Hook Elementary School shooting in Newtown, Connecticut; the 2018 Marjory Stoneman Douglas High School shooting in Parkland, Florida; and the increase in natural disasters such as Hurricanes Katrina (2005), Sandy (2012), Harvey (2017), Jose (2017), and Irma (2017). The fourth initiative focuses on recovery support to assist individuals in recovery from mental illness and substance use disorders and their family members to maximize use of appropriate programs and systems to maintain recovery, and to improve housing and employment options (SAMHSA, 2014a, p. 23). Health information technology (HIT) is at the center of the fifth strategic initiative for SAMHSA. The use of HIT to measure and track health disparities and their reduction, and the use of smartphones to make HIT accessible across diverse populations are two aspects of this initiative (SAMHSA, 2014a, p. 27). Lastly, the sixth strategic initiative addresses workforce development to expand the behavioral health workforce and improve behavioral health knowledge and skills of those not working in the field of behavioral health (SAMHSA, 2014a, p. 31). SAMHSA provides various engagement strategies aimed at collecting data on national and state levels of alcohol, tobacco, and illegal drug use and abuse, and their effects on behavioral health, including the National Survey on Drug Use and Health (NSDUH) and the Behavioral Health Barometer (SAMHSA, 2017).

State-Related Mental Health Policies

In addition, SAMHSA conducts public awareness campaigns aimed at underage drinking and mental health; the Synar Program established in compliance with the Synar Amendment (Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act, Public Law 102-321, sec. 1926) to prevent tobacco sales to minors; as well as work-related programs to provide drug-free workplaces, methadone–opioid treatment programs, and workplace drug-testing programs. By providing grants, SAMHSA helps in the creation of a variety of programs such as: (1) homelessness reduction; (2) criminal justice services for those suffering from mental illness; (3) zero suicide programs; (4) systems of care planning and expansion; (5) tribal behavioral health screening, brief intervention, and referral to treatment and prescription drug monitoring programs; (6) minority fellowship programs; (7) workforce development; and (8) the Strategic Prevention Framework–Partnership for Success (SPF-PFS) grant program aimed at preventing underage drinking for individuals age 12 to 20 and avoiding prescription drug misuse by persons age 12 to 15 (SAMHSA, 2014a, p. 5). NIMH and SAMSHA lead the way on a national level; with these supports and resources, states have improved provision of mental health services to some extent.

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State-Related Mental Health Policies

The increases in federal government opportunities led to increased interest and participation on the state level through block grants allowing states to address Medicaid, insurance parity, workforce capacity, school-based mental health, criminal justice, and suicide prevention. Less well addressed are early identification and intervention programs, school-linked mental health services, housing, and employment (National Alliance on Mental Illness [NAMI], 2015). At the same time, states have been and continue to be affected by the recent economic recession. The National Alliance on Mental Illness

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(NAMI), a grassroots organization advocating for those with mental illness and their families, reviewed the status of the provision of mental health services by states’ efforts (NAMI, 2015). The economic recession resulted in state budget cuts of $4.3 billion from the overall mental healthcare system. Only 12 states have steadily increased investments in mental health services (Arizona, Colorado, Connecticut, Delaware, Idaho, Minnesota, New Hampshire, New Jersey, South Carolina, South Dakota, Virginia, and Washington) while other states have declined in budgeted funds provided for mental health services, including Kentucky, Arkansas, Alaska, North Carolina, Wyoming, Iowa, Kansas, Ohio, and the District of Columbia (NAMI, 2015). Strong leaders in the field of mental health are Minnesota, New York, and Virginia. While there is mixed reporting of progress at the state level, progress for state initiatives in the form of significant block grants is available or potentially available through the 21st Century Cures Act (Public Law No. 114-255), signed into law on December 13, 2016 by President Obama. Block grants issued by the federal government allow states to determine the proportion of funding to be ascribed to particular public needs (Congressional Budget Office, 2013). This law focuses on many areas of policy weakness in the fields of mental health and behavioral health from the criminal justice system, homelessness, underage substance abuse, extension of child psychiatry services, and workforce issues. With states having the decision-making power for allocation of grant block funds, in many states, there has been a decline in funding for mental health services, as noted above. 21st Century Cures Act, Titles VI, VII, VIII, and IX address strengthening community mental health services through increasing community mental health services block grants, and additional programs to provide enhanced relief for homeless individuals, individuals in need of substance abuse recovery programs, grants for jail diversion programs, dealing with suicide, assisted outpatient treatment, and underage drinking prevention programs, among other state-based

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efforts. The 21st Century Cures Act also addresses strengthening the healthcare workforce, particularly in the area of grants for mental and behavioral health education and training, minority fellowships, eligibility for loan repayment programs, and college mental health services. Children and adolescents are to benefit from this bill through increased programs for children with serious emotional disturbances, increased access to pediatric mental health care, substance abuse treatment and early intervention services for children and adolescents, trauma recovery, and screening and treatment for maternal depression. Mental health and substance use disorder parity for insurance coverage, as well as Medicaid and Medicare coverage, is addressed within this bill. Mental health and safe communities (Title XIV) address innovations in assisted outpatient treatment programs, federal drug and mental health courts, co-occurring substance abuse and mental health challenges in drug courts, and active shooter training for law enforcement among other initiatives.

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City and Community-Directed Mental Health Care Efforts

City services and community-directed mental healthcare efforts provide many new initiatives in line with federal and state initiatives and grant funding. New York City’s provision of 24/7 mental health counseling services highlights the city’s commitment to improving and ensuring its citizens’ mental health. These services are publicized throughout the mass transit system, as well as through local television. New York City text and/or phone services for emergency mental health situations provide advice for confidential mental health or substance abuse situations. Mobile crisis teams are available to assist in emergencies including providing services to family members attempting to

assist relatives suffering from severe persistent mental illness. Services are also provided on a home-based intervention or emergency hospitalization intervention for children and adolescents under the age of 18 (Crisis Mental Health ­Services, 2018). Inpatient facilities are not the only option for New Yorkers. There are many supportive living communities for formerly homeless, mentally ill individuals in New York City. An example is the housing facilities set up by Community Counseling & Mediation Services in Brooklyn, funded by a variety of city, state, and federal grants (www.ccmnyc.org). New York City has also set up a strong infrastructure in the justice system to improve the lives of those affected by mental illness through Court-based Intervention and Resource Teams (CIRTs), which were created through the ­Mayor’s Office for Criminal Justice in collaboration with the New York City Departments of Correction and Mental Hygiene. CIRTs operate in each borough of the city, focusing on people detained at Rikers Island who have symptoms of mental illness and can be safely supervised in the community. These teams are structured to provide an alternative to detention for people awaiting trial and alternatives to incarceration for those facing short jail sentences (CASES, 2017). Although New York City and other cities provide a variety of support services for mental health and substance abuse crisis, these types of services may not be available to all our nation’s citizens. There are significant differences in available workforce members and mental health services provided between urban/suburban and rural communities. The first national survey of programs serving American Indian and Alaska Native (AIAN) communities was conducted by Rieckmann, Moore, Croy, Novins, & Aarons (2016). They found that “programs in rural areas were less likely to have nurses, traditional healing consultants, or ceremonial providers on staff, to consult outside evaluators, to use strategic planning to improve program quality, to offer pharmacotherapies, pipe ceremonies, and cultural activities among their services

Policies Encouraging Consumer-Directed Mental Health and Behavioral Health Services (The Recovery Movement)

and to participate in research or program evaluation studies” (Rieckmann et al., 2016, p. 46). Rural providers were “more likely to employ elders among their traditional healers, offer AAopen group recovery services and collect data on treatment outcomes” (Rieckmann et al., 2016, p. 46). Substance abuse, including binge drinking, is prevalent in this population. There is a “disparity in the rates of substance abuse disorders among AIAN populations, and a mismatch between the geographic distribution of the AIAN population and access to Indian Health Service coverage” (Rieckmann et al., 2016, p. 47). Programs are tribally owned or owned by the Indian Health Service or federal entities. “Funding comes from several sources such as direct funding (Indian Health Service), enhanced funding (state block grant, tribal) and reimbursed services (fee for service, including Medicaid). Grants (federal and non-federal grants or contracts) were utilized by slightly more than one-third of the programs” (Rieckmann et al., 2016 p. 52). These sorts of disparities are seen across the nation, mapped through the areas of health shortages by the federal government. In addition to federal, state, city, and community services, we also see the active involvement on all levels by consumers of mental health services themselves.

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Policies Encouraging Consumer-Directed Mental Health and Behavioral Health Services (The Recovery Movement)

Mental health care has been traditionally designed without the input of the consumers (formerly known as patients). Care was given to consumers with or without their consent but not necessarily with their input into the environment in which care was to be given. Current policy

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perspectives have placed significantly more input in the hands of consumers and their significant others. The United States moved over a period from 1840 through 1854 from unsanitary, dangerous environments for the mentally ill to state hospital systems in at least 18 states (Parks & Radke, 2014). The state psychiatric hospital systems continued to expand until the 1960s and 1970s when deinstitutionalization became the norm, dismantling many of these state hospital systems following the passage of the Community Mental Health Centers (CMHC) Act of 1963, (Public Law 88-164, 77 Stat. 282). At that point, many of the state hospital systems were dismantled and patients deinstitutionalized. Investigative reporting, such as that completed by Geraldo Rivera, led to the discovery of numerous patient abuses at Willowbrook State Psychiatric Center, leading to its closure and alerting the public as to the conditions under which those with mental health issues had been suffering (Rivera, 2017). The recovery movement has flourished; recovery was defined by the New Freedom Commission on Mental Health (2003) as: “the process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms” (p. 5). Community-based services in which consumers (formerly referred to as patients) participate fully, serve on committees, and act as decision makers, have become the norm. A full exploration of the development, challenges, and successes of the recovery movement is beyond the scope of this chapter; however, Braslow (2013) provides an excellent overview of the historical development and current status of this movement. Clubhouse International (2016) provides environments in which individuals recovering from mental illness can rejoin or engage in additional education, employment, family, and friendship opportunities while being supported and restored to health. There are hundreds of

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clubhouses around the world, some accredited by Clubhouse International and others that are freestanding. The Rainbow Heights Club provides services to a specific set of consumers, describing its mission as: “to bring innovative, affirming, and effective treatment advocacy and support services to LGBT people living with mental illness provided in an atmosphere of hope, recovery and partnership” (2017). Consumers themselves have formed charitable organizations to provide services and information to other consumers and to assist in the creation and maintenance of mental health consumer rights (MindFreedom, n.d.).

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Challenges in the Provision of Mental Health and Behavioral Health Services

There are many challenges from a historic viewpoint, as well as from the current healthcare landscape, which make the provision of healthcare services that much more difficult. Some of those challenges involve workforce availability and structure, some challenges affect the provision of health care to vulnerable groups, and some challenges are financially based. There is a workforce shortage in the areas of mental and behavioral health.

Workforce Availability The population of practicing psychiatrists in the United States declined 10.2% per 100,000 residents in hospital referral regions between 2003 and 2013 (Bishop, Seirup, Pincus, & Ross, 2016). 9.8 million adults, or 4.0% of the U.S. adult population, have a serious mental illness that interferes with their major life activities (Center for Behavioral Health Statistics and Quality, 2016). Primary care physicians reported difficulty in referring patients for mental health care and only

55% of office-based psychiatrists accept health insurance. Patients who actually see a psychiatrist may also incur large out-of-pocket expenses (Bishop et al., 2016). The Health Resources and Services Administration (HRSA) estimated that the current supply of psychiatrists only meets the need in half of the Health Professional Shortage Areas (HPSAs) (Bishop et al., 2016). This is despite the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343, 122 Stat.5765), which calls for treatment of mental illness and substance use disorders on the same scale as treatment for other health conditions. Policymakers and the healthcare community must address shortages and improve access to mental health care. Bishop and colleagues (2016) suggest that this can be accomplished by “increasing the number of students pursuing careers in psychiatry, reducing attrition among practicing psychiatrists and developing alternative workforce strategies” (p. 1275). Increased compensation and loan repayment programs could serve as incentives (Bishop et al., 2016). The number of psychiatric nurse practitioners in the U.S. who are able to diagnose and treat mental illness, including prescription of medication, has increased, possibly easing the shortage of mental healthcare providers able to both diagnose and prescribe. The recently passed 21st Century Act (2016) contains provisions aimed at increasing education and training in the fields of mental health and behavioral health. An expanded and well-educated workforce will be essential to keep pace with the increasing mental health and behavioral health needs of our society. In addition to increasing the workforce, services to vulnerable populations must also be created, supported, and defended.

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Groups Requiring Additional Political Protection

In the past decades, the LGBT-Q (lesbian, gay, bisexual, transgendered, and queer) community

Lower Socioeconomic Status–Related Mental Health Policies

has moved its legal rights and political agenda forward, particularly in the arena of health care. Additional rights include insurance coverage tangentially made possible via the Marriage Equality Act as upheld in Obergefell v. Hodges by the Supreme Court of the United States (2015) and through extension of federal rights to same sex partners. Obergefell held that marriage is a fundamental constitutional right given that, regardless of sexual orientation, marriage is one of life’s most intimate decisions— whatever one’s sexual orientation. The Court in Obergefell (2015) set forth the right to marry as a safeguard for children and families and described marriage as a keystone of the nation’s social order (Obergefell, 2015, p. 16). Despite this resounding support of marriage equality, the rights of the LGBT-Q community continue to be challenged, creating and exacerbating attendant mental health stressors. Movement forward in one sphere of engagement has also involved movement in reverse in others, particularly for transgendered individuals. Today, 150,000 students between the ages of 13 and 17 (0.7% of this age group) identify as transgendered (Williams Institute, 2017) and 0.6%, or 14 million individuals, identify as transgender in the United States (Flores, Herman, Gates, & Brown, 2016). A large online survey of the experiences of transgendered individuals across the United States found increased minority stress for these individuals. Experiences that increased stress and decreased health were, in part, related to the lack of public policy initiatives to “confront social structures, e.g., gender-segregated restrooms and social groups), norms (e.g., gender role expectations) and attitudes (e.g., prejudice in the workplace) that produce minority stress to reduce the high rates of psychological distress found among transgender and other minority populations” (Bockting, Miner, Romine, Hamilton, & Coleman, 2013, p. 950). The U.S. Department of Justice and the U.S. Department of Education, with the support of then President Barack Obama, released joint guidance, pursuant to Title IX of the Education Amendments of 1972, to assist schools

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in ensuring the civil rights of transgender students, including policies concerning use of school bathrooms consistent with the gender identity of the student (2016). The U.S. Departments of Justice and Education rescinded the original “Dear Colleague” letter on February 22, 2017 (U.S. Department of Justice and U.S. Department of Education, 2017). The U.S. Supreme Court subsequently refused to hear the case of Gavin Grimm, a transgender high school student, and reversed the lower court ruling in favor of the student, which addresses the question as to the rights of a transgender high school student to use the bathroom of his choice (Gloucester County School Board v. G.G., 2017). Support for the transgender community’s mental health and behavioral health needs continues to be weakened and require further activism and support. Additional support through the enactment of anti-discrimination and hate crime legal protections is warranted. A recent study of transgendered veterans, for example, in states with and without such protections found that employment nondiscrimination protection was associated with 26% decreased odds of mood disorders and 43% decreased odds of self-­directed violence (Blosnich et al., 2016). Other vulnerable populations require policy support to obtain appropriate mental health and behavioral health services.

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Lower Socioeconomic Status–Related Mental Health Policies

Socioeconomic disparities affect mental health. States have not only approached improving mental health via traditional health services approach, but have attempted to improve socioeconomic aspects of individuals’ and families’ lives with the goal of improving mental health. Offering of housing vouchers is one such approach that has been utilized in an attempt to improve mental health outcomes for

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vulnerable populations. Families with adolescents aged 12-19 were offered housing vouchers under a “Moving to Opportunity” experiment (Nguyen, Rehkoph, Schmidt, & Osypuk, 2016). Comparison was made between 2,829 adolescents whose families were offered housing vouchers versus those families living in public housing. It was determined that housing vouchers alone were not the sole determinant of benefit to participants. Simply changing participants’ zip code did not guarantee an improvement in mental health; rather, supplemental services may also be needed to improve the health of these vulnerable subgroups, such as health clinics, youth programs, child care providers, transit authorities, and career services (Nguyen et al., 2016). In addition to the LGBT-Q population and populations faced with lower socioeconomic status challenges, veterans have also become a population requiring targeted mental health and behavioral health policies. These policies have benefits and drawbacks as seen next.

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Veterans’ Use of Mental Health Services and Policy Issues

We have seen an upswing in the use of mental health services by U.S. veterans between 2001 and 2010 (Tsai & Rosenheck, 2016). Veterans of the Persian Gulf, Iraq, and Afghanistan wars are more likely to have used mental health services than in previous eras. In addition, these groups of service personnel are more likely to have received U.S. Department of Veterans Affairs (VA) disability compensation (Tsai & Rosenheck, 2016). It will be one of the future challenges of our mental health and behavioral health policymakers to ensure continued access to services that meet future demands and keep pace with the growth in need for these services. In addition to attention focused upon

transgendered service people, attention has been focused upon servicewomen and female veterans in recent years. United States Army women suffering administratively recorded sexual assault had significantly elevated odds ratio of subsequent mental health treatment, posttraumatic stress disorder treatment, inpatient treatment, and demotion or attrition. Suicide attempts and poor career outcomes are also related to sexual assault during military service. It was concluded that “sexual assault victimization is associated with considerable suffering and likely decreased force readiness” (Rosellini et al., 2017, p. 732). LGBT-Q service officers have been encouraged by health policy changes offered through the passage of the Don’t Ask, Don’t Tell Repeal Act of 2010 (Public Law No: 111-321) paving the way to allow soldiers allowing these soldiers to “come out” to their commanders and colleagues and receive mental health accommodations and treatment. An abrupt reversal of this policy has been set in motion through a Presidential Memorandum for the Secretary of Defense and the Secretary of Homeland Security (2017) prohibiting service by transgender service members and barring funding to pay for sex reassignment surgeries except to protect the health of a serviceperson whose surgical course was already in progress. This executive order affects the mental health of those service people who now face uncertainty in both their service in the military and uncertainty in the availability of health care connected to gender preference. In response, on October 12, 2017, the U.S. House of Representatives introduced H.R. 4041, the aim of which is to provide for the retention and service of transgender members of the Armed Forces. We have seen the effects that policies may have on the mental health of vulnerable populations. Given the number of Americans across the board who require assistance and support in the areas of both mental health and behavioral health, it is important to examine some of the financing issues involved in access to care.

Policy Innovations to Improve Mental Healthcare Outcomes

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Policy Innovations to Improve Mental Healthcare Outcomes

It is insufficient to spend funds on various approaches to mental health and behavioral health services. It is important to give thought to whether those funds are being used wisely so as to maximize benefits to both the participants and the healthcare system. Improvements in mental health, employment, and quality of life outcomes for people on Social Security Disability Insurance (SSDI) were had through the Social Security Administration’s Mental Health Treatment Study (MHTS). At the same time, provision of services did not reduce the number of SSDI recipients (Drake, Frey, Karakus, Salkever, Bond, & Goldman, 2016) leading to the recommendations of focusing future research on prevention rather than rehabilitation, streamlining funding and infrastructure for training and service integration, and improving financing strategies for insurance coverage for individuals with disabilities. Again, as with the Indian Health Service and funds utilized for treatment for AIANs, there are significant concerns about political intent to reduce the overall SSDI expenditures with a concomitant reduction in care for affected individuals. Few people who obtain SSDI return to work; once individuals start receiving payments and Medicare insurance, there is little incentive to leave the system (Drake et al., 2016, p. 2). The Affordable Care Act remedied some of these issues by allowing individuals with preexisting conditions to obtain insurance and also through expansion of Medicaid in some states. As the Trump Administration seeks to repeal or significantly alter the Affordable Care Act, those individuals receiving SSID may, once again, remain on the public dole, fearing to participate in gainful employment for fear of losing valuable and irreplaceable benefits. Adding additional coverage for

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increased services to improve mental health has been proposed. Funding for services related to common sequelae of mental illness has also come under consideration. Adults with serious mental illness have a decreased life expectancy than the average American by about 10 years, yet, exercise, which is a first-line treatment to combat cardiovascular disease, diabetes, and obesity, is not a funded treatment under Medicare, Medicaid, nor private insurers. It is suggested that new legislation is needed to allow for reimbursement of “evidence-based exercise programs for people with serious mental illness treated in community mental health settings to foster improved mental and physical health outcomes and reduce healthcare costs for this vulnerable population” (Pratt et al., 2016, p. 478). Currently, healthcare policies deny community mental health programs the financial ability to offer exercise programming. Funds for training staff to deliver preventive health services in community mental health programs are scarce and “billing rules set by the Centers for Medicare & Medicaid Services (CMS) and private insurers prohibit most allied health professionals from receiving reimbursement for providing exercise programming in mental health settings” (Pratt et al., 2016). The Society of Behavioral Medicine and the American College of Sports Medicine recommend promotion of evidence-based exercise programming for people with serious mental illness by allowing reimbursement by regional and national healthcare providers in SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) and requiring the provision of programs of adequate duration, frequency of contact, and support from fitness professionals (Pratt et al., 2016). Secondly, they recommend expanded healthcare services for people with serious mental illness by specifying exercise programming as a reimbursable service through the Affordable Care Act, including Medicaid 1915(i) State Plan and Community-Based Services Program and adaptations of the Specialty Health

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Home Program (Pratt et al., 2016). In addition to finding financing for mental health and behavioral health services, more financially efficient ways of delivering these services have been explored. Expanding services tangentially related to mental health is one approach to enhancing outcomes. Utilizing new technology to deliver services is another. Mental health and behavioral health services are not always available to individuals living in remote areas or individuals living in areas designated as suffering from healthcare professional shortages. Various alternative delivery services to rural populations have been explored in an effort to increase services using modern technology, rather than in-person, face-to-face appointments. One study examined the cost of delivering behavioral health services to rural Native American populations via telecommunications and compared that cost with the travel costs associated with providing equivalent care. “The average per-patient cost of providing behavioral healthcare via telehealth was $138.24 and the average per patient travel cost was $169.76 for physicians and $333.52 for patients” (Horn, Barragan, Fore, & Bonham, 2016, p. 47). Choices concerning the possibilities of reimbursement for types of care or methods of delivery of care are policy choices. Choosing telehealth and allowing reimbursement for equipment and underlying technical support so as to expand availability to rural individuals who might otherwise go without is a policy choice. Choosing to reimburse exercise as treatment helpful to those with chronic mental illness who suffer from multiple comorbidities is a policy choice. Each choice comes with financial ramifications and with the hope that money spent will result ultimately in better health at lower costs. The ongoing and ever-changing market powers and political waves have brought an ongoing debate to the provision of health care in the United States, particularly aimed at the strengths and minuses of the Affordable Care Act.

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Ongoing Challenges: A Look to the Future of Policy Making in Mental Health and Behavioral Health

The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010 with most major provisions in force by 2014. The bill ended the exclusion of prior medical conditions provisions should individuals choose to move jobs and purchase new insurance policies. The Mental Health Parity Act of 2008 provided for parity between payment of medical services and payment for mental and behavioral health services. The Comprehensive Addiction and Recovery Act of 2016 (CARA) provided for efforts to be made to curb the nation’s opioid crisis encompassing prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal. $181 million in funding was provided for each year. As of 2017, proposed (not yet approved) funding is increased. There are several bills recently introduced into Congress aimed at improving mental health and/or behavioral health care (TABLE 6-2), including a bill introduced by Senator Kennedy of Massachusetts to provide mental healthcare parity to children covered under CHIP. The Better Care Reconciliation Act (BCRA) was voted down in Congress in July 2017. This Act would have left 22 million Americans uninsured and decreased Medicaid funding by $772 billion (Congressional Budget Office, 2017). The Obama Care Repeal Reconciliation Act (ORRA), which according to the Congressional Budget Office (2017) would result in 32 million uninsured individuals and eliminate Medicaid expansion entirely, was also voted down in Congress. As of the writing of this chapter, no further action on health care appears to be contemplated by Congress in light of the recent defeats of proposed changes

Ongoing Challenges: A Look to the Future of Policy Making in Mental Health and Behavioral Health

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TABLE 6-2  2017 Congressional Bills Related to Mental Health and/or Behavioral Health Sciences Citation for Bill

Purpose of Bill

Status of Bill

Civic Impulse. (2017). H.R. 3192— 115th Congress: CHIP Mental Health Parity Act. Retrieved from www .govtrack.us/congress/bills/115 /hr3192

This bill requires Children’s Health Insurance Program (CHIP) plans to cover mental health and substance use disorder services. Financial requirements and treatment limitations applicable to such services shall not differ from those applicable to other medical services under CHIP.

Introduced into Congress July 12, 2017.

Civic Impulse. (2017). H.R. 2509—115th Congress: Medicare Mental Health Inpatient Equity Act of 2017. Retrieved from www .govtrack.us/congress/bills/115 /hr2509

This bill removes the 190-day lifetime limit on inpatient psychiatric hospital services under Medicare.

Introduced into Congress March 16, 2017.

Civic Impulse. (2017). H.R. 1575—115th Congress: Addiction Recovery through Family Health Accounts Act. Retrieved from www .govtrack.us/congress/bills/115 /hr1575

To amend the Internal Revenue Code of 1986 to expand to family members with respect to whom treatment for alcohol and drug addiction is treated as a qualified medical expense for purposes of health reimbursement arrangements, health flexible spending arrangements, and health savings accounts.

Introduced into Congress March 16, 2017.

Civic Impulse. (2017). S. 448—115th Congress: Medicare Mental Health Access Act. Retrieved from www .govtrack.us/congress/bills/115/s448

A bill to amend Title XVIII of the Social Security Act to provide for treatment of clinical psychologists as physicians for purposes of furnishing clinical psychologist services under the Medicare program.

Introduced into Congress February 27, 2017.

Civic Impulse. (2017). S. 1370—115th Congress: Mental Health in Schools Act of 2017. Retrieved from www.govtrack.us /congress/bills/115/s1370

A bill to amend the Public Health Service Act to revise and extend projects relating to children and violence to provide access to schoolbased comprehensive mental health programs

Introduced into Congress June 15, 2017.

(continues)

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TABLE 6-2  2017 Congressional Bills Related to Mental Health and/or Behavioral Health (continued) Sciences Citation for Bill

Purpose of Bill

Status of Bill

Civic Impulse. (2017). H.R. 2677—115th Congress: Stop Mental Health Stigma in Our Communities Act. Retrieved from www.govtrack .us/congress/bills/115/hr2677

To amend the Public Health Service Act to provide for behavioral and mental health outreach and education strategies to reduce stigma associated with mental health among the Asian American, Native Hawaiian, and Pacific Islander population.

Introduced into the House of Representatives May 25, 2017.

Civic Impulse. (2017). S. 867—115th Congress: Law Enforcement Mental Health and Wellness Act of 2017. Retrieved from www.govtrack.us /congress/bills/115/s867

To provide support for law enforcement agency efforts to protect the mental health and well-being of law enforcement officers, and for other purposes.

Passed by the Senate; next passed by the House 5/26/17.

to the Affordable Care Act. Despite the salvage of the ACA, a recent survey of 11 countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States) reveals that adults in the U.S. still face significant barriers to affordable access to health care (Osborn, Squires, Doty, Sarnak, & Schneider, 2016). U.S. adults reported poorer health with at least two chronic conditions (28%), as well as reporting significant emotional distress (26%) (Osborn et al., 2016). U.S. adults were more likely to report “that they were ‘always’ or ‘usually’ worrying about having enough money to buy nutritious meals and to pay their rent or mortgage” (Osborn et al., 2016, p. 2). Primary care providers are reported as failing to discuss mental health problems such as depression and anxiety by 34% of adults surveyed. Low-income adults in the U.S. (43%) continue to report barriers to health care (Osborn et al., 2016, p. 6). The current state of our nation’s health insurance scheme is in flux. The Affordable Care Act has been, and is presently being, critiqued for a myriad of perceived

weaknesses including cost of premiums and burdens allegedly placed on employers. President Trump’s Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States (2017) seeks to restructure the healthcare insurance markets and options available both to individuals and employers. At the time of the submission of this chapter, the impact of this executive order is unknown. Along with the future of health care, rises and falls exist as well for the future of mental health care and behavioral health challenges.

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Summary

This chapter provided an overview of the policies that have shaped and continue to shape the provision of mental health and behavioral health care services in the United States. The chapter explored mental health and behavioral health resources available on national, state, and local levels throughout the United States. A discussion of policies that support expansion of mental health and behavioral

References

health services to include active participation of consumers was had. Policies aimed at promotion or limitation of mental health and behavioral health options for specific vulnerable groups were described. The chapter concluded with an overview of the future possibilities of care in the mental health and behavioral health arenas.

Discussion Questions 1. 2. 3.

4.

5.

Discuss the strengths and weaknesses of the mental health systems and services in place across the United States today.  Discuss the current state of the opioid crisis in America and evaluate the steps currently underway to deal with the crisis.  What steps could be taken to further empower those with mental illness and substance use disorders and their families to improve opportunities for successful integration into society at large?  Discuss current legislation, rules and regulations affecting the mental health and health care rights of the LGBT-Q community. What suggestions can be made for improvements to access and range of services?  What mental health and behavioral health services are currently offered for our veterans of the Armed Forces? Evaluate the strengths and weaknesses of these offerings. What suggestions could improve care rendered to veterans?

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discrimination and hate crime legal protection. American Journal of Public Health, 106(3), 534–540. Bockting, W. O., Miner, M. H., Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943–951. Braslow, J. T. (2013). The manufacture of recovery. Annual Review of Clinical Psychology, 9, 781–809. Center for Alternative Sentencing and Employment Services (CASES). (2017). Manhattan CIRT. Retrieved from https://www.cases.org/manhattan-cirt/ (accessed August 6, 2017). Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http:// www.samhsa.gov/data/ Children’s Health Act of 2000. Pub.L. No. 106–310, 114 Stat. 1101. City of New York (2014). Mayor’s task force on behavioral health and the criminal justice system: Action plan. New York, NY: City of New York. Retrieved from https:// www1.nyc.gov/assets/criminaljustice/downloads/pdfs /annual-report-complete.pdf  Clubhouse International, Inc. (2017). What do clubhouses do? Retrieved from http://clubhouse-intl.org/what-we-do /what-clubhouses-do/ Combating Autism Act of 2006. Pub. L. No. 109-416, 120 Stat. 2821 (2006). Community Counseling & Mediation. (n.d.). Who we are. Retrieved from https://www1.nyc.gov/site/doh/health /health-topics/child-and-adolescent-mental-health -emergency-crisis.page Community Mental Health Act of 1963 (CMHA), Pub. L. No. 88-164 (1963), 77 Stat. 282. Comprehensive Addiction and Recovery Act of 2016. Pub. L. No. 114-498, 130 Stat. 695 (2016). Retrieved from http:// www.cadca.org/comprehensive-addiction-and-recovery -act-cara Crisis Mental Health Services. (2018). Crisis services and mental health. Re­trieved from https://www1.nyc.gov /site/doh/health/health-topics/crisis-emergency -services.page Congressional Budget Office (2013, March). Federal grants to state and local governments. Retrieved from https://www .cbo.gov/sites/default/files/113th-congress-2013-2014 /reports/43967federalgrants.pdf Congressional Budget Office (2017, June 26). H.R. 1628, Better Reconciliation Act of 2017. Retrieved from https://www .cbo.gov/publication/52849 Congressional Budget Office (2017, July 19) H.R. 1628, Obamacare Repeal Reconciliation Act of 2017. Retrieved from https://www.cbo.gov/publication/52939

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Davis, J. H., & Cooper, H. (2017, July 26). Trump says transgender people will not be allowed in the military. The New York Times. Retrieved from https://www.nytimes .com/2017/07/26/us/politics/trump-transgender -military.html Don’t Ask, Don’t Tell Repeal Act of 2010. Pub. L. No. 111-321, 124 Stat. 1535 (2010). Drake, R. E., Frey, W., Karakus, M., Salkever, D., Bond, G. R., & Goldman, H. H. (2016). Policy implications of the Mental Health Treatment Study. Psychiatry Services. Retrieved from https://ps.psychiatryonline.org/doi/abs /10.1176/appi.ps.201500336 Flores, A. R., Herman, J. L., Gates, G. J., & Brown, T. N. T. (2016). How many adults consider themselves to be transgender In The United States? Los Angeles, CA: Williams Institute: UCLA School of Law. Retrieved from https://williamsinstitute.law.ucla.edu/wp-content /uploads/How-Many-Adults-Identify-as-Transgender -in-the-United-States.pdf Gloucester County School Board v. G.G. (2017) Oyez: Cornell Law School Legal Information Institute, Chicago-Kent College of Law, and Justia.com. Retrieved from https:// www.oyez.org/cases/2016/16-273 Horn, B. P., Barragan, G. N., Fore, C., & Bonham, C. A. (2016). A cost comparison of travel models and behavioural telemedicine for rural, Native American populations in New Mexico. Journal of Telemedicine and Telecare, 22(1), 47–55. Mental Health Study Act of 1955. 96 Stat. 381, Ch. 417, 42 U.S.C. 201 (1955). Mental Retardation Facilities and Community Mental Health Centers Construction Act. Pub. L. No. 88-164, 77 Stat.282 (1963). MindFreedom (n.d.). Who we are. Retrieved from http:// www.mindfreedom.org/who-we-are National Alliance on Mental Illness (NAMI) (2015). State mental health legislation, 2015: Trends, themes & effective practices. Retrieved from https://www.nami.org/About -NAMI/Publications-Reports/Public-Policy-Reports /State-Mental-Health-Legislation-2015 (accessed July 31, 2017). National Institute of Mental Health (NIMH) (2017). Important events in NIMH history. Retrieved from https:// www.nih.gov/about-nih/what-we-do/nih-almanac /national-institute-mental-health-nimh#chronology National Mental Health Act of 1946. Pub. L. No. 487. 60 Stat 421 (1946). New Freedom Commission on Mental Health (2003). Achieving the promise: Transforming mental health care in America: Final report. Publication SMA-30-3832. Rockville, MD: U.S. Department of Health and Human Services. Retrieved from http://govinfo.library.unt .edu/mentalhealthcommission/reports/FinalReport /downloads/FinalReport.pdf

Nguyen, Q. C., Rehkopf, D. H., Schmidt, N. M., & Osypuk, T. L. (2016). Heterogeneous effects of housing vouchers on the mental health of US adolescents. American Journal of Public Health, 106(4), 755–762. Obama, Barack (2012, August 31). Executive Order – Improving Access to Mental Health Services for Veterans, Service Members, and Military Families. Retrieved from https://obamawhitehouse.archives.gov/the-press -office/2012/08/31/executive-order-improving-access -mental-health-services-veterans-service Obergerfell, et al. v. Hodges, Director, Ohio Department of Health, et al. 576 US___ (2015). Osborn, R., Squires, D., Doty, M. M., Sarnak, D. O., & Schneider, E. C. (2016, December). In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Affairs, 35. https://doi: 10.1377/hlthaff.2016.1088 Parks, J., & Radke, A. Q. (2014). The vital role of state psychiatric hospitals. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. Retrieved from https://www .nasmhpd.org/sites/default/files/The%20Vital%20Role% 20of%20State%20Psychiatric%20HospitalsTechnical% 20Report_July_2014.pdf Patient Protection and Affordable Care Act. Pub. L. No. 111-148, 124 Stat. 119 through 124 Stat. 1025 (2010). Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Pub. L. No. 110-343, 122 Stat.3765 (2008). Pratt, S. I., Jerome, G. J., Schneider, K. L., Craft, L. L., Buman, M. P., & Stoutenberg, M... Goodrich, D. E. (2016). Increasing US health plan coverage for exercise programming in community mental health settings for people with serious mental illness: A position statement from the Society of Behavior Medicine and the American College of Sports Medicine. Translational Behavioral Medicine, 6(3), 478–481. Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States (2017, October 12). Retrieved from https://www.whitehouse. gov/the-press-office/2017/10/12/presidential-executiveorder-promoting-healthcare-choice-and-competition Presidential Memorandum for the Secretary of Defense and the Secretary of Homeland Security (2017, August 30). 84 FR 41319, pages 41319–41320, Document number 2017-18544. President’s Commission on Mental Health (1977, February 17). Executive Order 11973. Retrieved from http://www .presidency.ucsb.edu/ws/?pid=6643 Rainbow Heights Club (2017). Our mission, our vision. Retrieved from http://www.rainbowheights.org/mission _vision.php Rieckmann, T., Moore, L. A., Croy, C. D., Novins, D. K., & Aarons, G. (2016). A national study of American Indian

References and Alaska Native substance abuse treatment: Provider and program characteristics. Journal of Substance Abuse Treatment, 68, 46–56. Rivera, G. (2017). Willowbrook: The last great disgrace, 1972. Retrieved from http://geraldo.com/page/willowbrook Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., & Monahan, J ., Bliese, P. D. (2017). Sexual assault victimization and mental health treatment, suicide attempts, and career outcomes among women in the US Army. American Journal of Public Health, 107(5), 732–739. Substance Abuse and Mental Health Services Administration. (2014a). Leading change 2.0: Advancing the behavioral health of the nation 2015–2018. HHS Publication No. (PEP) 14-LEADCHANGE2. Rockville, MD: Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration. (2014b). National behavioral health quality framework— overview. Retrieved from https://www.samhsa.gov /data/national-behavioral-health-quality-framework #overview Substance Abuse and Mental Health Services Administration. (2016). Strategic initiatives. Retrieved from https://www .samhsa.gov/about-us/strategic-initiatives (accessed July 31, 2017). Substance Abuse and Mental Health Services Administration. (2017). Behavioral health barometer: United States; Volume 4: Indicators as measured through the 2015 National Survey on Drug Use and Health And National Survey of Substance Abuse Treatment Services. HHS Publication

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No. SMA-17-BaroUS-16. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://store.samhsa.gov/shin/content /SMA17-BAROUS-16/SMA17-BAROUS-16.pdf To provide for the retention and service of transgender members of the Armed Forces. H.R. 4041, 115th Congress (2017–2018). Tsai, J., & Rosenheck, R. A. (2016). US veterans’ use of VA mental health services and disability compensation increased from 2001 to 2010. Health Affairs, 35(6), 966–973. U.S. Department of Health and Human Services. (2017). What is mental health. Retrieved from https://www.mental health.gov/basics/what-is-mental-health/index.html U.S. Department of Justice and U.S. Department of Education (2016, May 13). Dear colleague letter on transgender students. Retrieved from https://www2.ed.gov/about/offices/list /ocr/letters/colleague-201605-title-ix-transgender.pdf U.S. Department of Justice and U.S. Department of Education (2017, February 22). Dear colleague letter. Retrieved from http://www.ctschoollaw.com/files/2017/02/guidance _letter_0_pdf Williams Institute (2017, January 17). New estimates show that 150,000 youth ages 13 to 17 identify at transgender in the US. Los Angeles, CA: Williams Institute: UCLA School of Law. World Health Organization (2014). Mental health: A state of well being. Retrieved from http://www.who.int/features /factfiles/mental_health/en/ (accessed July 29, 2017).

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CASE STUDY Reality Check: How an Education Justice Project Became More Yael Rosenstock Associate Director Center for Ethnic, Racial, and Religious Understanding – Queens College, City University of New York

Background With discussions of the opportunity gap versus the achievement gap and a rallying cry for education justice, the staff at the Center for Ethnic, Racial, and Religious Understanding (CERRU) at Queens College wanted to act. Opportunity gap research goes beyond achievement gap research by not only observing differences, but trying to understand the underlying factors that lead to a student’s success in school, or lack thereof. Factors include socioeconomic status, structural racism, inequitable funding, etc.—issues important to the Center’s mission (Flores, 2007). The CERRU team decided I would reach out to a local urban high school student population in the Northeast to develop a participatory action research (PAR) project to work with teens towards change beginning January 2016. PAR is an epistemology that challenges the general understanding of what it means to be a researcher and how to define the term “expert” (Datta et al., 2015; Langlois, Goudreau, & Lablonde, 2014). PAR acknowledges the importance of knowing a community’s needs in order to develop interventions and programs to address those needs (Kombluh, Ozer, Allen, & Kirshner, 2015). PAR is research for and by the community. The research project was as much a pilot for the facilitator as it was for the student researchers, and all involved discovered that the experience went beyond expectations. The students chose to focus on addressing communication issues between students and their teachers and the perceived social support students receive at their school. However, I, as the facilitator, quickly recognized that self-perception, confidence, and self-esteem were essential precursors for working towards any other goals. This case study reflects on the use of non-standard education techniques used outside

of school settings with students who do not feel prioritized or valued at school. It also reflects on the ways in which mental illness, self-esteem, and feeling respected interact with a student’s ability to engage. Throughout the school year, I combined skills-based learning objectives (survey development, focus group analysis, facilitation skills, etc.) with confidence and team building activities inspired from my understanding of positive youth development constructs to influence individual and group morale in regards to self-worth and interest in extracurricular activities (Shek, Sun, & Merrick, 2012). The group had several iterations before arriving at the final six students for the project. One goal of the project was to work with students with lived experiences of being failed by the current system—for example, those at risk of dropping out or failing—to inform our collaborative work. However, the recommendations received from a consulted guidance counselor and teacher did not meet that description. In fact, most candidates were athletes and therefore had a sense of belonging at school. Their sports practice commitments led them to drop the program except for one student, Marissa.* Marissa had to leave eventually but brought in two more friends who brought in others and we formed our current group with students who rarely engage in team sports and do not belong to any other student groups. It was clear that in this group, many of the students struggle with academics and all of them struggle with symptoms of depression, anxiety, and/or bipolar disorder. These are students who are not expected to succeed. Rebecca* reported that a teacher expressed surprise at learning that she was involved in facilitating a focus group and in having electively joined a research team. Despite the disbelief of teachers and other adults, this group of students consistently attends weekly meetings to engage in collaborative work and does so throughout the summer months as well as other vacations. Their dedication can be attributed to (1) the respectful and positive space we have created together, (2) a desire to be actively engaged in an activity, and (3) the sense of community and social support that mediates negative mental health outcomes. With the positive youth development constructs of promoting bonding, social, and emotional competence in mind, each week

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effects, observations of the group’s development and explicit discussions with the students lends evidence to these claims. Though I have heard the words, “I am worthless” and other phrases of that sort multiple times within our space, and I have seen the students feel dejected, lost, and unmotivated, I have witnessed incredible changes. Before we began the meeting groups, most of the students were not considering college as an option; now they’re considering future pathways towards a successful career, which may or may not include traditional college. While self-doubt is still rampant and depression remains a reality, the students report positive mental health outcomes when we discuss the role PAR has played for them. Students with presentation fears and social anxiety have presented at public events, volunteered at public events, and invited community members into our space. The students feel respected, important, and valued by me and by one another. Despite the moans and groans heard during the “I am a badass” exercise, the students almost unanimously voted to keep the activity because it reminds them that they are worth celebrating. When an individual is struggling with an activity, the others are happy to remind each other what makes each of them special and what positive actions they have each completed. They now recognize their teachers as independent beings who have their own stories, histories, experiences, and therefore unique points of views, even if they appear flawed from a student perspective. Despite the reputation of some as students uninterested in education and in their own future, they were excited and eager to choose a new topic and begin a second year of research. Their new focus is mental health and understanding the needs of their community, building awareness, addressing stigma, and developing pride and love of oneself as a person who is diagnosed with a mental illness. Our work together demonstrates the importance of addressing mental health needs within educational and noneducational programs in order for students to access their own potential. The work points to the motivating drive students feel when they are respected and asked to engage in high-level work relevant to their lives as a way to develop both cognitive skills and resiliency. The importance of building a shared space where students feel supported and safe to address problems that arise at home is necessary, as it is

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began with the exercise, “I am a badass because. ...” (Shek, Sun, & Merrick, 2012). The activity requires that each student celebrate him- or herself for something positive he or she has done, which was regularly met with audible groans as the students had trouble seeing themselves positively. The team is mostly Latinx and female, both of which are risk factors for low self-esteem, low school performance, weight, involvement in team sports, as well as parenting styles that varied among the group (McClure, Tanski, Kingsbury, Gerrard, & Sargent, 2010). When unable to come up with their own, students would volunteer badass statements for each other; this provided an opportunity to bond while still develop social and emotional competence. Other exercises have equally horrified them in the moments they were presented; however, they speak very positively of these experiences despite the initial stress they caused because of the perceived benefits. These perceived benefits include relationships with one another as well as moments of pride and self-appreciation. The year weaved traditional research methods with exercises practiced for personal and group development. The traditional learning goals addressed the positive youth development constructs of promotion of cognitive competence, development of self-efficacy, and cultivation of self-determination (Shek, Sun, & Merrick, 2012). Students engaged with work in our space and sometimes on their own to work towards our shared research goals. They were challenged to be creative within the context of research and programming. Towards the end of the project I offered the opportunity to each individual to create their own presentation and lead a conversation on any topic of their choosing. Though this was completely voluntary, each student chose a week and took the opportunity to collect information on his or her own and present to his or her peers. This is significant for the participants because of their reputation as unmotivated, as well as the general fear the group shared of presenting. Topics included gender identity, bipolar disorder, gentrification, and many more. The combination of methods and goals worked towards promotion of moral competence, cultivation of resilience, beliefs in the future, development of clear and positive identity, opportunity for prosocial involvement, and recognition for positive behavior (Shek, Sun, & Merrick, 2012). Though not quantifiable in its

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difficult for adults to access information about the personal lives of students that can highly affect their school performance and mental health. Over the year, three of the six students appeared in my office during a time of need or crises because they wanted adult support and felt it was the only place to go at the time. It was an important development for them to seek assistance from an adult figure. A recommendation for educators and health practitioners is to create more programs that develop spaces where students are challenged, respected, heard, and supported as a way to encourage academic success, as well as positive mental health development. PAR projects are particularly apt for this endeavor because it prioritizes those with lived experiences as experts in the development of research projects and interventions, thereby creating opportunities for leadership and confidence development. The challenges for practitioners and program developers are time, funding, and space. Our group continues to meet weekly with the support of the CERRU team to have some of my hours dedicated to this project. As part of a college, we have access to free space and have otherwise maintained very low costs. However, without existing staff dedicating hours and readily available space, this could be significantly more costly. Training is required to develop PAR projects and facilitate teen groups with an inclusive atmosphere. Lastly, this project is difficult to facilitate with large groups. Attention should be focused on (1) students struggling with mental health needs where there are lacking resources and (2) students with difficulty navigating the current school system to maximize effects. * Student names have been changed for purposes of this case study.

Case Study Questions 1. Why were athletes recommended for the group when persons at the high school were asked to recommend students at risk of failing or struggling with the school system? 2. How could the teacher’s statement of surprise towards Rebecca influence her self-perception? 3. Consider ways to engage routinely marginalized youth populations that are neglected by formal structures and lack

4.

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access to adequate resources. How would you approach, invite, and sustain a group? What about the epistemology of PAR (research by the community for the community) lends itself to addressing the positive youth development constructs? How can PAR be used to counter the negative messages young people receive? How can it be used to encourage interest and motivation towards future goals that may or may not be consistent with higher education? What would be the most challenging aspects of facilitating a group of youth researchers? Keep in mind that PAR groups should be nonhierarchical and that everyone is valued for the unique expertise they provide to the group. What kind of background and training would be useful for facilitating a group of youth researchers, particularly one that matches the demographics depicted in this case study?

References Datta, R., Khyang, U., Prue Khyang, H. K., Prue Kheyang, H. A., Ching Khyang, M., & Chapola, J. (2014). Participatory action research and researcher’s responsibilities: An experience with an indigenous community. International Journal of Social Research Methodology, 18(6), 581–599. doi: 10.1080/13645579.2014.927492 Flores, A. (2007). Examining disparities in mathematics education: Achievement gap or opportunity gap? High School Journal, 91(1), 29–42. Kombluh, M., Ozer, E., Allen, C., & Kirshner, B. (2015). Youth participatory action research as an approach to sociopolitical development and the new academic standards: Considerations for educators. Urban Review, 47(5), 868–892. doi:10.1007/s11256-015-0337-6 Langlois, S., Goudreau, J., & Lalonde, L. (2014). Scientific rigour and innovations in participatory action research investigating workplace learning in continuing interprofessional education. Journal of Interprofessional Care, 28(3), 226–231. doi:10.3109/13561820.2014.885003 McClure, A., Tanski, S., Kingsbury, J., Gerrard, M., & Sargent, J. (2010). Characteristics associated with Low self-esteem among US adolescents. Academic Pediatrics, 10(4), 238–244. Shek, D. T., Sun, R. C., & Merrick, J. (2012). Positive youth development constructs: Conceptual review and application. Scientific World Journal, 2012(2012), 152923. doi:10.1100/2012/152923

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CASE STUDY

Janice Selekman Professor, University of Delaware – Newark

What Is the Impact of State and National Policies on Transgender Youth? There are no national statistics on the prevalence of transgender youth, yet the issue has become so significant in the schools that the U.S. Department of Education (DOE, 2016) issued a monograph on transgender students that provided civil rights protections to these youth. These included allowing transgender students to participate in activities and to use the bathroom and locker rooms that matched their gender identity rather than their birth gender. Eleven states filed lawsuits and President Trump withdrew and rescinded the guidelines in March 2017, saying that the states can decide but that it was not the job of the federal government. Laws are meant to protect the public, yet who is protecting the welfare of young people who are part of the sexual minority? It appears that the lack of protection is based on a misunderstanding of terms used to describe youth who are transgender, the impact of religious voices, the politically conservative leaning of some legislators and district administrators, and unfounded fears. Yet who is considering the best interests of the child?

Background The first national estimate of students in grades 9 to 12 who are gay, lesbian, and bisexual (LGB) revealed that 88.5% of youth identify as heterosexual, 2% as gay or lesbian, 6% as bisexual, and 3.2% are not sure of their sexual identity (Centers for Disease Control and Prevention, 2016). This means that there are approximately two students in every classroom in the country who are LGB. This study did not

ask about transgender youth. The prevalence is thought to be 0.25% to 1% of the U.S. population (Blad, 2017). Many in society have difficulty differentiating the terms related to sex and sexuality. Biological sex is the sex assigned at birth; it is on a continuum from male to intersex to female (The Trevor Project, n.d.). Gender identity is part of one’s self-concept. It is how one feels inside and only the person can describe it; it is not a choice. It describes whether the person feels like a male or female, regardless of their biological sex. Sexual orientation is defined as the object of one’s sexual attraction: whether one is attracted to someone of their same biological sex, the opposite sex, or both. These are two very different groups; the laws are written only for those with a gender identity different from their assigned birth gender, yet the rationales for these laws often focus on sexual orientation. Title IX of the Education Amendments of 1972 prohibits discrimination based on sex in any educational program or activity receiving federal financial assistance. The issue in the courts is whether this can be interpreted as applying to gender identity. Does the law protect against discrimination and harassment on the bases of failure to conform to gender stereotypes?

Case Analysis Consider a 16-year-old transgender female named Jesse. She was born a male but became aware that her gender identity was that of a female when she was 6. Since the age of 8 she has assumed a female identity and lives as a female; she started on hormone therapy at age 13 but has not yet had surgical intervention. What are the issues she faces on a daily basis in the school setting? 1. What are the fears the public has regarding transgender children? The voiced fears are (a) that my child will see a penis in the bathroom and (b) that a predator will molest my child. a. There are NO reports of either of these events happening involving the hundreds of transgender children in schools and public buildings (i.e., female bathrooms have stalls and therefore no one sees another while he or she is on the toilet).

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Examining the Policy Issues for Transgender Teens: Bathrooms, Bullying, and Mental Health

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b. There is the fear of sexual predators masquerading as transgender women, yet there is no similar concern voiced regarding fear of homosexual activity (i.e., there are multiple reports of homosexual activity and sexual abuse in male-only facilities, including religious settings, yet these facilities have never been the focus of laws; there are no reports of the transgender individual as the predator, although he or she is often the victim). c. Many institutions have gone to single occupant, either-gender bathrooms (i.e., the bathroom in the office of the school nurse or teacher’s lounge is often used by transgender students for toileting and locker room needs; this separates students from their peers, but it does provide safety and privacy; and the Rehabilitation Act speaks of reasonable accommodations for students with chronic conditions). 2. So what are reasonable accommodations for transgender students and do they qualify under this law as having a disability? The 2016 DOE document stated that denying transgender students the right to use the bathroom of their choice violated federal prohibitions against sex discrimination. a. Opponents say the accommodations violate student privacy and traditional values. (Note: In addition to activities where students visit other schools, “bathroom and locker room laws” restricting bathrooms to one’s assigned birth gender would also affect convention-goers and stadium restroom policies.) b. How would those policing these laws know if someone was transgender or not, especially since some states allow the birth certificate to be changed (although usually not until gender reassignment surgery has occurred)? 3. What are the laws protecting transgender students from violence or bullying? a. There is concern that forcing students to use a bathroom that does not coincide with their gender identity will put them in physical danger (from bullying and harassment) as well as negatively affect

their psychological well-being. Note the following:  71% of transgender youth hear peers make negative remarks about their gender expression; 57% hear teachers make negative remarks.  82% are verbally harassed because of their gender expression.  38% of transgender youth report physical attacks based on their gender expression (American Psychological Association, 2015).  More than one anti-transgender murder is reported every month in the U.S. (Human Rights Campaign, 2017). b. Schools have the responsibility to protect all students from bullying and harassment and provide a safe environment in which to learn, including for transgender students. c. The federal government plays a role in ensuring that all children are able to attend school free of discrimination. 4. How do laws and beliefs that fail to protect and support transgender students affect their mental health? a. Removing protections may result in children being afraid to go to school. b. Those who do not believe sexual identity is a healthy choice question the mental health of the transgender individual; the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes the diagnosis of gender dysphoria. This means that the outcome for the teen is a function of who is defining the issue. c. While most conservative/orthodox religious groups teach that homosexuality is wrong and are unaccepting of those who participate in that activity, almost all religions advocate love and compassion for others. Nonsupport and nonacceptance can result in poor self-esteem and feelings of lack of support and safety and exclusion from the home, community, and religious institution. d. Gender nonconforming youth are more at risk for self-harm, suicide attempts,

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Conclusion Policies that affect children who are transgender must consider their safety, their psychological well-being, and their educational success. These children need to have their civil rights upheld. Adults must act as protective agents committed to the safety and well-being of all youth. The American Nurses Association (ANA) promotes the inherent dignity, worth, unique attributes, and human rights of all individuals. The ANA Code of Ethics promotes the role of nurses as advocates for social justice and human rights, especially for those whose rights are more easily violated (Morgan & Stokes, 2017).

Case Study Questions 1. How can nurses play a role in educating others about the differences in gender identity and sexual orientation as they relate to the health needs of the teen or youth? 2. What areas of primary prevention might be paramount in working with Jesse in her school situations? 3. What organizations might be appropriate to contact or learn more about the lesbian, gay, bisexual, transgender, or queer (LGBT-Q) community? 4. What role does nursing play in advocating on behalf of the public to protect teens and youth

who are nonconforming in general or facing problems with their own gender identity? 5. If Jesse is hospitalized and no private rooms exist, what goes into determining Jesse’s room assignment? 6. According to the definition of disability as per the Americans with Disabilities Act, is being transgender a disability? Is it a mental health disorder?

References American Psychological Association. (2015). Supporting transgender and gender diverse students in schools: Key recommendations for school administrators. Washington, DC: APA. Blad, E. (2017, March 7). How many transgender children are there? Education Week, 36(24), 6. Retrieved from http://www.edweek.org/ew/articles/2017/03/08how -many-transgender-children-are-there.html Centers for Disease Control and Prevention. (2016). Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9–12 – United States and Selected Sites, 2015. Morbidity and Mortality Weekly Report, 65(9), 1–202. Human Rights Campaign. (2017). Violence against the transgender community in 2017. Retrieved from http://www.hrc.org/resources/violence-against-thetransgender-community-in-2017 (accessed August 25, 2017). Morgan, S., & Stokes, L. (2017). Overcoming marginalization in the transgender community. American Nurse Today, 12(5), 34–35. Olson, K., Durwood, L., DeMeules, M., & McLaughlin, K. (2015). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3), e20153223. The Trevor Project website. (n.d.). Retrieved from http://www .thetrevorproject.org U.S. Department of Education, Office of Elementary and Secondary Education, Office of Safe and Health Students. (2016). Examples of policies and emerging practices for supporting transgender students. Washington, DC: U.S. Department of Education.

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mood disorders, suicidality, substance use, and low school performance. They face discrimination and exclusion. Laws do matter and play a role in affecting these teens’ lives. e. Children who have socially transitioned to their gender identity and who feel supported by their family and community showed no increase in depression compared to the general population (Olson, Durwood, DeMeules, & McLaughlin, 2015).

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CASE STUDY Workplace Violence: Safety of Patients and Staff in Acute Care Psychiatry Lois B. Moylan

Problem Violence in the workplace has become a widespread problem in the general population. The National Institute for Occupational Safety and Health (NIOSH) identifies four types of workplace violence: criminal intent, customer/client violence, worker on worker violence, and personal relationship violence (Centers for Disease Control, 2016) (see TABLE 6-3). The healthcare workplace, due to the high levels of stress, experiences frequent incidents of workplace violence. Of all the specialty areas in health care, acute care psychiatry has the highest number of aggressive incidents by patients on staff (Type II classification), which result in assault and injury (Stevenson, Jack, O’Mara,

& LeGris, 2015). The high frequency of violence in psychiatry shows this to be a serious public health concern. It is the healthcare provider’s responsibility to support the right of patients to be treated with respect and dignity and allow the patient autonomy as guaranteed by case law and required by professional ethics. Yet it is also the provider’s responsibility to provide safety to other patients, staff, and self. This is also a legal mandate. Balancing these responsibilities can present unique challenges. Approaches to this problem must consider the needs of both patients and staff. Policies should ensure that all human and civil rights of the patient are protected and, at the same time, that the safety of patients, staff, and others is maintained.

Stakeholders Over the last 50 years, great advances have been made in the field of psychiatry, which have resulted in far more humane treatment of patients. Increased understanding of psychodynamics and development of increasingly sophisticated pharmacotherapy have resulted in treatment and therapeutic interventions that can be effective in improving the emotional, social, cognitive,

TABLE 6-3  CDC Classifications of Workplace Violence Type I: Criminal intent

In this kind of violent incident, the perpetrator has no legitimate relationship to the business or its employee(s). Rather, the violence is incidental to another crime, such as robbery, shoplifting, or trespassing. Acts of terrorism also fall into this category.

Type II: Customer/client

When the violent person has a legitimate relationship with the business—for example, the person is a customer, client, patient, student, or inmate—and becomes violent while being served by the business, violence falls into this category.

Type III: Worker on worker

The perpetrator of Type III violence is an employee or past employee of the business who attacks or threatens other employee(s) or past employee(s) in the workplace.

Type IV: Personal relationship

The perpetrator usually does not have a relationship with the business but has a personal relationship with the intended victim.

Data from Centers for Disease Control and Prevention. (2013). The National Institute for Occupational Safety and Health (NIOSH): Workplace violence prevention for nurses. Retrieved from https://wwwn.cdc.gov/wpvhc/Course.aspx/Slide/Unit1_5

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Public Policy Organizations such as the National Alliance on Mental Illness (NAMI) have worked to shape a national public policy for people with mental illness that recognizes and ensures that patients’ rights are maintained and that patients be treated with dignity and respect. Throughout its existence, the profession of nursing has also actively engaged in policy creation that promulgated the need to protect the rights of psychiatric patients. The American Nurses Association (ANA) has a long history of recognizing the rights of patients. In the ANA Code of Ethics, the 1968 revision included recognition of specific human rights such as the right of all patients to be treated with dignity and their right to privacy. The current revision of the ANA Code of Ethics (2015a) specifically enumerates responsibilities of nurses in providing autonomy (respect for self-determination), beneficence (moral requirement to promote good), non-malfeasance (do no harm), stewardship (preserve your own being), and justice (fair and equitable

determination distribution of resources and fair treatment for individuals and society). There is no question or disagreement within nursing or among nurses that those with mental illness are deserving of ethical treatment. However, how this is carried out has, at times, become controversial, especially in regard to the use of restraints in the psychiatric setting.

Terms and Position Statements The term “restraint,” when used in relation to management of a psychiatric patient, may refer to several types of restrictive measures taken to control aggressive behavior. The most common types of restraint are: (a) mechanical restraint, which is the use of a device to restrict movement; (b) manual restraint, which is the therapeutic holding of a patient by staff; and (c) chemical restraint, which is the use of pharmacological agents to immobilize the patient. There are serious reasons for the controversy surrounding restraint use. In addition to depriving patients of the rights discussed above, accounts of patient death and injury during the retraining process are well documented (Berzlanovich, Schöpfer, & Keil, 2012; Rakhmatullina, Taub, & Jacob 2013). Nurses have also been reported to suffer injury during a restraining intervention. A study by Moyo and Robinson (2012) showed that while 14 female nurses out of a sample of 32 nurses who restrained patients were injured during restraint, a slight majority of these injuries resulted from assault by the patient rather than by the mechanics of the restraint. Serious injuries are often experienced by nurses from patients who are aggressive and not restrained (Moylan & Cullinan, 2011). In 2000, the ANA published a formal position paper titled, “Reduction of Restraint and Seclusion in Health Care Settings,” which was revised in 2012. That paper discusses the need to use physically restrictive measures only as a last resort when no other intervention would provide safety. Specifically addressing the psychiatric setting, the American Psychiatric Nurses Association (APNA) published “APNA Position on the Use of Seclusion and Restraint” in 2000; a revised version was produced in 2014, which calls for the ultimate elimination of restraints. These papers addressed many areas of concern surrounding the use of seclusion and restraint in relation to the issue of patients’ rights. Both documents mandate that use

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and behavioral function of patients. Along with the scientific advances of this period, society has become more concerned with the rights of psychiatric patients. In the United States, multiple court cases during the last 50 years have established the right of psychiatric patients to refuse treatment and medication and to require informed consent for treatment (Simon & Shuman, 2007). Among the rights of psychiatric patients found in the aforementioned legal cases were the right to autonomy, safety, and humane treatment. However, court cases also found the right to autonomy and freedom may be suspended if the patients become an imminent danger to themselves or other (Simon & Shuman, 2007). Nurses have the duty to provide safety when working in the psychiatric setting. Balancing the rights of the patient with the duty of maintaining safety can, at times, seem to conflict when seriously aggressive behavior erupts suddenly. Nurses can be charged with negligence if they fail to control the patient and injury occurs, and they can be charged with battery if a patient believes that restraint was unjustly used (Simon & Shuman, 2007). The discussion below attempts to address the issues involved in providing quality therapeutic care for the patient while also protecting the safety of the care givers and others in acute care psychiatry.

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of restrictive measures can only be justified when no other less restrictive means can prevent harm to self or others. Therefore, all other supportive therapeutic approaches should be tried prior to secluding or restraining a patient. The papers discuss the need for proper training of staff in the manner of secluding or restraining a patient, and the monitoring and care of the patient to maintain safety. Additionally, when a patient requires restrictive measures, care should also be taken to support the patient’s dignity, privacy, and, if possible, some degree of autonomy. Therefore, attention should be paid to the psychosocial and emotional needs of the patient during such a stressful time (Moylan, 2009a). Additionally, New York State has very recently updated the guidelines for use of restraint and seclusion (New York Office of Mental Health, 2017).

Conflicting Viewpoints The advance toward more humane treatment and recognition of human rights of psychiatric patients has resulted in a movement toward “zero restraint” over the past two decades. The nonprofit advocacy group Mental Health America states, “as a matter of fundamental policy, Mental Health America (MHA) urges abolition of the use of seclusion and restraints.” The movement toward “zero restraint” is not only occurring in the United States, but has been recognized by law and policy in many industrialized countries. A report produced by the United Nations (UN) in 2013, “Torture in Healthcare Settings,” called for “an absolute ban on all forced and nonconsensual medical interventions against persons with disabilities. Included are the nonconsensual administration of psychosurgery, electroshock and mind-altering drugs such as neuroleptics, the use of restraint and solitary confinement, for both long- and short-term application” (cited in Levin, 2014, p.1). It also spoke against any involuntary hospitalization of the mentally ill. This document caused an outpouring of responses from international professional groups that believed the policy was unwise and dangerous. The report’s author, United Nations Human Rights Council Special Rapporteur Juan Mendez, J.D., responding in a letter to the leaders of the American Psychiatric Association and the World Psychiatric Association (WPA) reversed himself, stating “I did not mean to propose an absolute ban on nonconsensual interventions (including

institutionalization and restraints) under any and all circumstances” (Levin, 2014). This presents a situation where confusion and ambiguity are fostered. The written official document of the UN states information that is incongruent with statements Mendez made in a subsequent letter. This is an example of the conflicting information about restraint use being communicated to nurses in the literature, by professional organizations, and by the institution in which they are employed. Unfortunately, as restraint use has decreased since the movement toward restraint reduction/ elimination began, some authors report that assault and injury of mental healthcare workers has increased (Liberman, 2006; Paterson & Duxbury, 2007). In a study done by Moylan and Cullinan (2011) in a sample of 110 nurses from 5 institutions, 80% of the nurses were assaulted, 65% had been injured, and 26% had been seriously injured. Injuries included fractures, eye injuries, orthopedic injuries, and permanent disabilities. Psychosocial and emotional responses to the assaults included flashbacks; nightmares; feelings of guilt and shame; feeling blamed by managers and/or colleagues; generalized feelings of fear, anxiety, anger, and hyper-vigilance; and fear when subsequently exposed to aggressive situations. The findings of this study were congruent with those of multiple other studies related to patient assault of nurses in acute care psychiatry. The topic of dealing with patient aggression in the psychiatric area is surrounded by controversy. Some nurses report feeling pressured by administration or the organizational culture to avoid the use of restraints in all circumstances, and some of these nurses also feel pressured to not report assault if it does occur (Moylan, McManus, Cullinan, & Persico, 2016). This is a serious consideration in developing policies in relation to management of the aggressive patient. The literature reports that every restraint episode is a treatment failure (Jacob et al., 2016). This is a view commonly expressed at conferences sponsored by psychiatric groups of interest and professional organizations. However, it seems that situations exist where this might not always be the case. For example, when a patient who is exhibiting acute steroid-induced psychosis is newly admitted to a unit, behavior is often totally out of control. The patient may be extremely violent as well as have above normal strength related to the drug.

Case Study

Prevention Policies in Psychiatric Settings The American Nurses Association (ANA, 2015b), New York State Nurses Association (NYSNA, 2011), and the American Psychiatric Nurses Association (APNA, 2014) have official policy statements related to workplace violence. The Centers for Disease Control and Prevention (CDC, 2016) offers an online course in preventing workplace violence specifically for nurses. The position statements of the professional organizations and the CDC all recognize the responsibilities of individual nurses and of the organization or employer in preventing

violence. APNA also identifies the need for advocacy by professional nursing organizations. In developing policies related to decreasing violence in the acute psychiatric setting, the needs of patients and staff must be considered. General responsibilities of the individual nurse include advocating for a culture of safety; participation in creating, supporting, and attending violence prevention programs intervention if violence occurs; and reporting of violent incidents. Responsibilities specific to the psychiatric area also include knowledge of therapeutic interaction, expertise in de-escalation techniques, use of the least intrusive approaches necessary to provide safety, and knowledge of applicable law. Responsibilities of the employer or healthcare organization are many and complex. Creation of a safe environment is a requirement that, specifically in psychiatry, entails attention to furnishings, eating utensils, cords on drapes, etc., which all may be used as weaponry. Currently, some hospitals are providing sophisticated personal alarm systems that monitor the location of all staff and provide the staff the ability to call for help in a high-risk or violent situation. In acute care psychiatry, the requirement for comprehensive workplace violence prevention programs includes specific content related to behavior control of the aggressive patient including safe procedures for secluding and restraining in situations of imminent danger (see TABLE 6-4 for description of a comprehensive program developed for the State of Connecticut Department of Mental Health and Addiction Services [DMHAS]). All staff interacting with patients should be trained in therapeutic communication skills, identification of signs of escalating aggression, supportive de-escalation techniques, environmental assessment, and self-protective behaviors congruent with legal and ethical standards (Moylan, 2012). Education and training should be based on evidence. Attendance at these programs must be ongoing and staff needs to be evaluated in their mastery of the content. There must also be a formal process for mandatory reporting of violent incidents and the policy needs to include a process of follow-up support for both the secluded/restrained patient and the victim of the assault. Reporting needs to ensure freedom from retaliation for reporting.

CASE STUDIES

A patient in this condition is unable to respond to any supportive therapeutic approach. Treatment of this patient cannot even commence until safety precautions are taken and, in this case, mechanical restraint is the only option. Another negative result of considering every restraint episode a treatment failure is that blame for making this clinical decision is often ascribed to the nurse. Although the cause may be medication insufficiency, or change in the patient’s cognitive function such as increasing paranoia or command hallucinations, the nurse’s clinical judgment in calling for restraint is often questioned. Yet, if an assault event occurs, the nurse is often blamed (Lanza, Zeiss, & Rierdan, 2006; Moylan, 2009b; Moylan & Cullinan 2011) and can be held legally responsible (Simon & Shuman, 2007). Assault and injury in the psychiatric setting is a critical situation affecting staff and other patients. This occurrence of Type 2 workplace violence is prevalent in the United States and worldwide and is a major public health concern. The issue of violence directed at healthcare workers is a universal problem. Studies have been done in Japan (Inoue, Tsukano, Muraoka, Kaneko, & Okamura, 2006), South Africa (Bimenyimana, Poggenpoel, Myburgh, & van Niekerk, 2009), Australia (Ward, 2013), New Zealand (Baby, Glue, & Carlyle, 2014), Israel (Yarovitsky & Tabak, 2009), the United Kingdom, and throughout Europe (Duxbury, Hahn, Needham, & Pulsford, 2008; Bak, Zoffmann, Sestoft, Almvik, & Brandt-Christensen, 2014) that identify the alarming rate of violence against healthcare workers. Chief among these workers are nurses, who are the most frequently assaulted (Lanza, Zeiss, & Rierdan, 2006; Moylan & Cullinan, 2011).

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TABLE 6-4  The Collaborative Safety Strategies Annual Inpatient Review Training Program

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Objectives 1. Create and maintain safe and therapeutic environments of care that are grounded in understanding the underlying causes of anger and related dangerous and violent behavior. 2. Use risk management strategies to prevent dangerous behavior from escalating to violence. 3. Use verbal and nonverbal communication with co-workers and patients in nonemergency and emergency situations to reduce the risks to staff, patients, and others that are associated with dangerous and violent behavior. 4. Use a variety of safety strategies in escalating and crisis situations to reduce the risk of physically, medically, and emotionally traumatizing effects resulting from dangerous and violent behavior and the use of restraint and seclusion. 5. Correctly use all of the physical techniques in emergency situations and, should they fail to be executed correctly, take immediate corrective action to reduce the rate and severity of injuries to staff, patients, and others. 6. Use mechanical restraints and seclusion per Department of Mental Health and Addiction Services (DMHAS) Restraint and Seclusion Policy and manufacturer’s instructions to prevent use-related physical injury or death.

Modules Module One: Introduction and Overview

The objectives and completion requirements are reviewed. A contextual framework is provided that addresses workplace violence and national injury rates for staff as well as DMHAS data regarding the use of restraints and seclusion.

Module Two: Creating Safe and Therapeutic Environments

Staff learns how to create and maintain safe and therapeutic environments of care that are grounded in understanding the underlying causes of anger and related dangerous and violent behavior. Two integrated models for understanding violence—the Cycle of Dangerous Behavior and Phases of a Crisis—are reviewed.

Module Three: Physical Techniques (Protective Skills)

Physical skills to protect against being grabbed (e.g., hair, wrists), strikes, and chokes are taught using physical demonstration. Staff practices the skills and must provide an accurate return demonstration.

Module Four: Risk Management

Staff learns how to identify the major clinical, situational, and environmental risk factors that increase the risk for violence, with a focus on triggering situations and situational awareness. Risk and protective factors are addressed and serve to inform critical thinking and decision making to determine interventions that have the greatest potential to succeed. The DMHAS policy and philosophy for preventing and managing dangerous behavior are reviewed. The MAPAT (Moylan Assessment of Progressive Aggression Tool [Moylan, 2009b]) is used at the end of the CSS-IR Risk Assessment module. This module teaches staff how to assess the risks of danger with a focus on situational risk assessment. It is played in its entirety and is followed by a facilitated discussion with key questions.

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Modules The focus of this module is on early intervention. Staff learns the key elements of nonemergency and emergency planning for patients at risk for violent behavior and that preplanning is essential. They learn an efficient and effective way to communicate in emerging behavioral emergencies.

Module Six: Managing Code Involving Restraints (Physical and Mechanical) and Seclusion

The focus of this module is on managing an emergency code using a variety of physically restrictive interventions (escorts, assists, and takedowns) and seclusion along the continuum of least to most restrictive. Since most injuries occur during the process of containing violent behavior, there is a major focus on using the team approach during physical interventions and the roles of the both the team leader and members in preventing the rate and severity of injuries. Restraint and seclusion application and discontinuation of mechanical restraints is practiced with a focus on their risks and how to manage them using the A-E assessment.

Module Seven: Safety Strategies for Escalating and Crisis Situations

The focus of this module is on critical thinking and decision-making skills in escalating and crisis situations to reduce the risk of physically, medically, and emotionally traumatizing effects resulting from dangerous and violent behavior and the use of restraints and seclusion.

Data from Ciarlo, S. and Moylan, L. (2013). Integration of the Audio-Visual Moylan Assessment of Progressive Aggression Tool(MAPAT) in a U. S. A. State-wide Training Program of Mental Health Workers. Paper presented at The 8th European Congress on Violence in Clinical Psychiatry October 23-26th, 2013. Ghent, Belgium.

It is imperative that organizations encourage a culture where, when the decision to restrain is made, the clinical judgment of the nurse is supported and respected.

Conclusion Acute care psychiatry is an area of extremely high risk for workplace violence. In an effort to meet the needs of both patients and healthcare providers, rigorous intensive education and training related to compassionate therapeutic approaches to the patient who is demonstrating behaviors of escalating aggression are needed. The goal of a restraint-free environment is an ideal worth pursuing but it may not be realistic in all situations, considering the nature of acute care psychiatry. In situations where patients become an imminent danger to themselves or others, restraint may be the only safe option. When a decision to restrain is made by the nurse, who has the legal responsibility to maintain safety, this decision

should be supported by the administration and the organization. In this way, safe, compassionate care can be provided to a vulnerable patient population without compromising the safety of patients, nurses, and other healthcare providers.

Case Study Questions 1. In a nurse–patient relationship where the nurse has a fiduciary responsibility to the patient, does the patient’s right to protection from harm supersede that of the nurse’s right to remain free from harm? 2. How can the ANA Code of Ethics for Nurses with Interpretive Statements be applied to the issue of violence in psychiatry where both the rights of the patient and nurse are addressed? 3. Is a patient’s right to autonomy absolute? 4. In psychiatry, can ethical conflict occur in balancing a patient’s right to autonomy and their right to beneficence?

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Module Five: Strategies for Enhancing Safety and Interrupting the Cycle

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References American Nurses Association. (ANA) (2012). Reduction of restraint and seclusion in health care Settings. Silver Spring, MD: Author. American Nurses Association. (2015a). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author. American Nurses Association. (2015, September 2). ’Zero tolerance’ for workplace violence, bullying. Position statement. Retrieved from http://www.nursingworld .org (accessed July 10, 2017). American Psychiatric Nurses Association (APNA) (2014). APNA position on the use of seclusion and restraint. Falls Church, VA: Author. Baby, M., Glue, P., & Carlyle, D. (2014). “Violence is not part of our job”: A thematic analysis of psychiatric mental health nurses’ experiences of patient assaults from a New Zealand perspective. Issues in Mental Health Nursing, 28(11), 647–655. doi:10.3109/01612840.2014.892552 Bak, J., Zoffmann, V., Sestoft, D., Almvik, R., & Brandt-Christensen, M. (2014). Mechanical restraint in psychiatry: Preventive factors in theory and practice. A Danish-Norwegian Association study. Perspectives in Psychiatric Care, 50(3), 155–166. doi:10.1111/ppc.12036 Berzlanovich, A. M., Schöpfer, J., & Keil, W. (2012). Deaths due to physical restraint. Deutsches Ärzteblatt International, 109(3), 27. Bimenyimana, E., Poggenpoel, M., Myburgh, C., & van Niekerk, V. (2009). The lived experience by psychiatric nurses of aggression and violence from patients in a Gauteng psychiatric institution. Curationis, 32, 4–13. Centers for Disease Control, National Institute for Occupational Safety and Health (NIOSH). (2016). Workplace violence prevention for nurses course. Retrieved from https:// www.cdc.gov/niosh/topics/violence/training_nurses.html Duxbury, J., Hahn, S., Needham, I., & Pulsford, D. (2008). The management of aggression and violence attitude scale (MAVAS): A cross-national study. Journal of Advanced Nursing, 62, 596–606. Inoue, M., Tsukano, K., Muraoka, M., Kaneko, F., & Okamura, H. (2006). Psychological impact of verbal abuse and violence by patients on nurses working in psychiatric departments. Psychiatry & Clinical Neurosciences, 60(1), 29–36. doi:10.1111/j.1440-1819.2006.01457.x Jacob, T., Sahu, G., Frankel, V., Homel, P., Berman, B., & McAfee, S. (2016). Patterns of restraint utilization in a community hospital’s psychiatric inpatient units. The Psychiatric Quarterly, 87(1), 31–48. doi:10.1007/s11126-015-9353-7 Lanza, M., Zeiss, R., & Rierdan, J. (2006). Violence against psychiatric nurses: Sensitive research as science and intervention. Contemporary Nurse, 21, 71–82. Levin, A. (2014, April 25). UN report says common psychiatric practices amount to ‘torture.’ Psychiatric News. Retrieved from http://wwsw.PsychiatricNewspsychiatryonline psychnews.psychiatryonline.org/doi/10.1176/appi .pn.2014.5a11 (accessed July 10, 2017).

Liberman, P. L. (2006). Elimination of seclusion and restraint: A reasonable goal? Psychiatric Services 57(4), 576. Mental Health America. (2015). Position statement 24: Seclusion and restraints. Retrieved from www.mentalhealthamerica .net/positions/seclusion-restraints Moylan, L. (2009a). Physical restraint in acute care psychiatry: A humanistic and realistic nursing approach. Journal of Psychosocial Nursing & Mental Health Services, 47(3), 41–47. Moylan, L. (2009b). Construction of an instrument to evaluate nurses’ decision making in relation to the use of restraint in acute care psychiatry. Issues in Mental Health Nursing, 30(11), 712–717. Moylan, L. B. (2012). Valuing the patient, valuing the caregiver: Effective approaches to the anxious, agitated or aggressive patient. In L. Berhard (Ed.), Advances in medicine and biology: Volume 57. Hauppauge, NY: Nova Science Publishers. Moylan, L. B., & Cullinan, M. B. (2011). Frequency of assault and severity of injury of psychiatric nurses in relation to the nurses’ decision to restrain. Journal of Psychiatric & Mental Health Nursing, 18(6), 526–534. Moylan, L. B., McManus, M., Cullinan, M., & Persico, L. (2016). Need for specialized support services for nurse victims of physical assault by psychiatric patients. Issues in Mental Health Nursing, 37(7), 446–450. Moyo, N., & Robinson, P. (2012). The safety of nurses during the restraining of aggressive patients in an acute psychiatric unit. Australian Journal of Advanced Nursing, 29(3), 5–13. New York Office of Mental Health. (2017, February 8) Implementation guidelines 14 NYCRR S5246.4: Restraint and seclusion. Retrieved from https://www.omh.ny.gov /omhweb/guidance/implementation-guidelines.pdf New York State Nurses Association. (2011). Position statement on workplace violence. Retrieved from www.nysna.org /position-statement-workplace-violence (accessed July 10, 2017). Paterson, B., & Duxbury, J. (2007). Restraint and the question of validity. Nursing Ethics, 14, 535–545. Rakhmatullina, M., Taub, A., & Jacob, T. (2013). Morbidity and mortality associated with the utilization of restraints. Psychiatric Quarterly, 1, 14. Simon, R. I., & Shuman, D. W. (2007). Clinical manual of psychiatry and law. Washington, DC: American Psychiatric Publishing. Stevenson, K. N., Jack, S. M., O’Mara, L., & LeGris, J. (2015). Registered nurses’ experiences of patient violence on acute care psychiatric inpatient units: An interpretive descriptive study. BMC Nursing, 14(1), 1–13. doi:1 0.1186 /s12912-015-0079-5 Ward, L. (2013). Ready, aim fire! Mental health nurses under siege in acute inpatient facilities. Issues in Mental Health Nursing, 34(4), 281–287. Yarovitsky, Y., & Tabak, N. (2009). Patient violence toward nursing staff in closed psychiatric wards: Its long term effect on staff’s mental state and behavior. Medicine and Law, 28, 705–724.

SECTION 3

Affordable Care Act: From Enactment to Sustainability CHAPTER 7

Affordable Care Act (ACA) Reframed and Uncertain

CHAPTER 8

Healthcare Quality

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CHAPTER 7

Affordable Care Act (ACA) Reframed and Uncertain (Excerpted from the 2018 Annual Health Reform Update by Wilensky and Teitelbaum)*

OVERVIEW The Patient Protection and Affordable Care Act (generally referred to as the Affordable Care Act, or ACA) is the most monumental piece of U.S. federal health policymaking in nearly 50 years. It reorders not only many aspects of the health insurance and healthcare delivery systems, but also long-standing relationships that underpin those systems. Implementation of the ACA is an ongoing, dynamic process for the federal government, states, employers, insurers, providers, patients, and others. In addition, there have been and, no doubt, will continue to be state and federal court decisions across the country that will alter the trajectory of the law and its implementation, assuming it is not repealed entirely. The future of the ACA was made even more uncertain by the monumental election cycle in 2016. Unexpectedly, Donald Trump was elected president in November of that year, and the Republicans maintained control of both the U.S. House of Representatives and the Senate. Having control of Congress and the White House gives Republicans a chance to fulfill a promise they have campaigned on for years—to repeal and replace the ACA. Even if they are not successful in passing a repeal and replacement bill, President Trump can use his executive powers to rewrite existing regulations and implement new policies that undermine and reshape the law. Although there has been general agreement about the problems facing the U.S. healthcare system—high costs, high uninsured rates, health disparities, quality concerns—politicians and voters have disagreed about the best solutions. As a result, many previous attempts to pass national health reform legislation did not succeed. This chapter begins with a discussion of why it has been so difficult (continues) *Wilensky, S. E., Teitelbaum, J. B. (2018). 2018 Annual Health Reform Update. Burlington, MA: Jones & Bartlett Learning. Wilensky, S. E., Teitelbaum, J. B. (2016). Essentials of Health Policy and Law. Burlington, MA: Jones & Bartlett Learning. © Anthony Krikorian/Shutterstock

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OVERVIEW

(continued)

to achieve broad health reform in this country. It summarizes the history of failed attempts at health reform and examines how health reform was enacted in 2010. It provides an overview of the law that eventually emerged, and covers the U.S. Supreme Court decision upholding its constitutionality. The chapter then raises questions about the current political climate and what it means for health reform going forward, including a discussion of key political and implementation issues. Several key themes are discussed: choosing between state flexibility and national uniformity; determining the appropriate role for government, the private sector, and the healthcare financing and delivery entities; defining a primary decision-making goal (e.g., fiscal restraint, equity/social justice, improved health outcomes, uniformity); and settling on the appropriate scope of coverage to offer beneficiaries.

OBJECTIVES ■■ ■■ ■■ ■■ ■■ ■■

■■

▸▸

Describe previous national health reform attempts. Discuss why national health reform has been difficult to achieve in the United States. Analyze why national health reform succeeded in 2010 when so many previous attempts had failed. Identify the key components of the Patient Protection and Affordable Care Act. Articulate the core rulings of multiple U.S. Supreme Court decisions related to the Affordable Care Act. Evaluate the political climate regarding repealing and replacing the Affordable Care Act, and understand the main features of legislation drafted toward that end. Describe key issues going forward related to implementation of the Affordable Care Act.

Health Reform in the United States: Recent and Past History

The array of problems facing the healthcare system has led to numerous health reform proposals and implemented policies. The concept of health reform can have several different meanings. Given the patchwork health insurance system, health reform often refers to changes that seek to reduce the number of uninsured. Due to the high and increasing cost of healthcare services, health reform might also include changes that seek to contain costs and control utilization. The notion of health reform could also address other shortcomings, such as trying to reduce medical errors, strengthening patient rights, building the public health infrastructure, and confronting the rising cost of medical malpractice insurance. The Affordable Care Act (ACA), the federal health reform law passed in

2010, touches on many of these issues (Patient Protection Affordable Care Act, 2010). Health reform has been difficult to achieve in the United States. Many reform efforts have been attempted, with varying degrees of success, on a national level. Numerous authors have addressed the main factors that deter significant social reform in this country, including health reform (Blake & Adolino, 2001; Gordon, 2003; Jost, 2004). Factors that are prominently discussed include the country’s culture, the nature of U.S. political institutions, the power of interest groups, and path dependency (i.e., the notion that people are generally opposed to change). Americans have a complicated and partisan view of the proper role of the federal government in the healthcare arena. On one hand, 60% of respondents to a 2017 survey felt that the federal government has a responsibility to ensure healthcare coverage for all Americans (Pew Research Center, 2017). This is much higher than the 47% who shared that view in 2010, at the height of the health reform debate

Health Reform in the United States: Recent and Past History

(Newport, 2010). Of those who supported federal intervention in the 2017 survey, 33% would like to see a single-payer system developed (Pew Research Center, 2017). At the same time, there was a stark difference of opinion based on the respondent’s political views. While 85% of Democrats and Democrat-leaning independents believed the federal government was responsible for ensuring healthcare coverage, only 32% of Republicans and Republican-leaning independents agreed (Pew Research Center, 2017). Even so, over half (57%) of Republicans and Republican-leaners supported the continuation of Medicaid and Medicare, the country’s largest public health insurance programs. Furthermore, only 5% of respondents thought the federal government should not have any role in ensuring healthcare coverage (Pew Research Center, 2017). Many aspects of the U.S. political system also make it difficult to institute sweeping reform. For example, although presidents have significant influence on policy agenda setting and proposing budgets, they have limited power to make changes without the assistance of the U.S. Congress. The federal government is often politically divided, with different parties holding power in the executive and legislative branches. This division often results in partisanship and policy inaction due to different policy priorities and views. Furthermore, although members of Congress may ride the coattails of a popular president from their own party, they are not reliant on the president to keep their jobs. The issues and views their constituents care about most may not align with the president’s priorities. In those cases, members of Congress have a strong incentive to adhere to the wishes of those who vote for them, instead of simply following the president’s lead. Barring an overwhelming wave of discontent, as occurred in the 2010 midterm elections when Democrats suffered historic losses in Congress, it is usually difficult to unseat incumbents. Even when there is a historic level of turnover, reelection rates remain very high. For example, 97% of House incumbents

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successfully defended their seats in 2016; even in the Senate, where turnover is relatively more common, 93% of incumbents won reelection in 2016 (Kondick & Skelley, 2016). As a result, legislators in Congress may have confidence in focusing on their district’s or state’s needs before those of the entire nation. Federal legislative rules also support inaction or incremental reform over sweeping changes. In the U.S. Senate, 60 (of 100) votes are needed to break a filibuster in most cases. Thus, even the political party in the majority can have difficulty effectuating change. One exception to the filibuster rule is the “reconciliation” process, which allows bills to pass with only 51 votes. Reconciliation is used as part of the budgetary process, and bills passed via reconciliation: (a) may not be filibustered (so can pass with 51 votes), (b) can only pertain to federal revenue and spending issues, (c) must comply with spending and revenue targets set forth in the budget resolution, and (d) must adhere to other budgetary rules (Tax Policy Center, 2017). The reconciliation process is being increasingly used when one party maintains a slim majority and that party cannot find 60 votes to pass a bill. In 2010, the Democrats used a reconciliation bill to pass the ACA after they lost their filibuster-proof majority, and recently, the Republicans attempted to use a reconciliation bill to pass their ACA repeal and replace bills.

Historical Attempts and Failures at Health Reform Since the early 1900s, when medical knowledge became advanced enough to make health care and health insurance desirable commodities, there have been periodic attempts to implement universal coverage through national health reform. The Socialist Party was the first U.S. political party to support health insurance in 1904, but the main engine behind early efforts for national reform was the American Association for Labor Legislation (AALL), a “social progressive” group that hoped to reform capitalism,

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not overthrow it (Starr, 1982, p. 243). In 1912, Progressive Party candidate Theodore Roosevelt supported a social insurance platform modeled on the European social insurance tradition that included health insurance, workers’ compensation, old-age pensions, and unemployment insurance. After his loss to Woodrow Wilson, the national health insurance movement was without a strong national leader for three decades. The AALL continued to support a form of health insurance after Roosevelt’s defeat and drafted a model bill in 1915. This bill followed the European model, limiting participation to working class employees and their dependents. Benefits included medical aid, sick pay, maternity benefits, and a death benefit. These costs were to be financed by employers, employees, and the state. The AALL believed that health insurance for the working population would reduce poverty and increase society’s productivity and well-being through healthier workers and citizens. Opposition to AALL’s bill came from several sources (Starr, 1982, pp. 247–249). Although some members of the American Medical Association (AMA) approved of the bill conceptually, physician support rapidly evaporated when details emerged about aspects of the plan that would negatively impact their income and autonomy. The American Federation of Labor (a labor union) opposed compulsory health insurance because it wanted workers to rely on their own economic strength, not the state, to obtain better wages and benefits. In addition, the federation was concerned that it would lose power if the government, not the union, secured benefits for workers. Employers were generally opposed to the bill, contending that supporting public health was a better way to ensure productivity. In addition, they feared that providing health insurance to employees might promote malingering instead of reducing lost workdays. After experiencing the high cost associated with workers’ compensation, employers also were not eager to take on an additional expensive benefit. Of course, the part of the insurance industry that had already established a profitable niche

in the death benefit business was strongly opposed to a bill that included a death benefit provision. Employers, healthcare providers, and insurers have, in general, remained staunch opponents of national health reform over the years, whereas unions have supported national reform efforts. However, this dynamic has changed recently with more provider groups, employers, and even some insurers calling for a national solution to the problems of rising healthcare costs and the uninsured. The country’s entry into World War I in 1917 also changed the health reform debate. Many physicians who supported the AALL bill entered the military, shifting their focus away from the domestic health policy debate. Anti-German sentiment was high, so opponents of the bill gained traction by denouncing compulsory health insurance as anti-American. One pamphlet read: “What Is Compulsory Social Health Insurance? It is a dangerous device, invented in Germany, announced by the German Emperor from the throne the same year he started plotting and preparing to conquer the world” (Starr, 1982, p. 253). The next time national health insurance might have taken hold was from the mid-1930s through the early 1940s as the country was coping with the difficulties of the Great Depression. During this time there was a significant increase in government programs, including the creation of Social Security in 1935, which provided old-age assistance, unemployment compensation, and public assistance. Yet the fourth prong of the social insurance package, health ­insurance, remained elusive. President Franklin Roosevelt heeded his staff ’s advice to leave health insurance out of Social Security because of the strong opposition it would create (Starr, 1982, p. 267). Opposition from the AMA was particularly strong—they believed that “socialized medicine” would increase bureaucracy, limit physician freedom, and interfere with the doctor–patient relationship. Even so, members of Roosevelt’s administration continued to push for national health insurance. The Interdepartmental Committee to

Health Reform in the United States: Recent and Past History

Coordinate Health and Welfare Activities was created in 1935 and took on the task of studying the nation’s healthcare needs. This job fell to its Technical Committee on Medical Care. Instead of supporting a federal program, the committee proposed subsidies to the states for operating health programs. Components of the proposal included expanding maternal and child health and public health programs under Social Security, expanding hospital construction, increasing aid for medical care for the indigent, studying a general medical care program, and creating a compensation program for those who lost wages due to disability. Although President Roosevelt established a National Health Conference to discuss the recommendation, he never fully supported the Medical Care Committee’s proposal. With the success of conservatives in the 1938 election and the administration’s concerns about fighting the powerful physician and state medical society lobbies, national health reform did not have a place on Roosevelt’s priority list. Senator Robert Wagner (D-NY) introduced a bill that followed the committee’s recommendations in 1939, and although it passed in the Senate, it did not garner support from the president or from the House. World War II provided another opportunity for the opposition to label national health insurance as socialized medicine. But once the war neared an end, President Roosevelt finally called for an “economic bill of rights” that included medical care. President Truman picked up where Roosevelt left off, strongly advocating for national health insurance. President Truman’s proposal included expanding hospitals, increasing public health and maternal and child health services, providing federal aid for medical research and education, and, for the first time, a single health insurance program for all (Starr, 1982, p. 281). Heeding lessons from earlier reform failures, Truman emphasized that his plan was not socialized medicine and that the delivery system for medical and hospital care would not change. Again, there was strong opposition to the proposal. The AMA vehemently rejected the

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proposal, and most other healthcare groups opposed it as well. Although the public initially approved of it, there was no consensus about how national health insurance should be structured, and more people preferred modest voluntary plans over a national, compulsory, comprehensive health insurance program (Starr, 1987, p. 282). Additional opposition came from the American Bar Association, the Chamber of Commerce, and even some federal agencies concerned about losing control over their existing programs. In the end, only the hospital construction portion of the proposal was enacted. When Truman won reelection on a ­national health insurance platform in 1948, it appeared the tide had turned. However, the AMA continued its strong opposition and its attempts to link national health insurance to socialism. Congress considered various compromises but never reached a consensus. The public remained uncertain about what kind of plan to favor. Employers maintained their opposition to compulsory insurance. In addition, one large group of potential supporters—veterans—was disinterested in the debate because they had already secured extensive medical coverage through the Veterans Administration. As the Korean War moved forward, Truman’s focus shifted away from national health insurance and toward the war effort and other priorities. National health insurance did not return to the national policy agenda until the 1970s. The landscape then was quite different from Truman’s era. Medicaid and Medicare had been created, healthcare costs had begun to rise exponentially, and the economy was deteriorating. In 1969, President Nixon declared that a “massive crisis” existed in health care and that unless it was fixed immediately, the country’s medical system would collapse (Starr, 1982, p. 381). The general public seemed to agree, with 75% of respondents in one survey concurring that the healthcare system was in crisis (Starr, 1982, p. 381). Democrats still controlled Congress by a significant margin, and Senator Edward Kennedy (D-MA) and Representative Martha Griffiths (D-MI), the first woman to serve on

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the powerful House Committee on Ways and Means, proposed a comprehensive, federally operated health insurance system. At the same time, a movement supporting health care and patient rights was gaining momentum. These included rights to informed consent, to refuse treatment, to due process for involuntary commitment, and to equal access to health care (Starr, 1982, p. 389). The public was both anxious to obtain care and willing to challenge the authority of healthcare providers. The Nixon administration’s first attempt at health reform focused on changing the healthcare system’s financing from one dominated by a fee-for-service system, which created incentives to provide more and more expensive services, to one that promoted restraint, efficiency, and the health of the patient. The result was a “health maintenance strategy” intended to stimulate the private industry to create health maintenance organizations (HMOs) through federal planning grants and loan guarantees, with the goal of enrolling 90% of the population in an HMO by the end of the 1970s (Starr, 1982, pp. 395–396). Ironically, group health plans, often labeled socialized medicine, had become the centerpiece of a Republican reform strategy. Nixon’s proposal included an employer mandate to provide a minimum package of benefits under a National Health Insurance Standards Act, a federally administered Family Health Insurance Program for low-income families that had a less generous benefit package than the one required by the National Health Insurance Standards Act; reductions in Medicare spending to help defray the costs; a call for an increase in the supply of physicians; and a change in how medical schools were subsidized. Opponents were plentiful, and this plan did not come to fruition. Some believed the plan was a gift to private insurance companies. Advocates for the poor were outraged at the second tier of benefits for low-income families. The AMA was concerned about HMOs interfering with physician practices and supported

an alternative that provided tax credits for buying private insurance. After the 1972 election, Nixon proposed a second plan that covered everyone and offered more comprehensive coverage. Private insurance companies would cover the employed and a government-run program would cover the rest of the population, with both groups receiving the same benefit package. Senator Kennedy and Representative Wilbur Mills (D-AR) supported a similar plan, and it appeared a compromise was close at hand. However, labor unions and liberal organizations preferred the original Kennedy plan and resisted compromising with the hope of gaining power in the 1974 post-Watergate elections. Fearing the same political shift, insurance companies actually supported a catastrophic insurance plan proposed by Senator Russell Long (D-LA), believing it was better than any plan that would come out of a more liberal Congress after the elections. Once again, there was no majority support for any of the bills, and a national health insurance plan was not enacted. Although President Jimmy Carter gave lip service to national health reform, he never fully supported a proposal. It was not until the election of Bill Clinton in 1992 that the next real attempt at national health insurance was made. The Clinton administration plan, dubbed the Health Security Act, was designed to create national health insurance without spending new federal funds or shifting coverage from private to public insurance. It relied on the concept of “managed competition,” which combined elements of managed care and market competition. Under the Health Security Act, a National Health Board would have established national and regional spending limits and regulated premium increases. “Health alliances” would have included a variety of plans that were competing for the business of employees and unemployed citizens in each geographic area. All plans were to have a guaranteed scope of benefits and uniform cost sharing. Employers would have been required to provide coverage for their workers

Health Reform in the United States: Recent and Past History

at a defined high level of benefits, and those with 5,000 employees or fewer would have had to purchase plans through the health alliance. Subsidies were provided for low-income individuals and small businesses. Funding was to be provided from cost-containment measures that were reinvested. Forced by the Congressional Budget Office (CBO) to provide an alternative funding strategy should the cost containment not create enough funds, the plan also included the option of capping insurance premium growth and reducing provider payments. Like the national health insurance plans before it, the Health Security Act had opponents from many directions. The health alliances were attacked as big government, employers resisted mandates and interference with their fringe benefits, some advocates feared that cost containment would lead to care rationing, the insured were concerned about losing some of their existing benefits or cost-sharing arrangements, the elderly feared losing Medicare, and academic health centers were concerned about losing funds based on new graduate medical education provisions. In addition, the usually strong support from unions was missing because of an earlier disagreement with the president on trade matters. It is also generally accepted that the Clinton administration made several political mistakes that made a difficult political chore nearly impossible. The Health Security Act never made it to a vote.

The ACA Becomes Law In many ways, 2010 was a very unlikely year to pass a national health reform plan. The country had been growing increasingly ideological, with the popular and electoral votes almost evenly split in both the 2000 and 2004 presidential elections. Even though Barack Obama won the electoral vote in a landslide over John McCain (365 to 173), only 53% of the population voted for Obama in 2008 (CNN, 2008). In addition to the ideological divide, and against a backdrop of a faltering economy,

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partisan differences, and the recent passage of two massive government spending bills, President Obama pursued a national health reform plan. Given the history of failed reform efforts, it would have been an accomplishment to pass health reform in the best of times, and clearly this was not the best of times. Health care has long been a priority for Democrats, and President Obama was no exception. Perhaps Obama’s dedication to passing health reform stemmed in part from his personal experience: Obama’s mother died of ovarian cancer, and he had seen her worry about paying her medical bills as much as beating the disease (CNN, 2007). Thus, for Obama, signing comprehensive health reform legislation into law would represent the opportunity to make sure that others would not endure the same experience. Health reform efforts did not begin smoothly. President Obama initially wanted former U.S. senator Tom Daschle to run both the U.S. Department of Health and Human Services (USDHHS) and the White House Office on Health Reform. It was thought that his experience in the Senate and relationships with legislators were the right combination to take the lead on health reform. When his nomination was derailed due to personal tax problems, it was not a good omen. As deliberations in Congress lagged, Democrats were not able to present a bill to President Obama before recessing for the summer. During the summer of 2009, members of Congress went home to their constituents and held town hall meetings to discuss health reform. Some of the meetings erupted in vocal opposition to health reform, and the media focused on these town hall meetings throughout the summer. Obama and the Democrats were criticized for losing the momentum for reform by letting the debate linger. At the same time, there were several instances when the health reform effort appeared politically doomed, and President Obama’s leadership made a clear difference. Obama attempted to reclaim the upper hand on health

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reform with a speech to a joint session of Congress in September 2009. He memorably proclaimed, “I am not the first president to take up health reform, but I intend to be the last” (The New York Times, 2009). Although public support for health reform had been on the decline for several months, September 2009 polls showed that 62% still thought it was important to address health reform at that time, and 53% thought the country as a whole would be better off if health reform passed (Kaiser Family Foundation, 2009). Less support existed for the Democrats’ specific reform proposal, however, with 46% in support of the proposed change and 48% opposed to it (Cohen & Baltz, 2009). In January 2010, an event occurred that some assumed was the death knell of health reform. In the 2008 elections, Democrats had made significant gains in Congress, earning a 59–41 majority in the Senate and a 257–178 majority in the House. Furthermore, Senator Arlen Specter of Pennsylvania switched parties, giving Democrats the crucial 60th vote needed for a filibuster-proof majority. Although the numbers were now in their favor, President Obama, Senate Majority Leader Harry Reid (D-NV), and House Speaker Nancy Pelosi (D-CA) would have to balance the competing interests of conservative Democrats who were concerned with having too much government intervention, progressive Democrats who sought a public insurance option to compete with private companies, Blue Dog Democrats who were most concerned with fiscal discipline, and pro-life and prochoice factions who would battle over whether and how abortion services would be included in any health reform bill. The Obama administration tried to avoid events that doomed earlier health reform efforts. Although the failed effort by the Clinton administration probably provided the most relevant lessons, Obama confronted some of the same obstacles that reformers had faced decades earlier. At times, President Obama was accused of learning some of the lessons too well, swinging the pendulum too far to the other side. Obama was not alone in providing leadership on health

reform. Reid’s and Pelosi’s determination to see health reform succeed, and their skill in mobilizing and controlling their caucuses, were essential to the passage of the ACA. It is likely that health reform would not have passed without the skillful efforts of all three leaders working together. Even so, it is clear that the health reform effort would not even have begun without a president who put health reform at the top of the agenda and stuck with it despite the pitfalls and political opposition. The legislative process for completing the bill was long, rocky, and ultimately partisan. The House of Representatives moved more quickly and with less fractious debate than the Senate. Instead of having multiple House committees work on competing bills, as occurred during the Clinton administration, House Democratic leaders created a “Tri-Committee” bill jointly sponsored by Charles Rangel (D-NY), Henry Waxman (D-CA), and George Miller (D-CA), the chairmen of the House Ways and Means, Energy and Commerce, and Education and Labor (later renamed the Education and Workforce committee) committees, respectively. On November 7, 2009, the House passed its health reform bill with only two votes to spare, 220–215 (Affordable Health Care for American Act, H.R. 3962, 2009). Only one Republican voted for it, and 39 conservative Democrats voted against it. The bill from the then-more-liberal House contained several provisions that were likely to be rejected by the Senate: a public health insurance option to compete with private plans, a national health insurance exchange instead of state-based exchanges, more generous subsidies for low-income individuals, a broader expansion of Medicaid, and higher taxes on wealthier Americans. Finance Committee Chairman Max Baucus (D-MT) led the effort in the Senate. The legislative process he established was lengthy, and some observers believed he compromised on too many issues in an attempt to forge a bipartisan bill. For a time Senator Charles Grassley (R-IA) actively participated in the health reform deliberations, and a few other Republican senators appeared willing to consider a bipartisan

Overview of the Patient Protection and Affordable Care Act

measure. Ultimately, however, a bipartisan agreement could not be reached. In a 2009 Christmas Eve vote, the Baucus health bill passed 60–39, with all Democrats and two Independents voting for the measure and all Republicans voting against it (Patient Protection and Affordable Care Act, H.R. 3590, 2009). Following tumultuous disagreements with versions of the plan, and the loss of a filibuster-proof majority, the House and Senate leaders agreed to use the budget reconciliation process to amend the Senate bill. The House then passed the Senate version of the bill along with a companion reconciliation bill that amended certain aspects of the Senate bill. The reconciliation bill included more generous subsidies for individuals to purchase insurance than existed in the standalone Senate bill, the closure of the Medicare Part D doughnut hole, a tax on more generous insurance plans, changes to the penalties on individuals who would not buy insurance and for employers that would not offer insurance, and an increase in Medicare and investment taxes for higher earners. The Senate then passed the reconciliation bill. Once again, the final vote to approve the bills was along party lines. The House approved the Senate bill by a vote of 219–212, with all Republicans and 34 Democrats voting against it (Khan, 2010). President Obama signed the bill into law on March 23, 2010 (Patient Protection Affordable Care Act, 2010). Some observers argue that Obama may have overlearned the lesson about working with Congress, and that in doing so, he did not provide enough guidance to legislators and allowed the debate over health reform to linger for too long (Morone, 2010, p. 1097). On the one hand, it is difficult to criticize Obama’s approach because he was ultimately successful. On the other hand, could the problems stemming from the 2009 town halls have been avoided? Would public opinion of the health reform effort be higher if the process had been better managed? Only time will tell whether Obama was successful over the long term. With the volatility and divisive partisan bickering of today’s Congress, what the future holds is still unclear.

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Overview of the Patient Protection and Affordable Care Act

While President Obama left the details of health reform legislation to Congress, he did lay out what he believed to be the most important principles that should guide the legislation’s development. Soon after becoming president in 2009, Obama delineated those principles, saying that any health reform measure should do the following:

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Protect families’ financial health (slowing the growth of out-of-pocket expenses and protecting people from bankruptcy due to catastrophic illness). Make health insurance coverage more affordable (reducing administrative costs, wiping out unnecessary tests and services, and limiting insurers’ ability to charge higher premiums for certain populations). Aim for insurance coverage universality. Provide portability of insurance coverage. Guarantee choice of health plans and providers (including keeping current ones). Invest in disease prevention and wellness initiatives. Improve patient safety and healthcare quality. Maintain long-term fiscal sustain­ ability (reducing cost growth, improving productivity, and adding new revenue sources).

The extent to which these principles were brought to life in what eventually became the Affordable Care Act lives along a spectrum: for example, (1) health insurance was absolutely made more affordable for millions of people; (2) disease prevention and wellness ­initiatives seem to be gaining momentum, though slowly; and

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(3) universal insurance coverage was absolutely not achieved. Whatever the case with any particular principle, it is instructive to look to four key reforms that became law under the ACA as having paved the way for President Obama’s overall vision to come to fruition. These four reforms essentially reordered long-standing relationships among health system stakeholders (individuals, providers, insurers, employers, governments, etc.). As a result of this ­reordering, all of these stakeholders were ­legally ­obligated to alter normative behaviors. These changes include: (1) mandates ­(individual and ­employer); (2) changes to private insurance rules; (3) ­creation of health insurance exchanges; and (4) expansion of Medicaid. The first major mandate change, known as the individual mandate, is a requirement that most individuals maintain “minimum essential health coverage” (i.e., health insurance) or face financial penalties that are spelled out in the ACA. This requirement was a critically important beam in the ACA architecture; because it creates a new, large pool of individuals who will be paying premiums to insurance companies, it created leverage for policymakers who were eager for private insurers to accept many of the ACA’s other insurance reforms that may otherwise have been unpalatable. For certain individuals whose socioeconomic status makes it impossible for them to purchase (or gain through an employer) the type of minimum coverage mandated by the ACA, and who do not qualify for Medicaid (even under the ACA expansion), federal subsidies are made available under the law. The individual mandate is an essential part of health reform for several key reasons: ■■

Adverse selection: Without the mandate, people who are in poor health or otherwise expect to use more healthcare services would be more likely to purchase health insurance, while healthier people would be more likely to opt out of insurance coverage. This would lead to an insurance pool that is relatively sick and thus more expensive, a problem referred to as adverse selection.

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Free riders: Without the mandate, some healthy individuals would choose not to purchase health insurance but then later need health care, and they will likely receive some care even though they are uninsured. This is especially true if the individuals have the resources to pay for healthcare services. These individuals are referred to as free riders because they avoid paying premiums for health insurance during their healthy years but then enjoy the benefits of healthcare services when they become sick. Funding: The penalty is intended to provide both an incentive to comply with the law and to raise funds to cover the cost of health care for those individuals who choose not to carry health insurance. In addition, it ensures that everyone covered by the mandate will be in an insurance pool to help cover costs and share risk.

If the individual mandate were not so important the ACA’s success, it would not have been included because it is politically unpopular; many feel it represents unwarranted government intrusion into private decision making. People have expressed that they do not like the federal government telling them to purchase health insurance, even if it is a choice they made on their own prior to the ACA. Even so, affordability, not government intrusion, has been the top concern raised about the ACA (DiJulio, Kirzinger, Wu, & Brodie, 2017; Kaiser Family Foundation, 2014). A parallel mandate change is the employer mandate. As written in the ACA, employers with 50 or more employees and at least 1 employee who qualifies for a tax credit were required to offer affordable health insurance or pay a penalty beginning in 2014. Given their smaller pool of employees, small businesses have often found it quite expensive to offer health insurance to their employees. In addition to exempting businesses with fewer than 50 employees from the employer mandate, Congress also included a small business tax credit to encourage these employers to provide coverage.

Overview of the Patient Protection and Affordable Care Act

Under the mandate, covered employers have three options: (1) provide affordable health insurance and not pay a penalty, (2) provide health insurance not considered affordable and pay a penalty, or (3) do not provide health insurance and pay a penalty. The penalties are based on whether an employer offers health insurance and whether any full-time employees take a premium tax credit. The amount of the penalty increases over time based on the national increase in premium costs. The employer mandate was put in place to encourage employers to continue offering or start offering health insurance. Without such a mandate employers may have found it profitable not to offer health insurance and let their employees purchase health insurance through state exchanges, shifting more of the costs of health reform to the public sector and taxpayers. The second fundamental change results from reforms that prohibit or curtail existing health insurer and health plan practices (i.e., rules that require insurers and health plan practices to assure their products do not restrict purchasers and provide certain eligible coverage). These rules limit discrimination by insurers, provide benefit guarantees, and address some costs concerns. Some of the key private insurance rule changes include: ■■

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Preexisting conditions: Individual and group plans may not exclude individuals due to their health status or based on preexisting conditions. Dependent coverage: Individual and group plans must provide dependent coverage up to age 26. Preventive services: New health plans may not impose cost sharing for certain preven­ tive services, including the following: • Preventive services with an A or B rating from the U.S. Preventive Services Task Force • Immunizations recommended by the Centers for Disease Control and Pre­ vention’s Advisory Committee on Im­ munization Practice

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Preventive care and screening for women based on guidelines to be issued by the Health Resources and Services Administration Coverage limits: Individual and group plans may not impose annual or lifetime dollar limits on coverage. Rescission: Individual and group plans may not rescind coverage except in the case of fraud. Appeals: New health insurance plans must have an effective appeals process that includes an external review option. Guaranteed issue and renewability: Individual and group plans may not exclude or charge more to individuals based on preexisting conditions or health status in the individual market, small-group market, and exchanges. Rate variation limits: Premium rates may only vary based on age, geographical area, family composition, and tobacco use in the individual market, small-group market, and exchanges. Essential health benefits: Insurers providing coverage to small businesses, individuals, and in the exchanges have to provide essential health benefits through one of four plan categories (bronze, silver, gold, or platinum) and adhere to annual cost-sharing limits. Wellness plans: Employers may offer rewards that reduce the cost of coverage to employees for participating in a wellness plan.

The third key change is the creation of health insurance “exchanges” or “marketplaces” in each state. These are essentially online shopping sites, the purpose of which is to make it easier for individuals and small employers to compare and purchase private health insurance plans. The exchanges are a critical component of health reform because it would be untenable to require individuals to purchase health insurance without also making comprehensive and affordable health insurance options available. The ACA originally included two exchanges, one for individuals (American Health Benefit

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Exchange) and one for small business (Small Business Health Options Program, or SHOP). The SHOP exchange struggled from the start with implementation delays and much lower than anticipated enrollment (Aron-Dine, 2017). The Trump administration has decided to end the SHOP exchange and look for alternative methods to assist small businesses. The Congressional Budget Office (CBO) projects that by 2027, 13 million individuals will purchase their own health insurance through an exchange (Jost, May 15, 2017). Premium subsidies are available to individuals, U.S. citizens, and legal immigrants who do not have access to affordable (as defined by the ACA) employer-sponsored insurance, meet specified income requirements, file taxes jointly (if married), are not incarcerated, and are not eligible for Medicaid, Medicare, or CHIP (Kaiser Family Foundation, November 8, 2017). In addition, cost-sharing subsidies are available to certain low-income individuals. The Trump administration recently decided not to fund the cost-sharing subsidies, so their continued existence is uncertain. Exchange plans must follow ACA criteria regarding plan benefits, payments, and consumer information. Plans may not design their benefit or reimbursement packages in ways that discriminate based on age, disability, or expected length of life (Rosenbaum, Teitelbaum, & Hayes, 2011). For the first time, private health insurance plans are subject to a federal standard regarding what benefits must be offered including the following essential health benefits: 1. 2. 3. 4. 5. 6. 7. 8.

Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health services and substance use disorder services, including be­ havioral health treatment Prescription drugs Rehabilitative and habilitative ser­ vices and devices Laboratory services

9. 10.

Prevention and wellness services and chronic disease management services Pediatric services, including vision and dental services

The final major reform is an expansion of the existing Medicaid program. Under the ACA, a new Medicaid category was created that ­expanded eligibility to all non-Medicare adults under age 65 who earned below 138% of the poverty level. This provision also included ­financing and benefit requirements specific to the expansion population. While Congress ­intended this expansion to be mandatory across the country, the Supreme Court determined that Congress did not have the authority to force states to expand Medicaid in this manner. As a result, the expansion is optional and as of ­November 8, 2017, 32 states and the District of Columbia have chosen to expand Medicaid under the ACA (Advisory Board, November 8, 2017). Medicaid expansion in the ACA provided a way to increase access to health care within the federal and state mechanisms already in place, but it remains controversial because many oppose the idea of expanding this entitlement program. Although the ACA does not completely alter the way health insurance is provided by esta­blishing a single-payer system or even a large government-run insurance plan to compete with private insurers, the law does make significant philosophical and practical changes in how health insurance is regulated, structured, and administered. Indeed, as a result of the reforms and reordering just described, recent estimates indicate that the ACA has resulted in 20 million people gaining insurance, dropping the uninsured rate from 16% in 2010 to a historically low 9.1% in early 2016 (Graves & Nikpay, 2017). In addition, as a result of the essential health benefits requirement, there is a large segment of the population that is no longer underinsured because of insurance plans that do not offer comprehensive benefits. Even so, many people contend that the ACA falls short in its reform of the healthcare delivery system. And in many cases they are correct. The

Financing Health Reform

ACA is most notable for the transformations it makes to health insurance—both access to it and its content—rather than for structural reforms made to the delivery system. Many provisions that focus on improving the healthcare delivery system, increasing the quality of care received by patients, reducing healthcare costs, and incentivizing providers to reconsider traditional methods of delivering care, often exist in the form of temporary pilot programs that may never be enacted permanently even if they prove to be valuable. Other analysts contend that these provisions were written as strongly as they could be at the time given the political environment and data available to policymakers. According to this view, the ACA provides the United States Secretary of Health and Human Services with unprecedented authority to make the pilot programs permanent, and it would have been irresponsible to implement more permanent, wholesale changes without more evidence. In any case, as sweeping as the ACA is, it is far from being the last step that needs to be taken to improve how health care is provided in the United States.

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Financing Health Reform

Congress financed health reform primarily through Medicare and Medicaid savings, excise taxes and fees on the healthcare industry, changes to the income tax code, a tax on some health insurance plans, and expected individual and employer payments for violating insurance mandates. Several of these financing changes were made as part of the deals the Obama administration struck with various stakeholders. The ACA’s main financing features are as follows: ■■

Medicare provider reimbursement: Reduces “market basket” or cost updates for inpatient and outpatient hospital reimbursement, reduces payments for preventable hospital readmissions and hospital-acquired infections, and includes productivity adjustments

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(an adjustment in the Medicare physician fee schedule pertaining to physician productivity) for certain providers that will result in lower reimbursement rates. Medicare Advantage payments: Reduces reimbursement rates and imposes costsharing limits for Medicare’s managed care plans. Medicare Part A (hospital insurance): Increases Medicare Part A tax rate for high-income earners. Medicare premiums: Reduces Medicare Part D (prescription drug) premium subsidy for high-income beneficiaries. Medicare employer subsidy: Eliminates tax deduction for employers who receive a Medicare Part D (prescription drug coverage) subsidy. Disproportionate share hospital (DSH) payments: Reduces Medicare payments to DSH hospitals; payments may increase over time based on percentage of uninsured served and uncompensated care provided; also reduces Medicaid DSH payments and requires USDHHS to develop a new funding formula. Medicaid prescription drugs: Increases rebates that drug manufacturers give to state Medicaid programs Income tax code provisions: Increases the threshold from 7.5% to 10% of adjusted gross income to claim deduction for unreimbursed medical expenses. Prohibits purchasing over-the-counter drugs with tax-free savings accounts, increases the tax burden on distributions not used for qualified medical expenses, and limits the amount individuals may put in accounts toward medical expenses. Health industry fees: Imposes a 10% tax on indoor tanning services, 2.3% tax on all taxable medical devices, annual fees on the pharmaceutical manufacturing sector, and fees on the health insurance sector. Health insurance plans: Imposes a tax on employer-sponsored health insurance

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plans with aggregate expenses that exceed $10,200 for individual coverage or $27,500 for family coverage. Although it is the responsibility of the CBO to estimate the cost of legislation as it is written, time-bound cost estimates (e.g., a 10-year estimate) have their limitations. First, the CBO must assume that all the provisions in the bill will be implemented as written. One of the most unpopular cost-saving tools—a tax on more generous health insurance plans—is not slated to take effect until 2018. Second, because the 10-year estimate, by design, does not consider costs beyond the first decade, some expected costs are not included in the estimate. Third, different methodologies may be used to calculate costs. Fourth, cost estimates cannot account for provisions that are left out of a bill. For these reasons, cost estimates should not be taken as the final word on the cost of any bill, because changes in political will can undermine the best projections.

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Quality Improvement and Prevention Initiatives

The ACA includes a wide range of quality improvement activities that fall into three main categories: evaluating new models of delivering health care, shifting reimbursement from volume to quality, and overall system improvement (Abrams, Nuzum, Ryan, Kiszla, & G ­ uterman, 2015). New models of healthcare delivery include accountable care organizations (ACOs), which combine a variety of providers who collectively assume responsibility for the cost and quality of patient care, and patient-centered medical homes, which provide comprehensive and coordinated primary care. Reimbursement reforms include strategies such as penalizing hospitals with high rates of hospital-acquired infections or providing bonuses or penalties based on performance on quality measurements. Finally, overall system improvement efforts are highlighted

by the National Strategy for Quality Improvement and the Patient-Centered Outcomes Research Institute (PCORI). The priorities of the National Strategy for Quality Improvement include improving delivery of healthcare services, patient outcomes, and population health. PCORI, a comparative effectiveness institute, was created to consider the clinical effectiveness of medical treatments. The idea behind comparative effectiveness is to determine which procedures, devices, and pharmaceuticals provide the best value for a given outcome. The institute is designed to supply information to help providers, patients, and others make decisions; Congress has stipulated, however, that findings from the institute may not be construed as mandates or recommendations for payment, coverage, or treatment decisions. The ACA also provides funds to promote public health, wellness, and a stable and high-quality healthcare workforce. In addition to the Public Health and Prevention Fund, the law calls for the creation of a new Regular Corps and a Ready Reserve Corps to assist when public health emergencies occur. Also, a variety of programs and incentives are in place to promote employer wellness programs. Finally, the workforce shortage is addressed through graduate medical education reforms that promote primary care training; increases in scholarships and loans to support primary care providers and workforce diversity; and education, training, and loan repayment programs to address the primary care nursing shortage.

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Constitutionality

U.S. Supreme Court’s Decision in the Case of National Federation of Independent Business v. Sebelius In November 2011, in the first of what would be several ACA-related decisions, the U.S. Supreme Court agreed to decide on key issues related to the

Constitutionality

legality of the ACA, including: (1) whether Congress had the power under the federal Constitution to enact the individual insurance coverage requirement, and (2) whether it was unconstitutionally coercive for Congress, through the ACA, to threaten to take away existing federal Medicaid funding from states that did not want to implement the Medicaid expansion. In June of the following year, the court handed down a remarkable 5–4 decision in the case of National Federation of Independent Businesses v. Sebelius, Secretary of Health and Human Services, et al. (2012). The opinion was surprising for two reasons: It defied expectation—few people thought that the entirety of the ACA would be found constitutional by a majority of the court—and because Chief Justice Roberts, a conservative, ended up in the majority with the court’s relatively liberal members (Justices ­Ginsburg, Breyer, Sotomayor, and Kagan).

Individual Mandate The court first tackled the question of whether Congress exceeded its authority in effectively forcing most everyone to carry health insurance. It concluded, not totally unexpectedly given the outcome of the court’s more recent Commerce Clause decisions (United States v. Lopez, 549 U.S. 1995; United States v. Morrison, 529 U.S. 598 2000), that the “individual mandate” amounted to an unconstitutional reach on the part of federal legislators: The individual mandate . . . does not regulate existing commercial activity. It instead compels individuals to become active in commerce by purchasing a product, on the ground that their failure to do so affects interstate commerce. Construing the commerce clause to permit Congress to regulate individuals precisely because they are doing nothing would open a new and potentially vast domain to congressional authority. (National Federation of Independent Businesses v. Sebelius, Secretary of Health and Human Services, et al., 2012, p. 2587)

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Surprisingly, however, the court’s analysis of the constitutionality of the individual mandate did not end there. The court majority pivoted to Congress’s power to tax, and ruled that under this separate power, the individual mandate passed constitutional muster. The court wrote: The exaction the Affordable Care Act imposes on those without health insurance [i.e., the financial penalty assessed on those who do not obtain minimum health insurance coverage] looks like a tax in many respects. . . . In distinguishing penalties from taxes, this Court has explained that “if the concept of penalty means anything, it means punishment for an unlawful actor omission.” While the individual mandate clearly aims to induce the purchase of health insurance, it need not be read to declare that failing to do so is unlawful. Neither the Act nor any other law attaches negative legal consequences to not buying health insurance, beyond requiring a payment to the IRS. (National Federation of Independent Businesses v. Sebelius, Secretary of Health and Human Services, et al., 2012, p. 2595) Read together, the Supreme Court’s analysis of the individual mandate under the Commerce Clause and the Taxing and Spending Clause leads to the following conclusion: Although Congress could not outright command Americans to buy health insurance, it could tax those who chose not to.

Medicaid Expansion The court next addressed whether the ACA’s Medicaid expansion was structured in a way that effectively, and unlawfully, coerced states into adopting it. Fully half of the states in the country—the 26 that sued to halt implementation of the ACA—believed the answer to be “yes.” As originally passed into law, the ACA allowed the U.S. Secretary of HHS to terminate all of a state’s Medicaid funding in the event

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that the state failed to implement the Medicaid expansion—even those Medicaid funds that a state would receive that were unconnected to the expansion. This allowance, the states argued, amounted to a coercively unacceptable choice: Either adopt the ACA Medicaid expansion or potentially receive no federal Medicaid financing at all. As a result, they asked the court to rule that the Medicaid expansion itself was unconstitutional. The court responded to this argument in two ways. On one hand, it determined that the Medicaid expansion itself was perfectly constitutional; on the other hand, the court ruled that it was indeed unconstitutional for USDHHS to penalize states that did not adopt the expansion by terminating all Medicaid funding: The Constitution simply does not give Congress the authority to require the States to regulate. That is true whether Congress directly commands a State to regulate or indirectly coerces a State to adopt a federal regulatory system as its own. . . . When, for example, such conditions take the form of threats to terminate other significant independent grants, the conditions are properly viewed as a means of pressuring the States to accept policy changes. . . . Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of healthcare, and requiring that States accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding. (National Federation of Independent Businesses v. Sebelius, Secretary of Health and Human Services, et al., 2012, pp. 2602-2607) This twin ruling had the effect of making the ACA Medicaid expansion optional rather than mandatory, and states have been deciding

individually whether to implement it. As of the time of this writing, 31 states and the District of Columbia have adopted the ACA’s Medicaid expansion, while 19 states have not adopted the expansion (though note that the latter number is noticeably lower than the number of states [26] that originally argued in NFIB v. Sebelius that the Medicaid expansion was unconstitutionally coercive) (Advisory Board, November 27, 2017).

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States and Health Reform

Before the ACA and in the wake of numerous failed attempts at national health reform, states had been active players in health reform. Filling the gap left by the lack of federal action, states took steps to experiment with individual mandates, employer mandates, small business pools, and programs to reduce the number of uninsured. Although the ACA is a federal law, it is full of state obligations and opportunities for state innovation. Even though governors in many states have expressed opposition to health reform, many states will expend significant efforts toward implementing the ACA over the next several years. The implementation challenges facing states are compounded by the poor economy, which has forced many to cut government agency personnel and budgets. States will have their hands full developing and running health insurance exchanges, regulating the private health insurance market, and implementing Medicaid changes. The Supreme Court’s decision to transform the ACA’s Medicaid expansion from a mandatory program change to a state option has significant ramifications. As noted previously, 31 states and the District of Columbia have chosen to expand their Medicaid program under the ACA ­(Advisory Board, November 27, 2017). As a result, by February 2017 there were 16 million more enrollees than prior to the ACA, with most new enrollment occurring in expansion states (Medicaid, CHIP Payment and Access Commission, n.d.).

Key Issues Going Forward

The number of new Medicaid beneficiaries will ultimately depend on how many states eventually choose to expand their Medicaid program. The court’s decision drastically changed the blueprint of health reform. The ACA was designed assuming Medicaid expansion in every state, meaning that there would be uniform coverage across the country for individuals earning below 138% of the federal poverty level. Under this plan, Medicaid would provide insurance for the lowest-income individuals, while state exchanges (with the assistance of federal subsidies) and employer-sponsored insurance would provide coverage for those who had higher earnings. It is now estimated that in states that do not expand their Medicaid program, 2.5 million people with incomes below the poverty line will remain uninsured because their incomes are too high to qualify for the state’s traditional Medicaid program, yet too low to be able to afford private insurance in the exchanges because they do not qualify for subsidies (because it was assumed Medicaid would be expanded nationally, premium subsidies are only available for individuals earning at least 100% of poverty) (Garfield, 2016).

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Key Issues Going Forward

At the time of this writing, the Republican effort to repeal and replace the ACA has stalled, although the individual mandate component has been repealed from the law with the passage of tax reform. Many in the party want to keep working toward that goal. Complicating matters further, President Trump is urging Republicans to keeping working on health reform, making it difficult to discern which issues—and which branch of government—will triumph in the coming year. Will Congress significantly change or dismantle the ACA, or will it move on to other policy debates? Will the Trump administration undermine the ACA through executive actions in the absence of congressional

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activity? Will continuing implementation concerns and market forces loom large? And what will be the political fallout, if any, from whatever does or does not happen to the ACA in this Congress? In the end, Congress may not make significant changes to the ACA, and as time passes, the law may become an accepted and welcome part of the fabric that holds together our healthcare and public health systems. Until that time comes to pass, however, we discuss here a few major political and implementation issues that will likely dominate the health reform discussion in the near term.

Congressional Activity The Republicans gained control of both chambers of Congress and of the White House in the 2016 election. After 7 years of campaigning on (and winning with) a platform that included repealing and replacing the ACA, Republican legislators feel a strong obligation to keep their promise. While the party is unified in its opposition to the ACA, it has been less successful agreeing on a replacement plan. With a slim majority in the Senate (52 Republicans and 48 Democrats) and no Democrats in the House supporting this effort, Republicans are finding it difficult to meet the demands of moderate Republicans who want to protect the ACA’s insurance gains and conservative Republicans who want to eliminate as many ACA requirements, regulations, and taxes as possible. Republicans face a similar dilemma in the House, although they have a little more room for disagreement, because they can survive with 21 Republican defectors and still pass a bill without support from the Democrats. Congress spent the better part of the spring and summer in 2017 wrestling with repeal and replacement bills. After much political drama, the House passed their replacement bill, the American Health Care Act of 2017 (AHCA), on May 4, 2017 by a narrow 217–213 margin. Every Democrat and 20 Republicans voted against the bill. In the Senate, Republicans drafted their bill, the Better Care Reconciliation Act of 2017

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(BCRA), which followed the same general contours of the AHCA. After barely mustering sufficient support to proceed with debate on the bill, the Senate voted against BRCA on July 25, 2017. All Democrats and 9 Republicans opposed the bill (Fox, Lee, Mattingly, & Barrett, 2017). The next day, all Democrats and 7 Republicans also voted against a bill that would have simply repealed the ACA (effective in 2 years) and did not include any type of replacement (Lee & Mattingly, 2017). This repeal-only bill actually passed Congress while President Obama was in office, but because members of Congress who voted for repeal knew that Obama would veto the bill, it was considered a protest vote more than an agreement on a policy position. During the 2017 Senate debate, Sen. John McCain (R-AZ), who at the time had been recently diagnosed with aggressive brain cancer, provided a moment of high drama. His “no” vote was the third Republican vote (along with Sens. Lisa Murkowski [R-AL] and Susan Collins [R-ME]) that ultimately doomed what was referred to as the “skinny repeal” option (Fox, 2017). The skinny repeal option eliminated just the individual and employer mandates as well as a tax on medical devices. It was a bill that few actually wanted to become law, and it was projected to increase premiums and drastically reduce the number of insured individuals. Even the senators who voted for the bill did so only after assurances that the House would not pass it. Why, then, move forward with a bill few supported? The goal was to reach a “conference committee” wherein the House and Senate could work to reach a repeal and replace compromise, which would then be sent back to each chamber for approval. At that point, the political pressure to support a compromise bill would have been immense. The vote for the skinny repeal bill was a vote to keep the health reform debate alive, but risked a result that few desired. In voting against this strategy, the three Republican senators who voted “no” urged their colleagues to move forward in a bipartisan manner and to follow regular order in the Senate (holding hearings, passing bills through committee, etc.).

One thing Congress has not tried yet is a bipartisan approach. A clear majority of the public (71%) strongly prefers for Republicans and Democrats to work together on health reform, and a number of legislators from both sides of the aisle have indicated a desire to do so. While a partisan divide remains here as well, 41% of all Republicans and 46% of Trump supporters would like to see the parties work together (Kaiser Family Foundation, 2017). After the failed ­Senate efforts, Sen. Lamar Alexander (R-TN), Chair of the Senate Committee on Health, Education, Labor and Pensions, agreed to open bipartisan hearings on fixing the individual marketplace (Park, 2017). In addition, a group of bipartisan legislators from the House announced a plan to improve the ACA. Their strategy includes paying low-income, cost-sharing subsidies to insurers, providing federal funds to the states to create reinsurance funds and other programs to lower premiums, applying the employer mandate to employers with 500 (instead of 50) or more employees, redefining full-time employee as those who work 40 hours per week, obtaining clarification from USDHHS about a §1332 waiver process, and repealing the medical device tax (Lee, 2017). They also recommended offsetting the federal funds spent on these ideas, but did not indicate how current funding should be cut. The political difficulty of repealing and replacing the ACA is not surprising. It is always difficult to take away benefits once people have started to use them. Supporting a bill that would result in over 20 million people losing insurance is clearly more politically perilous than not supporting legislation (i.e., the ACA) that would deliver health insurance to 20 million people for the first time. This is particularly true for federal legislators who hail from states that (a) implemented the ACA’s Medicaid expansion and (b) have Republican governors. Why? Much of the savings from the House and Senate bills came from reduced Medicaid spending, both through the elimination of the expansion and by changing the entire program from an entitlement program to a block grant or per capita allotment. In turn, states would either have

Key Issues Going Forward

had to absorb the federal spending reductions in their own budgets or absorb the healthcare costs of having more uninsured residents. Indeed, the proposed changes to Medicaid, which went well beyond repealing and replacing the ACA, resulted in many of the biggest criticisms from moderate Republicans. Also, Medicaid has become even more important to the nation now that it is grappling with an opioid epidemic, because Medicaid and CHIP cover approximately one-third of individuals with an opioid addiction. This is nearly double the share covered by Medicaid in 2005 and the increase is mostly due to the ACA Medicaid expansion (Kaiser Family Foundation, n.d.). The Senate Republican leadership also made a difficult political situation even harder by alienating several of their own members when the leadership decided that the ACA repeal bills would be drafted in relative secret, ignored regular process (by not holding hearings, debates, mark-ups), used reconciliation to avoid a filibuster, and expected their members to vote on bills they had little time to review. Sen. John Cornyn (R-TX), the second-ranking Republican in the Senate, went so far as to say that knowing prior to the start of debate which bill the Republicans would be voting on was “a luxury we don’t have” (Sullivan, 2017). This was a hard pill to swallow for many Republicans who vilified the Democrats for their partisan approach to passing the ACA and who mocked then–House Speaker Nancy Pelosi (D-CA) for saying, “we have to pass the healthcare bill so that you can find out what’s in it” (Capehart, 2012). While ultimately Republican leaders were not successful in getting the legislation passed, they decided that the negative ramifications of these hardball tactics were easier to survive then the negative publicity of a drawn-out process where opposition groups could mobilize their resources.

The Trump Administration Even if Congress cannot agree on a new health reform bill, the Trump administration wields significant power over the future of health reform

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through its executive authority. The key question is whether President Trump will follow through on his threat to “let Obamacare fail” with the goal of (a) pinning the collapse on Democrats and (b) forcing Democrats to negotiate with Republicans on a repeal and replacement bill (Tillett, 2017). Trump has asserted that “Republicans are not going to own [Obamacare’s collapse],” but because Republicans hold power in Congress and the White House, they may end up being blamed for future healthcare woes (Tillett, 2017). So far, Trump’s actions and indecision on health reform issues have negatively impacted the ACA. On his first day in office, Trump signed an executive order that allowed USDHHS and other agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the [ACA] that would impose a fiscal burden” on the states, individuals, or other entities involved in health care (Jost, January 20, 2017). While the specific changes that could take place under this Order are unclear, the intent to free individuals and states from ACA obligations is ­unmistakable. The administration also proposed a rule to make it more difficult to sign up for insurance during a special enrollment period, shortened the length of the next open enrollment period, and made it easier for insurers to collect back premiums (Associated Press, 2017; Jost, January 20, 2017). In addition, the administration weakened enforcement of the individual mandate by ordering the Internal Revenue Service (IRS) to continue processing tax returns even if filers do not indicate whether they had insurance coverage (Associated Press, 2017). ­Examples of other actions the administration could take ­include withdrawing the appeal of a lawsuit that could eliminate cost-sharing subsidies (discussed more later), granting more hardship waivers to exempt people from complying with the ­individual mandate, limiting advertising and outreach during the next open ­enrollment period, granting waivers to the states to allow Medicaid-related work requirements or increased cost sharing, rewriting regulations to

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allow for skimpier benefits under the essential health benefits requirement, and eliminating contraceptives from the list of women’s preventive services (Bagely & McIntyre, 2017; Newkirk, 2017; Pear & Abelson, 2017).

Insurance Plan Premium Rates One of the key issues to monitor going forward is the affordability of health insurance plans under the ACA. Most people were pleasantly surprised by premium rates for 2014 and 2015, although there was a lot of variation across the country. Insurers had incentive to keep premiums low because they wanted to encourage people to enroll in their health plans. In addition, there was limited information about who would be in the insurance pools that could have assisted insurers with premium rate setting, and many plans contracted with a narrower set of providers as a way to keep premiums low. Going into 2018, insurers are facing significant uncertainty due to the political landscape. With Congress reviewing a variety of repeal and replacement plans and the Trump administration threatening to let ACA reforms fail, insurers do not know what to expect in the upcoming year, and uncertainty is not something that makes for a stable health insurance market. As a result, insurers are asking for delays in submitting premium rates, and some are even submitting two rates depending on the outcome of certain political decisions (Mangan, 2017). Many insurers that are submitting rates are asking for double-digit increases (a review of silver plans in 8 states showed an average increase of 18% (Adamczyk, 2017), while other rate requests are even higher. For example, insurers in Maryland are asking for rate increases ranging from 18% to 60%, and in Connecticut the range is 15% to 34%. Nevada is requesting an average rate hike of 38%, and Colorado’s request is similar, with an average increase of 41% (Livingston, 2017; Luhby, 2017). The main sources of uncertainty are whether the Trump administration will fund cost-sharing subsidies and enforce the individual mandate

(Livingston, 2017). Cost-sharing subsidies offset the cost of care for low-income consumers. These subsidies have been the subject of litigation brought by House Republicans under the Obama administration. Insurers do not know whether to expect the $7 billion owed to them for providing the subsidies in 2017 or the billions that would be owed to them in future years. The Trump administration decided to end funding for the cost-sharing subsidies and it remains to be seen whether Congress will restore the funding. In addition, other actions, such as not enforcing the individual mandate and limiting outreach efforts, make it less likely that healthier individuals will enroll in the plans, resulting in a sicker and more expensive pool. Some insurers are responding to the uncertainty by exiting the market, while other insurers have increased their offerings (Fise, 2017). While thousands of enrollees were expected to be in counties in which no insurer is offering a product on their exchange in 2018 (referred to as “bare” counties), there are no longer any bare counties due to recent decisions by insurers (with prodding by state insurance agencies) (Levy, 2017). Given the rising premiums and reduced insurance offerings, there is a debate about whether the exchanges are collapsing or stabilizing. While some analyses show a stabilizing market, continued subsidy support and increased enrollment of healthier individuals are key factors to the long-term success of the exchanges (Cox & Levitt, 2017; McKinsey Center for Health System Reform, 2016; Zeitlin, 2017).

ACA Litigation Legal challenges to the ACA did not end with the Supreme Court’s National Federation of Independent Business v. Sebelius decision in 2012, and the Supreme Court has handed down rulings in other ACA lawsuits. In 2014 the court decided Burwell v. Hobby Lobby, which answered whether, under a federal statute called the Religious Freedom Restoration Act (RFRA), closely held private corporations have a legal right to refuse to comply with provisions of the ACA that

References

require them to provide certain contraceptive coverage to employees. (Note: A closely held corporation is one that has a limited number of shareholders; in the Hobby Lobby case, the plaintiffs were two private, for-profit companies owned by members of a single family—Hobby Lobby Stores [owned by Evangelical Christians] and Conestoga Wood Specialties [owned by Mennonites]). In a 5–4 decision, the court majority determined that the ACA’s contraception mandate imposed a significant enough burden on the plaintiff companies’ exercise of their beliefs so as to violate RFRA. Then in 2015, the Supreme Court decided King v. Burwell, which held that subsidies available under the ACA to help individuals and small businesses buy insurance were available whether the insurance was purchased through a state-run or federally facilitated insurance exchange. Most recently, in 2016, the Court heard Zubik v. Burwell, a case that is an offshoot of its earlier decision in Burwell v. Hobby Lobby. After the Hobby Lobby decision, the Obama Administration offered an accommodation to religious entities that objected to the requirement to provide contraceptive coverage without cost sharing: Simply inform USDHHS of your objection and identify your insurer, at which point the USDHHS would take responsibility for ensuring that contraceptive services are provided by the insurer without the involvement of the religious organization. The accommodation, however, was not acceptable to a number of religious entities, which filed their own RFRA lawsuits. At the time of this writing, many cases remain pending in the appellate courts. In August 2017, the Third Circuit Court of Appeals ruled by a 2–1 margin in favor of the federal government in Real Alternatives v. HHS. Specifically, the two judges in the majority ruled that (1) the government need not exempt from the mandatory coverage requirement an employer that objects on moral, as opposed to religious, grounds; and (2) individuals who object to contraceptives on religious grounds need not be allowed to purchase insurance that does not cover contraceptives. Over the past years, cases

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related to subsidies have faced religious challenges and have yielded a variety of judgments that have and will continue to rise through the court systems. Given these and other lawsuits still to come, it is unlikely that the Supreme Court has cleared the ACA from its docket. However, irrespective of whether the Supreme Court hands down ACA-related cases in the future, what bears keeping in mind is that judicial decisions may continue to shape the contours of the ACA for years to come.

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Conclusion

After decades of trying and against the predictions of numerous experts, the United States passed a health reform law that provides insurance coverage on a more universal scale than ever before, includes protections for individuals who have been historically excluded from the insurance market, and shows a concern for improving healthcare quality and access to preventive care. From a philosophical perspective, the ACA moves the United States toward a society where (almost) everyone is expected to have adequate access to affordable health insurance. Under this perspective, health insurance is considered both an obligation and a right: Individuals are required to obtain insurance and the government is obligated to make it affordable and accessible. At the same time, there remains, in some quarters, strong philosophical and political opposition to the ACA, which continues to be challenged both legislatively and in the courts. Because of this opposition and because the ACA is still not close to engendering the type of support reserved for Medicare, the full story of the ACA is far from being completed.

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/issue-brief/individual-insurance-market-performance -in-early-2017 (accessed July 31, 2017). DiJulio, B., Kirzinger, A., Wu, B., & Brodie, M. (2017, March 2). Data note: Americans’ challenges with health care cost. Kaiser Family Foundation. Retrieved from http://www.kff.org/health-costs/poll-finding/data-note -americans-challenges-with-health-care-costs/. Fise, P. (2017, June 8). Cost sharing reduction subsidies: What happens if they aren’t paid? Bipartisan Policy Center. Retrieved from https://bipartisanpolicy.org /blog/cost-sharing-reduction-subsidies-what-happens -if-they-arent-paid/ (accessed July 26, 2017). Fox, L. (2017, July 26). John McCain’s maverick moment. CNN. Retrieved from http://www.cnn.com/2017/07/26 /politics/health-care-bill-wednesday/index.html (accessed July 31, 2017). Fox, L., Lee, M. J., Mattingly, P., & Barrett, T. (2017, July 26). Senate rejects proposals to repeal and replace Obamacare. CNN. Retrieved from http://www.cnn.com/2017/07/25 /politics/senate-health-care-vote/index.html (accessed July 26, 2017). Garfield, R. (2016, October 19). The coverage gap: Uninsured poor adults in states that do not expand Medicaid. Kaiser Family Foundation. Retrieved from http://www.kff.org /uninsured/issue-brief/the-coverage-gap-uninsured -poor-adults-in-states-that-do-not-expand-medicaid/ (accessed July 25, 2017). Gordon, C. (2003). Dead on arrival: The politics of health care in twentieth-century America. Princeton, NJ: Princeton University Press. Graves, J., & Nikpay, S. (2017). The changing dynamics of US health insurance and implications for the future of the Affordable Care Act. Health Affairs, 36(2), 297–305. Jost, T. (2004). Why can’t we do what they do? National health reform abroad. Journal of Law, Medicine & Ethics, 32, 433–441. Jost, T. (2017, January 20). Trump executive order on ACA: What it won’t do, what it might do, and when. Health Affairs Blog. Retrieved from http://healthaffairs.org /blog/2017/01/20/trump-executive-order-on-aca-what -it-wont-do-what-it-might-do-and-when/ (accessed March 31, 2017). Jost, T. (2017, February 16). Unpacking the trump administration’s market stabilization proposed rule. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2017/02 /16/unpacking-the-trump-administrations-market -stabilization-proposed-rule/ (accessed April 4, 2017). Jost, T. (2017, May 15). CMS announces plans to effectively end the SHOP exchange. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog.2017/05/15/cms -announces-plans-to-effectively-end-the-shop-exchange/ (accessed July 24, 2017). Kaiser Family Foundation. (n.d.). The opioid epidemic and Medicaid’s role in treatment: A look at changes over time. Powerpoint. Retrieved from http://www.kff.org /slideshow/the-opioid-epidemic-and-medicaids-role

References -in-treatment-a-look-at-changes-over-time/ (accessed July 26, 2017). Kaiser Family Foundation. (2009, September 1). Key findings: Kaiser health tracking poll—September 2009. Retrieved from http://www.kff.org/kaiserpolls/upload/7990.pdf (accessed July 26, 2017). Kaiser Family Foundation. (2014, April 29). Kaiser health tracking poll—April 2014. Retrieved from http://kff.org /health-reform/poll-finding/kaiser-health-tracking -poll-april-2014/ (accessed July 26, 2017). Kaiser Family Foundation. (2017, July 14) Kaiser health tracking poll—July: What’s next for Republican ACA repeal and replacement plan efforts? Retrieved from http://www.kff .org/health-reform/poll-finding/kaiser-health-tracking -poll-july-2017-whats-next-for-republican-aca-repeal -and-replacement-plan-efforts/ (accessed July 26, 2017). Kaiser Family Foundation. (2017, November 8). Explaining health care reform: Questions about health insurance subsidies. Retrieved from http://kff.org/health-reform /issue-brief/explaining-health-care-reform-questions -about-health/ (accessed August 7, 2017). Khan, H. (2010, March 22). Health care bill aftermath: Rep. Patrick Kennedy hails dad’s dream; Sen. John McCain sees heavy price. ABC News. Retrieved from http://abcnews. go.com/GMA/HealthCare/health-care-congress-passes -landmark-reform-obama-sign/story?id=10167139 (accessed August 7, 2017). Kondick, K., & Skelley, G. (2016). Incumbent reelection rates higher than average in 2016. Rasmussen Reports. Retrieved from http://Rasumssenreports.com/public _ content/political_commentary/commentary_by_kyle _kondik_incumbent_reelection_rates_higher_than _average_in_2016 (accessed July 19, 2017). Lee, M. (2017, July 31). Bipartisan coalition looks to solve problem of individual market. Modern Healthcare. Retrieved from http://www.modernhealthcare.com /article/20170731/NEWS/170739986 (accessed August 7, 2017). Lee, M. J., & Mattingly, P. (2017, July 26). Health care debate: Senate rejects full Obamacare repeal without replacement. CNN. Retrieved from http://www.cnn .com/2017/07/26/politics/health-care-bill-wednesday /index.html (accessed July 26, 2017). Levy, G. (2017, August 24). Last ‘bare’ county in US to have Obamacare coverage in 2018. US News and World Report. Retrieved from https://www.usnews.com/news /national-news/articles/2017-08-24/last-bare-county -in-us-to-have-obamacare-coverage-in-2018 (accessed August 30, 2017). Livingston, S. (2017, May 10). Health insurers’ proposed 2018 rate hikes are early warning signs. Modern Healthcare. Retrieved from http://www.modernhealthcare.com /article/20170510/NEWS/170519999/ (accessed July 26, 2017). Luhby, T. (2017, July 29). Repeal is dead (for now). CNN Money. Retrieved from http://money.cnn.com/2017/07

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/29/news/economy/obamacare-repeal/index.html (accessed July 31, 2017). Mangan, D. (2017, April 28). California will allow insurers to file two sets of rates: One for ’Trumpcare,’ other for ’Obamacare.’ CNBC. Retrieved from http://www.cnbc .com/2017/04/28/california-will-allow-health-insurers -to-file-two-sets-of-rates-one-for-trumpcare-other-for -obamacare.html (accessed July 26, 2017). McKinsey Center for Health System Reform. (2016, May 13). Exchanges three years in: Market variations and factors affecting performance. Retrieved from http://healthcare .mckinsey.com/sites/default/files/Intel%20Brief% 20-%20Individual%20Market%20Performance% 20and%20Outlook%20%28public%29_vF.pdf (accessed July 31, 2017). Medicaid, CHIP Payment and Access Commission. (n.d.). Medicaid enrollment changes following the ACA. Retrieved from https://www.macpac.gov/subtopic/medicaid -enrollment-changes-following-the-aca/ (accessed July 25, 2017). Morone, J. (2010). Presidents and health reform: From Franklin D. Roosevelt to Barack Obama. Health Affairs, 29(6), 1096–1100. National Federation of Independent Business v. Sebelius, Secretary of Health and Human Services, et al. (2012). 132 S. Ct. 2566. Newkirk, V. (2017, March 25). Obamacare isn’t out of the woods yet. The Atlantic. Retrieved from https://www .theatlantic.com/politics/archive/2017/03/the-aca-isnt -out-of-the-woods-yet/520830/ (accessed April 3, 2017). Newport, F. (2010, November 18). U.S. still split on whether gov’t should ensure healthcare. Gallup. Retrieved from http://news.gallup.com/poll/144839/Split-Whether -Gov-Ensure-Healthcare.aspx (accessed August 2, 2017). Obama’s health care speech to Congress. (2009, September 9) The New York Times. Retrieved from http://nytimes .com/2009/09/10/us/politics/10obama.text.html (accessed July 26, 2017). Park, M. (2017, August 2). Senator announces bipartisan hearing on Obamacare. CNN. Retrieved from http:// www.cnn.com/2017/08/02/politics/senate-health -care-hearing-bipartisan/index.html (accessed August 7, 2017). Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148, H.R.3590. Retrieved from https://www .congress.gov/bill/111th-congress/house-bill/3590 (accessed November 27, 2017). Pear, B., & Abelson, R. (2017, March 30). Health subsidies for low-earners will continue through 2017, G.O.P. says. The New York Times. Retrieved from https://www .nytimes.com/2017/03/30/us/politics/health-insurance -republicans.html (accessed April 3, 2017). Pew Research Center. (2017, June 23). Public support for single payer health coverage grows, driven by Democrats. Retrieved from http://www.pewresearch .org/fact-tank/2017/06/23/public-support-for-single

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-payer-health-coverage-grows-driven-by-democrats/ (accessed July 18, 2017). Rosenbaum, S., Teitelbaum, J. & Hayes, K. (2011). Crossing the Rubicon: The impact of the Affordable Care Act on the content of insurance coverage for persons with disabilities. Notre Dame Journal of Law, Ethics & Public Policy, 25(2):527–562. Starr, P. (1982). The social transformation of American medicine: The rise of a sovereign profession and the making of a vast industry. New York, NY: Basic Books. Sullivan, P. (2017, July 20). Cornyn: Knowing health plan ahead of vote is "luxury we don’t have." The Hill. Retrieved from http://thehill.com/policy/healthcare/342980 -cornyn-knowing-health-plan-ahead-of-vote-is-luxurywe-dont-have (accessed July 26, 2017). Tax Policy Center. (2017). What is reconciliation? Tax Policy Center Briefing Book. Retrieved from http://www

.taxpolicycenter.org/briefing-book/what-reconcilation (accessed July 19, 2017). Tillett, E. (2017, July 18). Trump on Senate’s health care failure: "Let Obamacare fail." CBS News. Retrieved from http://www.cbsnews.com/news/trump-on-senates-health -care-failure-let-obamacare-fail/ (accessed July 26, 2017). United States v. Lopez. 514 U.S. 549 (1995). Possession of a gun near school is not an economic activity that has a substantial effect on interstate commerce. United States v. Morrison. 529 U.S. 598. (2000). Federal Violence Against Women Act of 1994 is unconstitutional violation of congressional Commerce Clause power. Zeitlin, J. (2017, February 16). Are the ACA exchanges really in a death spiral? We asked the experts. Advisory Board. Retrieved from https://www.advisory.com /daily-briefing/2017/02/16/death-exchange-market (accessed July 31, 2017).

Case Study lives, and the federal government has an array of tools to bring the rise of health care costs under control. However, the work toward a high-quality, affordable, accessible health care system is not over. (Obama, 2016, p. 526)

CASE STUDY

Sara E. Wilensky and Joel B. Teitelbaum When I took office, health care costs had risen rapidly for decades, and tens of millions of Americans were uninsured. Regardless of the political difficulties, I concluded comprehensive reform was necessary. The result of that effort, the Affordable Care Act (ACA), has made substantial progress in addressing these challenges. Americans can now count on access to health coverage throughout their

Discussion Question 1 Even though the primary legislative bills to repeal and replace the Affordable Care Act (ACA)—the AHCA and BRCA—did not have sufficient support across U.S. Congress to become law, and some of their provisions may not have been allowed under reconciliation rules, it is worth considering the main features of the bills to understand the type of health reform changes many Republicans support (see TABLE 7-1). Overall, these bills reduced taxes, eliminated government mandates, lowered federal government spending, lowered premiums

TABLE 7-1  Comparison of U.S. House and Senate ACA Replacement Bills Provision

AHCA (House)

BRCA (Senate)

Premium tax credits

Replaces with tax credits based on age only, not income or geographic area.

Keeps tax credits, eligibility lowered to 350%, includes those under 100% FPL, tied to less expensive benchmark, changes individual contribution levels so older consumers pay more.

Individual mandate

Eliminates penalties; replaces with 1-year 30% premium surcharge if lapse in coverage.

Eliminates penalties, replaces with 6-month waiting period if lapse in coverage.

Employer mandate

Eliminates penalties.

Eliminates penalties.

Medicaid expansion

Phases out by end of 2019.

Phases out by end of 2024.

ACA taxes

Eliminates most key taxes.

Eliminates many key taxes, keeps Medicare surtax and investment tax on high-income earners.

Essential health benefits

Allows state waivers to redefine.

Allows state waivers to redefine.

(continues)

CASE STUDIES

The Work Continues: Case Discussion Questions

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CASE STUDIES

TABLE 7-1  Comparison of U.S. House and Senate ACA Replacement Bills

(continued)

Provision

AHCA (House)

BRCA (Senate)

Medicaid program

Changes to block grant or per capita allotment in 2020; allows work requirements.

Changes to block grant or per capita allotment in 2020; allows work requirements.

Cost-sharing subsidy funds

Funds through 2019, repeals in 2020.

Funds through 2019, repeals in 2020.

Women’s health services

Defunds Planned Parenthood for 1 year; redefines qualified plan to exclude plans that provide abortion services except for rape, incest, or life of mother in danger.

Defunds Planned Parenthood for 1 year; redefines qualified plan to exclude plans that provide abortion services except for rape, incest, or life of mother in danger.

Private market rules

Keeps guaranteed issue, dependent coverage until 26; preexisting condition protection remains.

Keeps guaranteed issue, dependent coverage until 26; preexisting condition protection remains; permits sale of noncompliant plans as long as selling one ACA-compliant plan.

State stabilization pool

Provides $123 billion over 9 years.

Provides $182 billion over 9 years.

Public health prevention fund

Eliminates.

Eliminates.

Age rating band

Changes to 5-to-1 but allows for state variation.

Changes to 5-to-1 but allows for state variation.

CBO estimate—uninsured

23 million more uninsured by 2026.

22 million more uninsured by 2026.

CBO estimate— federal savings

$119 billion.

$321 billion.

for some people while increasing them for others, phased out the Medicaid expansion under the ACA, and ended Medicaid as an entitlement program. According to the nonpartisan Congressional Budget Office (CBO), the effect of the bills would be to significantly increase the number of uninsured, significantly reduce the deficit, lower costs for young and healthy

consumers, and increase costs for older and poorer consumers (Congressional Budget Office, June 26, 2017; Congressional Budget Office, July 23, 2017). Everyone agrees the ACA can be improved. Are there features of these bills that you think have merit? Should states have more flexibility under the ACA? How much of the cost burden should young and healthy individuals bear in order to make

Case Study health insurance more affordable for elderly and sicker individuals?

Discussion Question 2

Discussion Question 3 There was a lengthy debate about whether to include a public option in health reform. A public option is some type of government-run health plan that would be available to compete with private plans. A public option could exist within the health exchange model or outside of it. Instead of a public option, Congress voted to require the Office of Personnel Management, which runs the Federal Employees Health Benefit Program, to contract with at least two multistate plans in every state health insurance exchange. What are the pros and cons of having a public option? Does the Office of Personnel Management compromise achieve all or some of the goals of having a public option? Why do you believe the Office of Personnel Management compromise was acceptable to legislators but the public option was not?

Discussion Question 4 Republican policymakers that are involved in bipartisan discussions to revise the ACA are focused on providing states with increased flexibility regarding benefit design, premium pricing, and other features. Although states are generally home to social welfare changes, it is difficult to provide universal health care on a state-by-state basis. If state health reform efforts lead the way, the country could have a patchwork of programs and policies that vary from state to state, with the potential to make health coverage even more complex and inefficient than it is currently. On the other hand, it is also important to recognize that a health reform strategy focusing on states has benefits as well. At its best, state-level reform can be accomplished more rapidly and with

more innovation than at the federal level. State legislatures may have an easier time convincing a narrower band of constituents important to the state than Congress has in accommodating the varied needs of stakeholders nationwide. What are the advantages and disadvantages of compromising regarding the state role in the ACA? Is it worth giving up some degree national uniformity and stronger consumer protections in exchange for political stability and allowing state to experiment with health reform design? How well do you think the public will be served in their access to affordable health insurance and access to health care if states have more control? How does your response differ if you are living in California or New York versus Texas or Florida?

Discussion Question 5 A group of friends were talking about the Affordable Care Act (ACA), illustrating the wide-ranging viewpoints about the law. Calvin, whose daughter Mia is struggling to make a living as an artist, is pleased that Mia has health insurance for the first time since graduating from college. Although Mia cannot stay on her parents’ insurance because she just turned 27, she can now afford a good health insurance plan that she found on her state’s health exchange. While Calvin has not noticed much of a change in his own health insurance coverage, which he obtains through his government employer, his friend Katherine is upset about health reform. She does not want the government forcing her to purchase health insurance (although she always chose to be insured in the past), and she recently found out that her old plan was cancelled because it did not meet the law’s requirements. Katherine found several new plan options to choose from, but none had her exact combination of benefits, providers, and price. In addition, Katherine’s uncle, Ethan, is 55 years old and self-employed. He purchases his health insurance on his state’s exchange and because he has preexisting conditions, he is grateful to be able to find a plan. Even so, Ethan’s premiums will increase by 15% this year and his deductible is $5,000, making health care difficult to afford even with insurance. Another friend, Jara, told Katherine she should be willing to pay a little more or change some aspects of her plan to help the millions of people who can now afford insurance for the first time as a result of the ACA.

CASE STUDIES

Are there alternatives to the individual mandate that accomplish the same goals without engendering so much political turmoil? Could policymakers have designed an incentive system that would be as effective as a mandate? What are the pros and cons of using a mandate versus an incentive? Can you think of incentives to encourage enrollment that have occurred in other parts of the healthcare system?

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After witnessing her uncle’s experience, however, Katherine is skeptical that the government is going to be able to keep its promises. What are the competing viewpoints about the ACA exemplified by these friends? Which of these friends’ views will be the most pressing concern going forward in the discussions about the ACA?

References Congressional Budget Office. (2017, June 26). Better Care Reconciliation Act of 2017—cost estimate. Retrieved from https://www.cbo.gov/system/files/115th-congress -2017-2018/costestimate/52849-hr1628senate.pdf (accessed July 26, 2017).

Congressional Budget Office. (2017, July 23). American Health Care Act—cost estimate. Retrieved from https:// www.cbo.gov/system/files/115th-congress-2017-2018 /costestimate/americanhealthcareact.pdf (accessed July 23, 2017). Obama, B. (2016). United States health care reform: Progress to date and next steps. Journal of the American Medical Association, 316(5), 525–532. doi:10.1001/jama.2016.9797

CHAPTER 8

Healthcare Quality Donna Middaugh

OVERVIEW This chapter presents an overview of human error, error theory, quality improvement, and the application of quality improvement concepts to healthcare delivery. Error measurement tools and injury prevention models are applied across healthcare settings. Public reporting systems and regulatory agency requirements are analyzed in conjunction with nursing performance measures. National initiatives and their impact on quality care are explored. In 2015, the overall share of the U.S. economy devoted to healthcare spending was 17.8%, amounting to $3.2 trillion (Centers for Disease Control and Prevention, 2017). Healthcare costs only accelerate with the aging of the population and its increased dependence on federal and state financing of health care. Yet despite our high national spending, health care in the United States is uneven in quality and is often wasteful, uncoordinated, and inefficient (Bipartisan Policy Center, 2013).

OBJECTIVES ■■ ■■

■■

■■ ■■

Explain relevant theories of error as they relate to patient care. Apply effective error management techniques from aviation and industry to the healthcare delivery system. Identify examples of quality care initiatives to reduce costs while improving patient safety and outcomes that are cost driven. Discuss the role of quality care mandates from regulatory agencies. Analyze the impact of national initiatives on quality care performance and outcomes.

© Anthony Krikorian/Shutterstock

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Quality Care and Public Policy

Above all, do no harm. —Hippocratic Oath Public belief and trust in the healthcare system was shaken in 1999 when the Institute of Medicine (IOM) reported that between 44,000 and 98,000 Americans die each year as a result of medical errors (Kohn, Corrigan, & Donaldson, 2000). The November 1999 report of the IOM, published in a book titled To Err Is Human: Building a Safer Health System, alerted healthcare institutions and professionals to the true scope of the quality problem (Kohn, Corrigan, & Donaldson, 2000). The reality is that errors occur across the healthcare sector, including clinics, physicians’ offices, pharmacies, homes, nursing homes, and hospitals. Every day, Americans expect to receive high-quality health care to maintain or restore their health and well-being. Unfortunately, every day thousands of Americans are exposed to unequal care and quality, and are injured or die in the course of treatment. For example, a hospital study conducted in New York state found that 3.7% of patients experienced adverse events: 12.6% of those events led to death, and 2.6% led to permanent disability. One-fourth of the events resulted from negligence (Agency for Healthcare Research and Quality [AHRQ], 2002). The IOM, now known as the National Academies of Medicine, released its staggering report on medical errors more than 17 years ago. It estimated that the United States lost more patient lives to safety incidents every 6 months than it did in the entire Vietnam War (Kohn, Corrigan, & Donaldson, 2000). Statistics indicate that more deaths occur in the United States each year from medical errors than from motor vehicle accidents, breast cancer, or acquired immunodeficiency syndrome (AIDS). Put in other terms, medical errors, if documented by the Centers for Disease Control and Prevention (CDC),

would rank as the third leading cause of death in the United States (Makary & Daniel, 2016). Today the numbers of medical errors are staggering. As many as 400,000 Americans succumb to medical errors annually. Another 10,000 suffer complications daily. The total cost of these errors is estimated at between $17 billion and $29 billion per year (Medcom, 2017). Medical errors are costly, leading to loss of trust within the healthcare system, decreased patient satisfaction, and degraded morale among healthcare professionals. The U.S. Food and Drug Administration (FDA) has estimated that medication errors cause at least one death every day and injure ­approximately 1.3 million people annually in the U.S. (FDA, 2016). When one considers the billions of medications that are prescribed at clinics and physician offices and taken home, it is staggering to think of the possible scope of error. All medication mistakes may and must be preventable. Healthcare providers, the public, and federal and state governments have investigated the facts and sought answers as to why these errors are so prevalent. A report published in 2013, American Hospital Quality Outcomes 2014: HealthGrades Report to the Nation, focused on the performance of more than 4,500 U.S. hospitals and covered 31 of the most common inpatient procedures and conditions during 2010 to 2012. The report showed that hospitals, physicians, and patients each have a role to play and each group must take specific actions to help improve quality outcomes at lower costs. The report identifies the following ­(HealthGrades, 2013): ■■

■■ ■■

Quality disparities persist within hospitals among different procedures and conditions, as well as among hospitals within local service areas. Patient complications and mortality in hospitals increase direct costs. The use of minimally invasive surgical techniques may hold promise for reducing mortality and length of stay.

Human Error

Hospitals have a moral and ethical imperative to improve their patient care outcomes, focus on quality, and strive for excellence in safety, quality, and overall performance. The 2014 HealthGrades report demonstrates that there is significant variation in hospital outcomes, even after accounting for patients’ severity of illness and population demographics. This translates into the fact that physicians should stay current on the latest approaches and techniques, perform procedures that have been shown to have lower complication and mortality rates, and use referral networks with surgeons who are trained in minimally invasive surgery options when appropriate. Patients should use quality performance data to make informed choices by finding out about the performance of hospitals based on complication and mortality rates. They should also be aware of the variation in direct costs incurred by hospitals, which are passed on to the consumer in the form of higher premiums, deductibles, and copays. The HealthGrades report highlights the connection between higher complication rates and increased costs. Choosing Wisely is an initiative of the American Board of Internal Medicine (2017) that aims to promote conversations between healthcare providers and patients. Their purpose is to help patients select care that is evidence based, not duplicative of tests or procedures they already received, and to receive care that is free from harm and is truly necessary. The Choosing Wisely website (www.choosingwisely.org) identifies a list of common tests and procedures from medical specialty organizations to empower the public to start conversations about what is appropriate care.

▸▸

Human Error

Errors may occur in all phases of healthcare delivery. Diagnostic errors may occur with improper testing, misread or misinterpreted laboratory results, or failure to act on the results. During patient treatment, technical errors may result in the inaccurate preparation or delivery

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of treatments. Treatment can be delayed, missed, or performed incorrectly. A medical error might mean the healthcare provider chose an inappropriate method of care, or the provider chose the right course of care but carried it out incorrectly (Nordenberg, 2000). Medical errors are not purposeful or reckless actions that are intended to harm a patient (Liang, 2001), and errors do not always result in harm. Adverse events, on the other hand, do imply harm to an individual. Throughout the literature, the term error is used to denote a mistake, close call, near miss, or active or latent error. Active errors occur at the level of the frontline provider—for example, administering the wrong medication. Active errors are limited in time and space, so they are easier to measure. Latent errors involve system defects, such as faulty maintenance on equipment, poor design, or inadequate staffing. Latent errors are more difficult to measure because they occur over greater periods of time and space and because they may exist for a long time before they lead to an error or adverse event (Thomas & Petersen, 2003).

Error Settings The use of outpatient settings, including physician offices, has risen dramatically. Hospitals are operating with fewer beds or closing outright to make way for new ambulatory care centers (Medcom, 2017). The shift to outpatient care is accelerating with new technology and better drugs allowing patients to receive treatment outside of hospitals. Even though the majority of health care takes place in the outpatient setting, efforts to improve safety have mostly focused on the inpatient setting. The nature of interactions between caregivers and patients can be a source of errors, particularly when multiple caregivers are involved. Medication errors are common in ambulatory care, with one study finding more than 4.5 million ambulatory care visits occur annually due to adverse drug events (Sarkar, López, Maselli, & Gonzales, 2011). Errors may occur during routine visits or during outpatient surgery procedures.

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Nursing Errors Woods and Doan-Johnson (2002) developed a classic taxonomy of nursing errors with prevention as the goal. To achieve this goal, they identified eight categories of errors, all of which include system, individual, and practice contributions. It is unclear whether the Practice Breakdown Research Advisory Panel studied subjects from all levels of nursing, including registered nurses and nurse practitioners; however, the following eight categories of nursing errors can be applied to all levels of nursing practice (Woods & Doan-Johnson, 2002): ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

Lack of attentiveness Lack of agency or fiduciary concern Inappropriate judgment Medication errors Lack of intervention on the patient’s behalf Lack of prevention Missed or mistaken patient orders Documentation errors

Lack of attentiveness can be caused by system-level problems, such as understaffing or fluctuations in patient acuity, and it often translates into lack of monitoring. Patient safety depends on attentiveness to both predictable and unpredictable conditions. Agency concern is defined as the moral agency of the nurse or his or her trustworthiness in working for the patient’s and family’s best interest. Moral agency is lacking when nurses do not advocate for the best interests of their clients. Failing to question an order, failing to call a physician for consultation, failing to heed a patient or family request for assistance, and breach of confidentiality are examples of lack of fiduciary concern. These can all contribute to causing harm to the patient. The U.S. Food and Drug Administration (FDA, 2016) identified that medication mishaps can occur anywhere in the medication distribution system: ■■ ■■ ■■

Prescribing Repackaging Dispensing

■■ ■■

Administering Monitoring

Common causes of medication errors include poor communication; poor procedures or techniques; ambiguities in product names, directions for use, or medical abbreviations or writing; and patient misuse because of misunderstanding (FDA, 2016). Additional causes may be related to job stress, lack of product knowledge or training, or similar labeling or packaging of a product.

Error Theory Human error has been studied extensively by James Reason (2000), who identified two approaches to the problem of human error: the person approach and the system approach. A person approach concentrates on the unsafe acts of individuals, which usually result in blame for forgetfulness, inattention, or moral weakness. A systems approach focuses on the conditions under which the person works and assumes that humans are fallible and errors are to be expected. Errors are then viewed as consequences rather than causes. The person approach has been the tradi­ tion in medicine, blaming someone for having made an unsafe choice of behavior (Reason, 2000). Shame and blame have been the method traditionally used by the medical profession to reduce medical errors. The person approach shames an individual into believing that his or her error denotes lack of professionalism and incompetence. The culture of blame seems to be reinforced throughout the education and training of physicians. Clinicians are led to believe that errors are caused by carelessness. This combined with the public’s and media’s quick-to-blame mentality results in fear of both making a mistake and being caught (Weinberg, 2002). There are experts who argue that in complex environments that undergo constant change, such as our healthcare environment, complete elimination of all error will never be possible (Ebright, Urder, Patterson, & Chalko, 2004).

Human Error

Reason’s theory of error has been used by airlines, railroads, nuclear power plants, financial management companies, and the military (Wachter & Shojania, 2004). Reason’s research led him to develop a model of system accidents. High-technology systems, such as health care, have many defensive layers. These can include technological barriers (alarms, automatic shutdowns, etc.), people (surgeons, nurses, etc.), and procedures or administrative controls. The function of these layers is to protect victims and assets from hazards. In an ideal world, each defensive layer would be solid and intact. Reason (2000) emphasizes that, by nature, there are always weaknesses or holes in these layers, making them similar to Swiss cheese. He calls this a Swiss Cheese Model for latent errors. Each slice of cheese represents a safety defense or system, which can have either small holes or large holes. Each hole allows errors to penetrate—the larger the hole, the more errors get through. Reason (2000) argues that when these holes in the cheese align, a number of slips can occur so an error finally reaches the patient. The presence of holes in one layer does not normally cause an adverse event, but these holes are constantly opening and shutting. This allows mistakes or errors to slip through, hopefully to be caught by the next layer. Adverse events can happen only when the holes in many layers momentarily line up to permit a trajectory of accident opportunity, which brings the hazards into contact with victims (Reason, 2000). These holes arise because of active failures or latent conditions. This suggests the need for a systems perspective toward patient safety. The Agency for Healthcare Research and Quality (AHRQ) states that medicine has traditionally treated errors as failings on the part of the individual providers, reflecting poor knowledge or skill (PSNet, June 2017a, p. 1). The systems approach takes the contrasting view that most errors reflect predictable human failings in the context of poorly designed systems. So, rather than focusing on corrective efforts of punishment or remediation, the systems approach

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seeks to identify factors that give rise to human error and to then change the underlying system of care to reduce the occurrence of errors. Reason promoted the idea that human error is inevitable, especially in such complex systems as health care. Expecting flawless performance from human beings working in high-stress, complex environments is unrealistic. The systems approach promotes efforts to catch human errors before they occur or block them from causing harm, which will be more fruitful than approaches that seek to create flawless providers (PSNet, June 2017a).

Error Management Reason (2000) believes that error management has two dimensions: limiting the occurrence of dangerous errors, and creating systems that are better able to tolerate errors and contain their damaging effects. He argues that there are high-reliability organizations that operate in hazardous conditions yet have few adverse events. He proposes that systems in health care should be modeled after these high-reliability organizations, such as U.S. Navy nuclear aircraft carriers, nuclear power plants, and air traffic control centers (Reason, 2000). These organizations anticipate the worst and equip themselves to deal with the worst at all levels. This literally means asking individuals in these systems to remain chronically uneasy, yet the culture of these high-reliability organizations provides employees with reminders and tools to help them remember to be afraid. They have created a culture that makes their system as robust as practicable in the face of both human and operational hazards. Characteristics that allow high-reliability organizations to accomplish this include the following (Reason, 2000): ■■ ■■ ■■

Being internally dynamic, complex, and interactive Performing exacting tasks under time pressure Carrying out demanding activities with low incident rates

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Managing complex, demanding technologies to avoid major failures Maintaining the capacity to meet periods of peak demand

■■ ■■ ■■ ■■ ■■

Medical Errors and Aviation Research on the factors that cause human error has been in existence since the 1940s. Some of the early studies involved aviation. The IOM’s 2000 report noted that the number of Americans who die each year as a result of medical errors is the equivalent of more than 230 full jumbo jets crashing each year (Kohn, Corrigan, & Donaldson, 2000). Today, with over 54 million flight hours annually, the number of airline fatalities has fallen to 250 per year. Yet, compared to health care, 200,000 preventable fatalities per year equals almost 3 fatal airline crashes per day (Kapur, Parand, Soukup, Reader, & Sevdalis, 2015). The aviation and nuclear power industries learned long ago not to rely on human perfection to prevent accidents. Experts have tried to assure the public that the United States healthcare system is safe despite the IOM statistics; however, compared to the complex aviation industry, the healthcare system is not safe. Aircraft accidents are infrequent, but when they occur, they often involve a massive loss of life and therefore gain world attention. Aviation accidents immediately stimulate an enormous, exhaustive investigation into the causes and needed remedial action. Adverse events in health care, on the other hand, involve individual patients and seldom receive even local, let alone national, publicity. There is no standardized method of investigation or remedial action; however, healthcare systems must use methods of examining the cause of errors, such as root cause analyses. The AHRQ Patient Safety Initiative (AHRQ, 2003) identified the most common root causes of medical errors: ■■ ■■

Communication problems/failure Inadequate information flow

■■

Human problems Patient-related issues Organizational transfer of knowledge Staffing patterns/work flow Technical failures Inadequate policies and procedures

Rivers, Swain, and Nixon (2003) looked at whether the safety techniques used in aviation could be applied to the healthcare delivery system. To test this idea, an aviation training team implemented 12 hours of error-reducing skills training for operating room personnel. The findings revealed a significant effect on the behaviors of operating room staff. Specific error-reducing behaviors resulted in more effective, efficient communication among team members, a 50% decrease in surgical count errors, early identification of potential red flags, standardized checklists and protocols, fewer delays in procedures, and savings in time and resources for the operating room as a whole (Rivers, Swain, & Nixon, 2003).

Error Management in Healthcare Settings Preventable adverse events can occur in any healthcare setting despite the best intentions. The National Quality Forum and the Agency for Healthcare Research and Quality (AHRQ) together have identified 30 safe practices that evidence shows can work to reduce or even prevent adverse events (AHRQ, 2005). These 30 practices have been endorsed by the National Quality Forum, which includes 215 of the nation’s leading healthcare providers, purchasers, and consumer organizations. All healthcare practitioners and organizations are strongly urged to adopt these practices to reduce the risk of harm to patients. The 30 practices are grouped under five major categories: ■■ ■■ ■■

Creating a culture of safety Matching healthcare needs with delivery capabilities Facilitating information transfer and clear communication

Patient-Centered Care ■■ ■■

Providing specific settings or processes of care Increasing safe medication use (AHRQ, 2005)

2.

All of the 30 recommended safe practices can be used by physicians and nurses. Of particular relevance to nurses are the safe practices that relate to communication with other healthcare providers and patients, and thorough regular evaluation and monitoring of clients for change in health status or risk of complications.

3. 4.

Strategies for Error Management The American Society of Anesthesiologists was one of the first groups to adopt specific error-reduction strategies. Their clinical practice guidelines and system improvements have significantly reduced anesthesia-related mortality (Spath, 1999). The risk management and error-reduction strategies listed here have been successfully applied in numerous industries. Spath suggests that these system and task redesigns could serve as the basis for improving quality in healthcare delivery as well: ■■ ■■

■■ ■■ ■■

Improve information access: Information should be readily available to all who need it. Reduce reliance on memory: Checklists, computerized decision aids, and protocols can minimize the need for reliance on human memory. Error-proof processes: Critical tasks should be structured so that errors cannot be made. Standardize tasks: Tasks are to be done in a standardized process. Reduce the number of handoffs: Processes and procedures should be restructured to minimize the number of people who are involved in transferring materials, information, people, instructions, or supplies.

James Lieber, author of the 2015 book Killer Care: How Medical Error Became America’s Third Largest Cause of Death and What Can Be Done About It has identified five reforms that could make hospitals less deadly. 1.

Adopt structured handoffs to reduce miscommunication during care

5.

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transitions, which cause two-thirds of deaths and serious injuries. Bring in the pharmacists to take part in hospital patient rounds. This could decrease errors by 45%. Get serious about infection by requiring hospitals to continually adhere to CDC guidelines for disinfecting. Fight diagnostic error by bringing in other physician specialists (i.e., pathologists and radiologists) to help diagnose. Make electronic health records interoperable. Currently, only 14% of clinicians share patient data beyond their care organizations. (Lieber, 2016, pp. 1–2).

Patient-Centered Care

One principle for transforming health care is patient-centered care. Dupree, Anderson, and Nash (2011) believe that health care should be designed around the interests and needs of patients and their families. The most crucial element is patient safety, where no deaths or injuries would occur due to preventable errors. Patients and their families have the best knowledge about their conditions, the evolution of symptoms, and response to treatments. In short, bring the patient and the family more deeply into care conversations.

Institute for Healthcare Improvement Mathews (2013) states that today’s healthcare system is still dominated by a fee-for-service system, which results in inefficiencies—namely, high service volume and unnecessary care. These are a detriment to quality. To address this, the Institute for Healthcare Improvement (IHI) developed a framework called Triple Aim. It describes an approach to optimizing health system

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performance through three aims (Institute for Healthcare Improvement, 2013): 1. 2. 3.

Improve the patients’ experience of care. Improve the health of populations. Reduce the per capita cost of health care.

The AHRQ Patient Safety Network (2017) has identified several methods that can be used for measuring patient safety events: 1.

Organizations that attain the Triple Aim will have healthier populations, in part because of new designs that better identify problems and solutions further upstream and outside of acute health care. Patients can expect less complex and more coordinated care. Businesses will have the opportunity to be more competitive with stabilization or reduction of the per capita cost of care for populations.

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■■ ■■ ■■

3.

4.

Error Measurement Tools

The abundance of scientific articles and news accounts of medical errors and adverse events have stimulated great efforts and research geared toward identification, measurement, and management of errors and adverse events (Kohn, Corrigan, & Donaldson, 2000). Garrouste-Orgeas, Philippart, Bruel, Max, Lau, & Misset (2012) offer two basic approaches to the evaluation and improvement of quality of care. The Plan-Do-Act Cycle (PDAC) from the IHI involves identifying the problems, devising plans to correct the problems, and assessing the effectiveness of the plans. The second way to measure safety is use of a monitoring system that detects problems and evaluates them using quality indicators. Specifically, at the hospital level, the following reporting systems are available: ■■

2.

The medical review, targeting select indicators Voluntary reporting. A method most often used to detect errors Direct observation at the bedside Learning directly from patient experiences of care (pp. 2–3)

5.

▸▸

Retrospective chart review. This is considered the gold standard but can be costly, labor intensive, and data limited. Voluntary error reporting. This method is useful for internal quality improvement, but many healthcare providers do not self-report errors. Automated surveillance. This can be used both prospectively and retrospectively, but is reliant upon electronic data to run. Administrative/claims data (e.g., AHRQ Patient Safety Indicators). This method is low cost and can track events over time but may lack detailed clinical data. Patient reports. These can capture errors that are not captured by other methods (i.e., errors in communication) but there are no standard measurement tools.

Agency for Healthcare Research and Quality

The AHRQ is the health services research division of the U.S. Department of Health and Human Services (USDHHS). It works in conjunction with the biomedical research mission of the National Institutes of Health (NIH). AHRQ research endeavors center around the following: ■■ ■■ ■■ ■■ ■■ ■■

Quality improvement and patient safety Outcomes and effectiveness of care Clinical practice and technology assessment Healthcare organization and delivery systems Primary care (including preventive services) Healthcare costs and sources of payment

National Database of Nursing Quality Indicators

Quality improvement is a comprehensive process and includes how people get access to health care, how much that care costs, and what happens to patients during that care. The ultimate goal is to improve patient safety. The AHRQ was established in 1989 to spearhead efforts to boost the quality of health care in the United States and to fund research on the comparative effectiveness of interventions. As a result of the 2009 American Recovery and Reinvestment Act, $473 million was invested in research supported by AHRQ (Kuehn, 2012). Comparative effectiveness research (CER) is a tool that generates and synthesizes evidence that compares benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions and to improve the delivery of care (Largent, 2011). The goal is to determine which interventions are most effective for which patients and thereby enable consumers, practitioners, and policymakers to develop informed decisions to improve population health. AHRQ developed the Guide to Patient and Family Engagement in Hospital Quality and Safety, which is an evidence-based resource to guide hospitals and families to improve quality and safety. The guide describes critical opportunities for hospitals to engage patients and families and to create partnerships between patients, families, and hospitals around the same goals. It also addresses real-world challenges and helps hospitals engage patients and families. This, in turn, helps hospitals improve quality and safety and helps them respond to healthcare reform and accreditation standards (AHRQ, 2013a).

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Patient Safety Indicators

The AHRQ continues to develop patient safety indicators, which are tools to help healthcare agencies identify potential adverse events that occur during hospitalization. Failure to rescue is one of the AHRQ patient safety indicators that has

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garnered much attention and research. Failure to rescue occurs when healthcare providers do not recognize signs and symptoms of impending arrest and fail to take appropriate action to stabilize the patient (Garvey, 2015). “Failure to rescue is a major cause of mortality in acute care settings . . . and nurses hold a significant key to addressing this issue” (Garvey, 2015, p. 145). Al-Qahtani and Al-Dorzi (2010) identified that failure to rescue is due to failure of the organization, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. It is estimated that adverse events occur in 10% of hospitalized patients with a mortality rate of 5% to 8%, half of which are preventable. Although the concept of failure to rescue a patient is not new, AHRQ research suggests that it is a sensitive indicator of both the quality and quantity of nursing care (Simpson, 2004).

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National Database of Nursing Quality Indicators

The National Database of Nursing Quality Indicators (NDNQI) is a repository for nursing-sensitive indicators developed by the American Nurses Association and managed by the University of Kansas School of Nursing. More than 1,200 hospitals across the United States participate, volunteering unit-level data measures quarterly (Kurtzman & Jennings, 2008). The NDNQI nursing-sensitive indicators are designed to be a sign of the structure, process, and outcomes of nursing care. Structure is indicated by the availability of nursing staff, skill level of nurses, and education and certification of nursing staff. Process indicators measure assessment, intervention of patient care, and registered nurse job satisfaction. Outcomes measured for nursing ­sensitivity are those that improve if there is a greater quantity or quality of nursing care. These might ­include patient falls, intravenous infiltrations,

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pressure ulcers, and so forth (American Nurses ­Association, 2009). In 2014, Press Ganey acquired the NDNQI database. Recently, the NDNQI has worked in conjunction with the National Q ­ uality Forum and The Joint Commission, using their nursing-sensitive indicators.

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National Error-Reduction Efforts

The Code of Silence A serious question is why the statistics of the IOM 2000 report were such a shock to people. Part of the answer is that fear of being sued suppresses discussion of medical errors. If procedures are done with the best intentions and skill, yet something does not turn out the way it was supposed to, the doctor often has to compensate the patient with a huge settlement. Patients have a desire for full disclosure of errors, which should incorporate: ■■ ■■ ■■ ■■ ■■

Disclosure of all harmful errors An explanation as to why the error occurred How the errors effects will be minimized Steps the physician and organization will take to prevent recurrences An apology (PSNet, June 2017b)

Data indicate that patients are less likely to sue if physicians apologize and fully disclose errors (PSNet, June 2017b). In practice, however, many providers fail to clearly explain the error and its effects on the patient’s health. Currently, 10 states mandate disclosure of unanticipated outcomes to patients. Many patients harmed by a medical error never learn of the error (PSNet, June 2017b). Physicians may shy away from discussing errors with patients due to fear of precipitating a malpractice lawsuit and embarrassment with the disclosure process. All professional codes of conduct require that breaches of professional behavior by colleagues

be reported to the profession or appropriate licensing body. This is to ensure that there will be some form of investigation and discipline for conduct or service below standards. Healthcare providers who witness negligent care share in the guilt if they refuse to speak out about it. Reasons why physicians may want to stay silent about errors by their peers include depending on each other for business. Breaking the code of silence may cause a loss of referrals and financial penalties (Allen, 2013). Physicians may also be wary of being sued or causing a colleague to face legal consequences. By definition, professionals self-regulate their practice, which requires a protective system for the society they serve. This concept is not unique to physicians. It is essential for all professionals, including advanced practice nurses. Self-regulation allows for mutual obligations shared between healthcare providers and society.

Sorry Works! Coalition The Sorry Works! coalition began in 2005 and is composed mostly of doctors, insurers, lawyers, and patient advocates (Sorry Works!, 2013). The organization advocates that full disclosure and apologies for medical errors are a “middle-ground solution” to the medical malpractice crisis (Sorry Works!, 2013, p.1). It is surmised that apologies for bad outcomes, adverse events, or medical errors, combined with upfront compensation, help to reduce the anger of patients and families. The healthcare providers apologize to the patient and family, admit fault, provide an explanation of what happened and how the hospital will fix the procedures so the error is not repeated, and make a fair offer of upfront compensation (Wojcieszak, Banja, & Houk, 2006). This approach is taken only after a root-cause analysis shows that the standard of care was not met. It is hoped that this, in turn, will lead to a reduction in medical malpractice lawsuits and associated defense litigation expenses. If the standard of care was met or if there was no medical error or negligence, the providers still meet with the patient and family and their

National Error-Reduction Efforts

attorney to explain what happened, apologize, and offer empathy. They do not admit fault or provide compensation or offer to settle any claim. These protocols are based on a disclosure program developed at the Veteran’s Administration Hospital in Lexington, Kentucky (Wojcieszak, Banja, & Houk, 2006). It is expected that this approach will spread to all healthcare organizations committed to creating a culture of safety and quality.

Safety Culture The Institute for Safe Medical Practices reported that 40% of clinicians either keep quiet or remain passive after witnessing an improper patient care event to avoid possible reprisals (Nurse. com, 2012). In 2012 the National Association for Healthcare Quality (NAHQ) issued a “Call to Action” for Enhancing Health Care Quality and Patient Safety. This initiative is designed to enhance overall quality of care, strengthen patient safety protection, and minimize costly medical errors. The call to action asks healthcare provider organizations to expect all clinical staff to be accountable for achieving meaningful quality improvements and to report potential safety risks. This helps create a strong safety culture in healthcare organizations, which will enhance best practices, improve quality, improve safety reporting, and protect staff. The NAHQ joined with more than 10 national organizations to develop recommendations.

■■ ■■ ■■

National Patient Safety Goals Quite a few years ago, through the AHRQ, the federal government adopted the term patient safety (Kohn, Corrigan, & Donaldson, 2000). Patient safety endeavors are crucial components of quality improvement and risk management activities in healthcare institutions. The Joint Commission has developed a set of National Patient Safety Goals (NPSGs) to help organizations address explicit areas of patient safety. Beginning January 1, 2003, all healthcare organizations accredited by The Joint Commission were required to demonstrate how they met the first six Joint Commission NPSGs. The Joint Commission has revised and expanded the NPSGs, which have been identified for the following specific healthcare arenas: ■■

Speak Up Campaign The Joint Commission initiated a new national Speak Up patient safety program in 2002, which urges Americans to take an active role in avoiding medication errors at the doctor’s office, pharmacy, hospital, and clinic. The acronym Speak Up stands for:

■■

■■ ■■ ■■

Speak up if you have questions or do not understand. Pay attention to the care you get. Educate yourself about your illness. Ask a trusted family member or friend to be your advocate.

Know what medications you take and why you take them. Use a hospital or clinic that has been carefully checked out. Participate in all decisions about your treatment (The Joint Commission, 2016).

Brochures and posters titled “Things You Can Do to Prevent Medication Mistakes” were mailed to the nation’s Fortune 1000 companies because The Joint Commission believes employers have a crucial role in developing informed healthcare consumers among their employees.

■■

■■

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■■ ■■ ■■ ■■ ■■

Ambulatory health care Behavioral health care Critical access hospitals Home care Hospital Laboratory Nursing care center Office-based surgery (The Joint C ­ ommission, 2017)

In June 2013, The Joint Commission approved a new NPSG, 06.01.01, on clinical alarm safety for hospitals and critical access hospitals. All these goals focus on problems in healthcare safety in hospital settings and how to solve them. The 2017 hospital NPSGs are summarized in BOX 8-1.

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BOX 8-1  2017 Hospital National Patient Safety Goals 1. Improve the accuracy of patient identification. •• Use at least two patient identifiers when providing care, treatment, and services. •• Eliminate transfusion errors related to patient misidentification. 2. Improve the effectiveness of communication among caregivers. •• Report critical results of tests and diagnostic procedures on a timely basis. 3. Improve the safety of using medications. •• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. •• Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. •• Maintain and communicate accurate patient medication information. 4. Reduce the harm associated with clinical alarm systems. •• Improve the safety of clinical alarm systems. 5. Reduce the risk of health care–associated infections. •• Comply with either the current Centers for Disease Control and Prevention or the World Health Organization hand hygiene guidelines. •• Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals. •• Implement evidence-based practices to prevent central line–associated bloodstream infections. •• Implement evidence-based practices for preventing surgical-site infections. •• Implement evidence-based practices to prevent catheter-associated urinary tract infections. 6. The hospital identifies safety risks inherent in its patient population. •• Identify patients at risk for suicide. 7. Prevent mistakes in surgery. •• Conduct a preprocedure verification process. •• Mark the procedure site. •• A time-out is performed before the procedure. Data from The Joint Commission. (2017). National Patient Safety Goals Effective January 2017. Retrieved from https://www.jointcommission.org /assets/1/6/NPSG_Chapter_HAP_Jan2017.pdf

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Public Quality Reporting Systems

Since the 2000 IOM report about medical errors, there have been considerable attempts to hold healthcare providers accountable for the quality of care. To accomplish this, an abundance of national policies, performance measurement tools, and public and private reporting mechanisms have been put into place. The effort to hold healthcare providers accountable has come

in response to lagging performance, mounting healthcare costs, and misaligned reimbursement systems (Kurtzman & Jennings, 2008).

Hospital Consumer Assessment of Healthcare Providers and Systems The Centers for Medicare & Medicaid Services (CMS) partnered with AHRQ to develop the Hospital Consumer Assessment of Healthcare

Centers for Medicare & Medicaid Services

Providers and Systems (HCAHPS). Data submitted to the HCAHPS data warehouse are analyzed by CMS, which then calculates the hospital HCAHPS scores and publically reports them on the Medicare website (www.medicare.gov /hospitalcompare/search.html) (Medicare, 2014). In 2013, the HCAHPS scores were one of 13 measures used by CMS to calculate $850 million in payments from its Hospital Value-Based Purchasing Program. Inpatient hospitals will see a 1% reduction in their Medicare payments, which will be used to fund incentives that must be earned back by hospitals on the basis of their quality of care (Kennedy, Craig, Wetsel, Reimels, & Wright, 2013). The HCAHPS survey is a standardized instrument and methodology that was developed in 2006 to measure patients’ perspectives of hospital care. This provides a national standard for collecting and reporting information to the public that allows valid comparisons of hospitals to enhance consumer decision making. BOX 8-2 lists the HCAHPS goals for the survey. The HCAHPS survey contains 27 items and is available in five languages. It is designed

BOX 8-2  HCAHPS Survey Goals HCAHPS has three broad survey goals: 1. The survey will produce comparable data on patients’ perspectives of care to allow objective comparisons among hospitals on topics that are important to consumers. 2. Public reporting of the survey results is designed to create incentives for hospitals to improve quality of care. 3. Public reporting serves to enhance public accountability in health care by increasing transparency (HCAHPS, 2017). Data from Centers for Medicare & Medicaid Services. (2018). CAHPS® Hospital Survey. Retrieved from http://www.hcahpsonline.org /#Background

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to take respondents an average of 7 minutes to complete. The survey contains 18 patient perspectives on care in 8 key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment. It also includes four screener questions and five demographic items. The NPSGs have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety. The criteria used for determining the value of these goals are based on the merit of their impact, cost, and effectiveness (AHRQ, 2013b).

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Centers for Medicare & Medicaid Services

CMS Reporting Hospital Quality Data for Annual Payment Update CMS collects 30 quality measures as part of its Hospital Inpatient Quality Reporting Program for the Annual Payment Update determination process. This program requires hospitals to submit data for specific quality measures for health conditions that are common among people with Medicare and that typically result in hospitalization. The initiative is designed to furnish consumers with quality of care information so they can make more informed decisions about their health care. It is also designed to encourage clinicians and hospitals to improve the quality of inpatient care provided to all patients.

Preventable Complications Section 3008 of the Affordable Care Act established the Hospital-Acquired Condition (HAC) Reduction Program to encourage hospitals to reduce these conditions (QualityNet, 2017).

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Beginning in 2015, this program requires the United States Secretary of Health and Human Services (HHS) to adjust payments to hospitals that rank in the worst-performing 25% of all subsection (d) hospitals with respect to HAC quality measures. CMS may reduce these hospitals’ payments by 1%. The preventable complications include those that are nurse sensitive and hospital acquired, including stage 3 and 4 pressure ulcers, falls with injuries, and nosocomial infections. For example, nursing homes will no longer receive insurance reimbursement from Medicare for treatment provided to patients with hospital-acquired (iatrogenic) stage 3 pressure ulcers. A community-acquired pressure ulcer that a patient comes into the hospital with, which is not documented on admission or within the time frame required by hospital policy, is considered hospital acquired (iatrogenic). Nurses must assess the patient’s skin with the same attention as the patient’s respiratory and cardiac status. This new Medicare standard essentially mandates that registered nurses who admit patients conduct a thorough skin assessment and document it appropriately. After the initial skin assessment is completed by the registered nurse, it is incumbent on the physician to order appropriate treatments ­specific to the pressure ulcer stage and thus reduce the risk of advancement of a stage 1 ­pressure ulcer to stage 3. Although pressure ulcers are widely viewed as a result of poor ­nursing care, the collaborative effort of the multidisciplinary healthcare team, or lack thereof, is responsible for the patient.

United States’ Best Hospitals In 1990 U.S. News & World Report magazine initiated an annual appraisal of U.S. hospitals. Patients who truly need outstanding care are the target of the magazine’s annual Best Hospitals rankings. Hospitals are judged, not on routine procedures, but on difficult cases across 16 specialties. Twelve of the 16 specialty rankings are driven largely by hard data; the other

4 rankings are based on 3 years of nominations by specialists. To be considered for the 12 data-driven specialties, a hospital had to meet at least one of three requirements: membership in the Council of Teaching Hospitals, affiliation with a medical school, or availability of at least 6 of 13 key technologies, such as robotic surgery. In 2017, U.S. News and World Report analyzed data from nearly 5,000 medical centers and over 30,000 physician surveys. Survival rates, patient safety, hospital reputation, and specialized staff were analyzed factors. In 2017, only 152 hospitals ranked in at least one of the specialties.

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Conclusion

This chapter has focused on the tremendous impact the seven primary IOM studies have had on quality efforts to reduce errors in health care. These studies include the following: ■■ ■■ ■■ ■■ ■■ ■■ ■■

The Future of Nursing Preventing Medication Errors Patient Safety: Achieving a New Standard for Care Keeping Patients Safe: Transforming the Work Environment of Nurses Health Professions Education: A Bridge to Quality Crossing the Quality Chasm: A New Healthcare System for the 21st Century To Err Is Human: Building a Safer Health System

Theories of error and error management were explored, along with numerous national healthcare initiatives and mandates. Healthcare providers must be committed to developing a culture of safety in which errors are accepted as inevitable, but members of the healthcare team are ever vigilant and committed to the prevention of error. This new culture of safety includes support and counseling for those who make mistakes and open communication of errors and safety issues (BOX 8-3).

References

BOX 8-3  Red Flag Alerts for Patient Safety Healthcare practitioners must be educated and alerted to red flags in their care of patients. When a red flag is identified, appropriate action should be taken to remedy the situation. Specific red flags include the following: ■■ Poor treatment results ■■ A lack of follow-up care ■■ Repetitious problems ■■ Equipment malfunctioning ■■ Dissatisfied patients or family members ■■ Poor staff–patient relations ■■ Intimidated patients ■■ Poorly maintained medical records ■■ A lack of policies or procedures ■■ Excessive volume of patients ■■ Acting outside the scope of practice ■■ Personality conflicts ■■ Performance of a procedure without needed supervision Data from Kavaler, F., & Spiegel, A. D. (2003). Risk management in health care institutions: A strategic approach (2nd ed.). Sudbury, MA: Jones & Bartlett Publishers.

Discussion Questions 1.

2. 3. 4.

Identify a common error in healthcare delivery and work through Reason’s Swiss Cheese Model, identifying how the holes can occur and what layers of protection should stop the error from getting to the patient. How has the code of silence changed over the past few years? Is it more or less prevalent? Why? What impact will the 2014 Hospital National Patient Safety goals have on hospital care? How will they effect reimbursement? Discuss how public reporting of the HCAHPS survey will create incentives for both hospitals and nurses to improve quality of care.

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References Agency for Healthcare Research and Quality (AHRQ). (2002, September). Improving health care quality. Fact sheet. (Agency for Healthcare Research and Quality Publication No. 02-P032, Vol. 2003). Rockville, MD: Author. Agency for Healthcare Research and Quality. (2003). AHRQ’s patient safety initiative: building foundations, reducing risk. Retrieved from https://archive.ahrq.gov/research /findings/final-reports/pscongrpt/psini2.html Agency for Healthcare Research and Quality. (2005). 30 safe practices for better health care (Agency for Healthcare Research and Quality Publication No. 05-P007). Retrieved from http://www.ahrq.gov/research/findings/factsheets /errors-safety/30safe/index.html Agency for Healthcare Research and Quality. (2013a). Guide to patient and family engagement in hospital quality and safety. Retrieved from http://www.ahrq.gov/professionals /systems/hospital/engagingfamilies/index.html Agency for Healthcare Research and Quality. (2013b). National patient safety goals. Retrieved from http://psnet.ahrq .gov/resource.aspx?resourceID=2230 Agency for Healthcare Research and Quality. (2017). Patient Safety Network: Detection of Safety Hazards. Retrieved from https://psnet.ahrq.gov/primers/primer/24/detection -of-safety-hazards Agency for Healthcare Research and Quality. (2014). CAHPS surveys and tools to advance patient-centered care. Retrieved from https://cahps.ahrq.gov/ Allen, M. (2013). Why doctors stay mum about mistakes their colleagues make. Retrieved from https://www.propublica.org /article/why-doctors-stay-mum-about-mistakes-their -colleagues-make Al-Qahtani, S., & Al-Dorzi, H. M. (2010). Rapid response systems in acute hospital care. Annals of Thoracic Medicine, 5(1), 1–4. American Board of Internal Medicine. (2017). Choosing Wisely. Retrieved from http://abimfoundation.org /what-we-do/choosing-wisely American Nurses Association. (2009). Nursing sensitive indicators. Retrieved from http://www.nursingworld .org/MainMenuCategories/ThePracticeofProfessional Nursing/PatientSafetyQuality/Research-Measurement /The-National-Database/Nursing-Sensitive-Indicators_1 Bipartisan Policy Center. (2013). A bipartisan Rx for patient-centered care and system-wide cost containment. Retrieved from http://bipartisanpolicy.org/library/report /health-care-cost-containment Byers, J. F., & White, S. V. (2004). Patient safety: Principles and practice. New York, NY: Springer Publishing Company. Centers for Disease Control and Prevention (CDC). (2017). Health expenditures. Retrieved from https://www.cdc .gov/nchs/fastats/health-expenditures.htm. DuPree, E., Anderson, R., & Nash, I. S. (2011). Improving quality in healthcare: Start with the patient. Mount Sinai Journal of Medicine, 78, 813–819.

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Ebright, P., Urder, L., Patterson, E., & Chalko, B. (2004). Themes surrounding novice nurse near-miss and adverse -event situations. Journal of Nursing Administration, 34(11), 531–538. Evans, M. (2015, February 21). Hospitals face closures as ‘a new day in healthcare’ dawns. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article /20150221/MAGAZINE/302219988 Garrouste-Orgeas, M., Philippart, F., Bruel, C., Max, A., Lau, N., & Misset, B. (2012). Overview of medical errors and adverse events. Annals of Intensive Care, 2(2), 1–9. Garvey, P. K. (2015). Failure to rescue: the nurse’s impact. MEDSURG Nursing, 24(3), 145–149. HCAHPS. (2017). HCAHPS Fact Sheet. Retrieved from http://www.hcahpsonline.org/globalassets/hcahps /facts/hcahps_fact_sheet_november_2017a.pdf HealthDay News. (2009, January 27). America’s top hospitals cut patient death rate 27%. U.S. News & World Report. Retrieved from http://health.usnews.com/health-news /managing-your-healthcare/treatment/articles/2009/01 /27/americas-top-hospitals-cut-patient-death-rate-27 HealthGrades. (2005, May). HealthGrades quality study: second annual patient safety in American hospitals report. Retrieved from http://hg-article-center.s3-website-us-east -1.amazonaws.com/a6/43/b94f277e492d9a416af1d51b487d /PatientSafetyInAmericanHospitalsReport2005.pdf HealthGrades. (2009). About us. Retrieved from http://www .healthgrades.com/about-us HealthGrades. (2013). American hospital quality outcomes 2014: HealthGrades report to the nation: Executive summary. Retrieved from https://d2dcgio3q2u5fb .cloudfront.net/56/90/e07df9f64a5fb741ab59924a9 e0d/2013-american-hospital-quality-outcomes-2014 -healthgrades-report-to-the-nation.pdf Helmreich, R. L. (2000). On error management: Lessons from aviation. British Medical Journal, 320, 781–785. Institute for Healthcare Improvement. (2013). The IHI Triple Aim. Retrieved from http://www.ihi.org/offerings /Initiatives/TripleAim/Pages/default.aspx Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2003). Special report! 2003 JCAHO national patient safety goals: Practical strategies and helpful solutions for meeting these goals. Joint Commission Perspectives on Patient Safety, 3(1). Retrieved from http:// www.teacherweb.com/NY/StBarnabas/Law-PublicPolicy /JCAHO-2003.pdf Kapur, N., Parand, A., Soukup, T., Reader, T., & Sevdalis, N. (2015, December 2). Aviation and healthcare: A comparative review with implications for patient safety. Journal of the Royal Society of Medicine Open, 7(1), 1–10. Kavaler, F., & Spiegel, A. D. (2003). Risk management in health care institutions: A strategic approach (2nd ed.). Sudbury, MA: Jones & Bartlett Publishers. Kennedy, B., Craig, J. B., Wetsel, M., Reimels, E., & Wright, J. (2013). Three nursing interventions’ impact on HCAHPS scores. Journal of Nursing Care Quality, 28(4), 327–334.

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Kuehn, B. M. (2012). A push for comparative effectiveness: US initiatives aim to empower patients, physicians. JAMA, 307(15), 1570–1571. Retrieved from http://jama .jamanetwork.com/data/Journals/JAMA/23306/jmn0418 _1570_1571.pdf%3FresultClick%3D1&rct=j&frm=1&q =&esrc=s&sa=U&ei=PhyaU7fhDai68AHKjI Fg&ved=0CCQQFjAE&sig2=8E3pcUHEs9Fsg G16mNVx7A&usg=AFQjCNGozwDwR3bY8xv 8qWImCPKtYGnHig Kurtzman, E. T., & Jennings, B. M. (2008). Trends in transparency: Nursing performance measurement and reporting. Journal of Nursing Administration, 38(7/8), 349–354. Largent, E. (2011). Comparative effectiveness research: What effects for nurses? Dimensions of Critical Care Nursing, 30(1), 19–24. Liang, B. A. (2001). The adverse event of unaddressed medical error: Identifying and filling the holes in the health-care and legal systems. Journal of Law and Medical Ethics, 29(3/4), 346–368. Lieber, J. B. (2016, May 17). How to make hospitals less deadly. The Wall Street Journal. Retrieved from https://www .wsj.com/articles/how-to-make-hospitals-less-deadly -1463526075 Makary, M. A., & Daniel, M. (2016, May 3). Medical error—the third leading cause of death in the US. BMJ, 353. Retrieved from http://www.bmj.com/content/353 /bmj.i2139 Mathews, C. (2013, January). Healthcare’s triple aim: How technology is facilitating collaboration among members, providers and payers. Health Management Technology, 31(1), 24. Retrieved from http://www.healthmgttech .com/articles/201301/healthcares-triple-aim.php Medcom. (2017). Medication errors in nursing: Common types, causes, and prevention. Retrieved from https:// www.medcomrn.com/index.php/articles/common -nursing-medication-errors-types-causes-prevention/ Medicare. (2014). Hospital compare. Retrieved from http://www.medicare.gov/hospitalcompare/search .html?AspxAutoDetectCookieSupport=1 National Association for Healthcare Quality. (2012, October 16). National Association for Healthcare Quality (NAHQ) issues ‘call to action’ for enhancing health care quality and patient safety. PR Newswire. Retrieved from http://www .prnewswire.com/news-releases/national-association -for-healthcare-quality-nahq-issues-call-to-action -for-enhancing-health-care-quality-and-patient -safety-174423331.html Nordenberg, T. (2000, September/October). Make no mistake: Medical errors can be deadly serious. FDA Consumer Magazine. Retrieved from https://groups .yahoo.com/neo/groups/csen-anesthesia-mailing -list/conversations/messages/6087

References Nurse.com (2012, October 17). Statement urges accountability for patient safety. Retrieved from http://news.nurse.com /article/20121017/NATIONAL02/110290006 PSNet. (2017a, June). Disclosure of errors. Retrieved from https://psnet.ahrq.gov/primers/primer/2/error-disclosure PSNet. (2017b, June). Measurement of patient safety. Retrieved from https://psnet.ahrq.gov/primers/primer/35 /measurement-of-patient-safety PSNet. (2017c, June). Patient safety primer: Systems approach. Retrieved from https://psnet.ahrq.gov/primers/primer /21/systems-approach QualityNet. (2017). Hospital-acquired condition reduction program. Retrieved from https://www.qualitynet.org /dcs/ContentServer?c=Page&pagename=QnetPublic %2FPage%2FQnetTier2&cid=1228774189166 Reason, J. (2000). Human error: Models and management. BMJ, 320, 768–770. Rivers, R. M., Swain, D., & Nixon, W. R. (2003). Using aviation safety measures to enhance patient outcomes. Association of Operating Room Nurses Journal, 77, 158–162. Sarkar, U. L., López, A., Maselli, J. H., & Gonzales, R. (2011). Adverse drug events in U.S. adult ambulatory medical care. Health Service Research, 46(5): 1517–1533. Simpson, K. R. (2004). Failure to rescue: Implications for evaluating quality of care during labor and birth. Journal of Perinatal Neonatal Nursing, 19(1), 24–34. Sorry Works! (2013). Sorry Works! history. Retrieved from http://sorryworkssite.bondwaresite.com/history-cms-29 Spath, P. L. (Ed.). (1999). Error reduction in health care: A systems approach to improving patient safety. San Francisco, CA: Jossey-Bass. The Joint Commission. (2013a). 2012 national patient safety goals. Retrieved from http://www.jointcommission .org/mobile/standards_information/national_patient _safety_goals

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The Joint Commission. (2013b). 2014 hospital national patient safety goals. Retrieved from http://www.jointcommission .org/assets/1/6/2014_HAP_NPSG_E.pdf The Joint Commission. (2016). Facts about Speak Up. Retrieved from https://www.jointcommission.org /facts_about_speak_up/ The Joint Commission. (2017, January). National patient safety goals, effective January 2017. Retrieved from https://www.jointcommission.org/assets/1/6/NPSG _Chapter_HAP_Jan2017 The Joint Commission. (2017). 2017 national patient safety goals. Retrieved from https:// www.jointcommission.org/standards_information /npsgs.aspx Thomas, E. J., & Petersen, L. A. (2003). Measuring errors and adverse events in health care. Journal of General Internal Medicine, 18(1), 61–67. U.S. Food and Drug Administration (FDA). (2016). Medication error reports. Retrieved from https://www.fda.gov /Drugs/DrugSafety/MedicationErrors/ucm080629.htm U.S. News & World Report. (2017). 2017–18 best hospitals. U.S. News Hospitals Rankings and Ratings. Retrieved from http://health.usnews.com/best-hospitals Wachter, R. M., & Shojania, K. G. (2004). Internal bleeding: The truth behind America’s terrifying epidemic of medical mistakes (1st ed.). New York, NY: Rugged Land. Weinberg, J. K. (2002). Medical error and patient safety: Understanding cultures in conflict. Law & Policy, 24(2), 93–113. Wojcieszak, D., Banja, J., & Houk, C. (2006). Forum: The Sorry Works! coalition: Making the case for full disclosure. Joint Commission Journal on Quality and Patient Safety, 32(6), 344–350. Woods, A., & Doan-Johnson, S. (2002). Executive summary: Toward a taxonomy of nursing practice errors. Nursing Management, 33(10), 45–48.

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CASE STUDY CASE STUDIES

Patient Risk Assessment Tools Helen Werner

Patient Falls: Morse Fall Scale Fall incidence and subsequent injuries are of great importance as nursing quality indicators. The Morse Fall Scale is not always an accurate assessment of fall risk, according to the guidelines developed by Morse (2009); therefore, the predictive value is indeterminate. A study conducted in Australia by McFarlane-Kolb (2004) found that the Morse Fall Scale, in combination with other risk factors, more accurately reflected fall risk among older persons admitted to an acute surgical unit. Major tranquilizer use and male gender were the most significant predictors of fall risk in this population. The Morse Fall Scale can easily be modified to include additional risk factors that are more accurate predictors of fall risk for the indigenous population. This is important in terms of guidelines that are developed by the hospital, which may be formulated based on a calculated fall risk that may be inaccurate for the population being served. If a patient is identified to be at risk for falls, a more in-depth assessment is needed to determine the causative factors, especially those that are treatable. Several fall-risk assessment tools were evaluated for validity by Ang, Mordiffi, Wong, Devi, and Evans (2007). The Morse Fall Scale, the St. Thomas Risk Assessment Tool in the Falling Elderly Inpatients, and the Heindrich II Fall Risk Model were all validated for interrater reliability and validity studies; however, only the Heindrich II Fall Risk Model had a higher level of specificity (61.5%) than the Morse Fall Scale (48.3%). The Morse Fall Scale is the gold standard for fall-risk assessment in the United States; however, if nurses demonstrate difficulty scoring a patient’s fall risk accurately, it may be necessary to consider piloting the use of another scale that may be more user friendly.

Patient Skin Assessment Tools It is not uncommon for clinicians to shorten or modify risk assessments, like the Braden Scale, according to Braden and Maklebust (2005). This

reduces the likelihood that a skin assessment will be predictive of pressure ulcer development during a hospitalization. The explanation is rather simple. The complete tool was tested for validity and reliability. Even minor changes can impact the accuracy of the scale. Research has been conducted by Bergquist (2001) testing modified Braden Scales and subsets to determine the extent of accuracy for predicting patients at greater risk of developing pressure ulcers. Bergquist found that the summative score, rather than any subset of the Braden Scale, was most predictive of pressure ulcer risk for older persons receiving home health care; however, researchers in China (Kwong et al., 2005) found a modified Braden Scale more predictive for pressure ulcer development, with the addition of skin and body build for height and the exclusion of nutrition, which was a surprising finding. One explanation offered by the researchers was that the focus of oral intake and protein only does not accurately represent patients’ nutritional status. It may also be necessary to explore modifications of the Braden Scale based on cultural differences. Assessment tools such as the Braden Scale may not be as accurate as nurses’ judgment. A study conducted by Lewicki, Mion, and Secic (2000) for cardiac surgery patients found that the sensitivity of the Braden Scale was 40% and its specificity was 70%, compared with nurses’ judgment, which was found to have a sensitivity of 49% and a specificity of 73%. Additionally, the researchers suggested that the cutoff score, which has been 16 or less, is more applicable to long-term care than acute care and may need to vary for each postoperative day. The National Database of Nursing Quality Indicators (NDNQI) accepts data from hospitals that use other skin assessment scales. Data from the Norton Scale are also acceptable and, in fact, are noted on the data collection tool that the designated NDNQI site coordinator must use to enter data. Unfortunately, there is no way to determine whether the calculated score using the Braden Scale or Norton Scale published on the NDNQI website for the participating hospitals is based on use of the complete Braden Scale, Norton Scale, or a modified version that had been previously tested for validity and reliability. The accuracy of this data is of great importance to the participating hospitals so individual units can compare themselves to similar types of

Case Study participating NDNQI units across the country. The collection and entry of data for quality improvement as a participating hospital in NDNQI is deemed necessary to attain Magnet certification.

References

Braden, B., & Maklebust, J. (2005). Preventing pressure ulcers with the Braden Scale. American Journal of Nursing, 105(6), 70–72. Kwong, E., Pang, S., Wong, T., Ho, J., Shao-ling, X., & Li-Jun, T. (2005). Predicting pressure ulcer risk with the modified Braden, Braden, and Norton Scales in acute care hospitals in mainland China. Applied Nursing Research, 18, 122–128. Lewicki, L. J., Mion, L. C., & Secic, M. (2000). Sensitivity and specificity of the Braden Scale in the cardiac surgical population. Journal of Wound, Ostomy and Continence Nurses Society, 27, 36–41. McFarlane-Kolb, H. (2004). Falls risk assessment, multitargeted interventions and the impact on hospital falls. International Journal of Nursing Practice, 10, 199–206. Morse, J. M. (2009). Preventing patient falls (2nd ed.). New York, NY: Springer Publishing Company.

CASE STUDIES

Ang, N. K. E., Mordiffi, S. Z., Wong, H. B., Devi, K., & Evans, D. (2007). Evaluation of three fall-risk assessment tools in an acute care setting. Journal of Advanced Nursing, 60(4), 427–435. Bergquist, S. (2001). Subscales, subscores, or summative score: Evaluating the contribution of Braden Scale items for predicting pressure ulcer risk in older adults receiving home health care. Journal of Wound, Ostomy and Continence Nurses Society, 28, 279–289.

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SECTION 4

Health Financing: Payers, Markets, and Models CHAPTER 9

Healthcare Costs: Follow the Money

CHAPTER 10 Private Health Insurance Market CHAPTER 11 Medicare: Protector to Innovator CHAPTER 12 Medicaid and the Financing of Care for Vulnerable Populations: A Story of Misconceptions CHAPTER 13 Innovation for the Delivery System of the Future: Medical Homes, Accountable Care Organizations, and Bundled Payment Initiatives

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Healthcare Costs: Follow the Money Prabal K. De

OVERVIEW When an ambulance brings in a patient to an emergency room with symptoms of a heart attack, the doctors and nurses immediately spring into action—connecting the patient to an EKG, having an IV line put in, possibly starting oxygen and medications. If you are a nurse, the last thing you are thinking about are the various costs associated with such procedures. The Emergency Medical Treatment and Labor Act (EMTALA) ensures that hospitals do not deny care to patients regardless of their insurance coverage. Unfortunately, what happens in such situations have far-reaching consequences for all parties concerned: the patient who would be facing a bill, the hospital that would run the risk of foregoing payments for their services, and the hospital employees whose salaries come from the hospital and have a stake in the financial health of the hospital. Collectively, such costs, both aggregate and how they are shared, have deep implications for the overall healthcare sector and the economy. In this chapter, we will analyze the economic aspects of healthcare production and delivery in the United States, including how market forces have shaped the organization of healthcare sector in U.S. in the last 60 years or so.

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Understand how health care is different from almost all other goods and services that we consume. Define the basic economics terms of health care—demand and supply. Describe the concepts of insurance and asymmetric information of moral hazard and adverse selection. (continues)

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OBJECTIVES ■■

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(continued)

Analyze the cost of care among various components of the health sector—hospitals, pharmaceuticals, and healthcare providers. Discuss the benefits and/or justification of cost inflation. Explore how the ACA and potential future health policy might influence cost.

Health Care Is Different

The first step to understanding the healthcare market is to understand the fact that health care is unlike any other goods and services that we consume. It is often easy to be swept away by popular catchwords such as “market-driven solutions.” Although we will talk about healthcare provision in the U.S. in terms of market forces, it is often fallacious to compare health care with markets of, say, broccoli. Some of the broad distinctions were laid out by Nobel prize–winning economist Kenneth Arrow in his seminal article (Arrow, 1963). He argues that the healthcare market has some unique risk elements because “Recovery from disease is as unpredictable as its incidence” (p. 951). These insights are still relevant in the U.S. market, so it is worth discussing them in some detail. First, the nature of demand is very different. The demand for health care is not like demand for broccoli that is predictable from an individual point of view. Apart from some goods and services like wellness and preventive cares (such as exercising, taking vitamins, and vaccinations), most of the medical services are sought if and when necessary. Second, the role of physicians and nurses as service providers is unique. Although it is true that there are other personal services—such as personal finance advisors, or even hair stylists— where the outcome can have important impacts and there has to be some unusual amount of trust associated with the provider, because physician’s services can alter the odds between life and

death, and care delivered by nurses is so personal, such trust has to be supreme. These services are also less substitutable compared to other services. Third, just like the service, the quality of product is also uncertain. If a person is involved in an accident, the paramedics would take the individual to the nearest emergency room, and may be admitted later in that hospital. Obviously, the victim would be in no position to compare hospitals in a way he or she would probably do before buying many other products. Moreover, for many of our day-to-day products and even services, we make repeated purchases. That is also not likely in medical care. A consumer may have only one shot with a pacemaker or a prosthetic knee. Fourth, production of healthcare professionals, including nurses, is different from the production of many other professional services. Although many professionals such as lawyers and social workers need licensing, the education of the numerous professionals in health care is long, intense, and expensive. Incentivizing the production of a licensed healthcare workforce is often subsidized by the U.S. Congress through Medicare and regulated by the disciplinary bodies for quality and limits or expansion in shortage times as needed. Fifth, the healthcare sector has some of the most sophisticated pricing practices in the whole economy. It is worth pointing out one remarkable pricing trait that economists call price discrimination—the practice of charging different prices to different customers for the same product at the same time. In some extreme cases, that price may be zero—hospitals and other providers

Resource Allocation and Market Role

often write off bills for patients who cannot afford to pay anything. They may be extraordinarily high for wealthy overseas patients seeking care in one of the top hospitals. There are commonalities in the issues of uncertainty and unpredictability. There is an underlying assumption of trust, which means that there is an inequality of information between individuals and healthcare services and product. To analyze these distinctions, it is important to begin with an introduction to the canonical economic thinking that is common in analyzing any economic situation in general.

▸▸

Resource Allocation and Market Role

Broadly speaking, economists study allocation of scarce resources among alternative, sometimes competing, uses. For example, should the federal government allocate more money to Medicaid, the program that provides health care to certain underprivileged groups like the poor and disabled, or to defense and national security? Or for a private healthcare practice, should the providers hire more secretaries to field patients’ calls for appointments or buy an expensive software application that moves the scheduling process online? Even though the two examples describe similar problems, there is one key difference. In the first case, the decision is taken by the federal government with no concerns for profit or loss. But in the second case, the practice, assuming that it is a private organization, wants to maximize its profit by maximizing revenue and minimizing cost. In this section, the concept of market-based health care is described. Any market is based on the idea of exchange, whereby some individuals barter some of their goods and services to other individuals in exchange for some other goods and services that those other individuals may offer, so that both of them get better off compared to their positions before the trade had taken place. This basic idea

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gives rise to the popular notions of demand and supply in basic economics. Let’s start with a commodity that many of us have ordered—hamburgers. Given someone’s income and preferences, one may ask here how many hamburgers an individual may eat a week when the price of a hamburger varies from 25 cents, $1, $2, up to $100. Intuition suggests that an individual would want to eat a lot of hamburgers when the price if 25 cents, and possibly none when it is $100. This hypothetical schedule is called the demand schedule and typically shows an inverse relationship between quantity demanded and the price of the product. While price is one of the most important determinants of demand, there are several other factors that affect demand for a good or service—income, taste and preference, availability of alternatives. However, they affect the core inverse relationship between a product and its quantity demanded, which is often called the law of demand, from outside only. The other side of the exchange is known as the supply side. For the hamburger restaurant, if they can get $100 per hamburger, they would want to sell many. Contrarily, if the price is 25 cents, they possibly would not want to sell any. This hypothetical schedule is called the supply schedule and typically shows a positive relationship between quantity supplied and the price of the product. Supply also depends on several factors other than the price of the commodity in question. The most important set of factors is called “inputs”—labor and other materials that go into the production of the commodity. How many hamburgers would be sold? This decision would be taken by what Adam Smith famously called the “invisible hand” of the market. Through some back and forth, the sellers and buyers would figure out the price at which all the hamburgers would be sold. If people are lining up for hamburgers, the price would go up; if the store has much inventory at the end of the day, price would fall. Let’s say $1.50 is the magical price where all hamburgers are sold and no one wants to change their

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buying and selling choice. This price is called the equilibrium price, a sort of status quo that once reached, tends to remain. It is worthwhile to appreciate both the elegance of this mechanism and its inadequacy to be fully applicable in the healthcare sector. A complex decision about how many hamburgers to produce was taken by anonymous interaction of many individuals without anyone (particularly the government) telling them how to behave. However, some of these notions make less sense, for example, a colonoscopy. How many colonoscopies would one choose to have in a year? Fortunately, economists have developed some apparatus to discuss health in terms of forces of demand supply that is both insightful and useful.

Demand for Health Even though our health is susceptible to various uncertainties, we can arguably control many aspects of it. For example, we can eat healthy, do more exercise, and cease smoking. In other words, we can exercise some choice with respect to the quality and quantity of health-related factors. At an individual level, economists characterize this process in the following way: Suppose you have a fixed monthly budget and you have to choose between housing and food. Within your budget, you can choose to have a smaller apartment to have better, more expensive food, and vice versa. (Note that this is nothing but a personal resource allocation problem that many of us solve all the time, perhaps unconsciously). Therefore, given the rents of various types of apartments and food prices that you cannot change, you can choose to have an optimal allocation between food and housing. Now suppose the price of food goes up. As a result, you will probably consume less food and vice versa. To summarize, for varying prices of a good, assuming that income and other prices remain the same, you will choose to consume more or less of a good or service (and this is exactly how the individual demand is drawn up as discussed above). Finally, we

need to make one more distinction—between consumer and capital goods. A consumer good is something that you consume within a period of time, say a month or year. Most of the conventional goods that you think of are consumer goods. A capital good, on the other hand, is something that you consume over a period of time, say a car. Extending this analysis to health choices, we can apply a framework that was developed by one of the pioneers in the field of health economics, Michael Grossman (1972). The first important insight is that individuals want a commodity akin to “good health” (not medical care per se). Second, this commodity is both a consumption and an investment good. It is a consumption good because individuals derive satisfaction from consuming good health. It is also an investment good because healthier days arguably lead to more productive days, helping earn higher income. However, we are also interested in knowing how the demand for such goods responds to prices to develop a demand schedule for health goods and services. The demand is tricky because of the factors associated with the unusualness of health products. One way to do this is to somewhat arbitrarily change healthcare access for a reasonably big population. For example, a group of people can be chosen by lottery to receive health insurance with no copay. In terms of the mechanism in the hamburger analogy, this would be tantamount to making hamburgers cheaper for a group of people. Question is: Would they consume more hamburgers? It is less obvious for health care because of the unusual nature of the product. But the equivalent question would be—Do consumers consume more health services such as visits to a doctor’s office if such visits are made cheaper? Two famous experiments—one conducted by the RAND Corporation (Newhouse et al., 1981) and the other by the state of Oregon (Baicker & Finkelstein, 2001) did something similar. They randomly assigned groups of people with no copay and positive copays. If there is an inverse relationship between price and quantity of medical care demanded,

Resource Allocation and Market Role

then the latter group, facing a higher price, would use less of it. The studies found broad support for the conjecture that zero copay leads individuals to consume more service (Newhouse et al., 1981; Baicker & Finkelstein, 2011).

Supply of Health Care What about the supply of health care? Although health services in the U.S. and elsewhere are provided by a variety of individuals and institutional settings, let us focus on two major pillars—professionals such as doctors and nurses, and institutions such as hospitals. In terms of the availability of physicians, the United States performs much worse than many other developed countries. According to the Organisation for Economic Co-operation and Development (OECD) data, there are 2.6 doctors per 1,000 inhabitants in the U.S. compared to 4.4 in Norway and 4.1 in Germany (Lafortune & Moreira, 2015). Additionally, this average number also masks the vast amount of regional inequality in physician availability in the U.S., where it is well known that rural areas are more underserved than their urban counterparts. The slow growth of doctor availability is not actually due to market forces. The supply of physicians, and to some extent nurses, is closely monitored by various agencies in the U.S. that affect the supply, including the parent organization and education accreditors for each—e.g., the American Medical Association (AMA), the American Association of Medical Colleges (AAMC), and in nursing, the American Association of Colleges of Nursing (AACN). In nursing, alliances of organizations have been instrumental in lobbying the U.S. Congress for incentivizing and growing the workforce supply during periods of shortages. As an example of the slow growth in doctor availability, ever since its foundation in 1847, the AMA has strived to regulate the profession of practicing medicine in a variety of ways. It powerfully lobbied state legislatures to require licenses to practice medicine, it tried to close low-quality medical schools in the early 20th century, and vigorously opposed

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single-payer systems contemplated in the late 1950s. In effect, the supply of doctors has increased only modestly in the U.S. Moreover, there has been fragmentation within the profession. In line with economic theory, higher price (payment from insurance companies and directly from patients) has attracted proportionally more doctors to more specialized fields, leaving basic areas like family medicine low in supply. In nursing, the shortage has increased funding for nursing education through periods of highs and lows, stimulating enrollments in schools relative to the period. The other major “supplier” of medical care is hospitals. Hospitals have evolved enormously over the years, transitioning from dingy, often unsanitary, unregulated places to modern-day, state-of-the-art facilities. Following the 1946 Hill-Burton Act, which provided federal funding for building hospitals, there has been a major expansion of hospitals in the U.S. However, that trend reversed from the mid-1970s for a variety of reasons. First, the direct incentives to build new hospitals dried up. Second, and more fundamentally, the rate of hospitalization in general also declined. The latter happened due to a few reasons. First, technologically, many procedures did not require hospitalization for treatment any more (i.e., the advent of laparoscopy). Second, insurance companies and the Centers for Medicare & Medicaid Services (CMS) did not always follow a fee-for-service (FFS) system and started basing their payments on patients’ medical conditions. Therefore, in the former system, the longer a patient stayed in a hospital, the more Medicare/Medicaid paid. Since Medicare subsequently paid a fixed amount, hospitals had less incentive to keep patients longer than necessary. National average hospital bed occupancy rate was only 61% in 2012 (Becker’s Hospital Review, 2014).

Insurance How does insurance impact the market? Unlike other markets, in general, individuals demanding

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the product and individuals and institutions supplying that product do not interact directly in the healthcare market. Again, this is because health products and their demand are rife with uncertainty. The standard approach to deal with uncertainly in economics is to insure oneself, be it accidents involving cars, flooding of basements, or losing or breaking your iPhone. In these cases, the cost of bad events is borne by a third party. What is insurance? At its core, insurance is based on the premise of idiosyncratic risk, which means while all individuals face the risk of falling sick or being in an accident, such risks are largely independent of each other, and the probability that all of them would be in an accident is very small. Therefore, if everyone contributes to a pot of money on a regular basis, called premiums, then if an individual faces a bad outcome, that pot of money can be used to pay for services needed. Although the idea seems straightforward, insurance is one of the most complex economic arrangements. The key reason behind this is what economists call the problem of information asymmetry. These asymmetries are broadly categorized as either hidden information or hidden action. Hidden information refers to the situation when one party (such as the customer of a health insurance company) has more information on the item being insured (his or her health) than the other party (such as the insurance company). Hidden action, on the other hand, refers to the situation when one party (i.e., the customer) takes action that affects the outcome of the contract that he or she has entered with the other party (i.e., the insurance company), which cannot necessarily be verified by the latter. Broadly speaking, both hidden information and hidden action affect the health insurance market. Examples follow.

Hidden Information Health insurance companies assess what is called the actuarial risk—a statistical method

of estimating the risk of a particular event’s occurrence, for example, a man between the ages of 65 and 75 having a heart attack for the first time. Assume for simplicity that the insurance company cannot test its potential customers for their existing health conditions and behaviors, but need to rely on their self-disclosure. The intuition does not change even if the insurance company uses a battery of tests. For example, a patient healthy at the time of testing may have a history of hypertension in his family. Even though the insurance company does not know individual risk profiles, it has an idea about the composition of high-risk and low-risk patients in the target population. It usually creates an average price, or premium, to collect from all its customers to cover the cost of care when one or few of its customers do suffer from events like heart attacks. Unfortunately, it might be the case that the premium is too high for individuals who have low risk of heart attack—as an example, a man who eats healthy, exercises regularly, and has no history of heart problems in the family. As a result, he may choose not to buy that insurance contract. Contrarily, for someone who knows that she is high risk, that premium may actually be a good deal to cover herself from the cost of treating a heart attack. Next, explore the consequences of these decisions for the insurance market. The company based its price on the assumption that both highand low-risk customers would buy that contract, lowering the average risk of a random client suffering from a heart attack. If many low-risk customers find the premium too high and withdraw from the insurance contract, the company would be left with only the high-risk customers. This is called the problem of adverse selection where high-risk customers self-select themselves into a contract meant for a more diverse risk pool. It is easy to see how this can destabilize the market. If higher risk customers over-represent the insured pool, then the insurance company may incur a loss in that period. Consequently, they may raise the premium for the same contract the following year. Unfortunately, that may not

Cost—The Main Problem

solve the problem. It may drive some moderate-risk customers out who may deem this new premium too high—driving the market relentlessly towards the point where only high-risk customers are willing to insure. In an extreme case, no feasible insurance contract may exist, even for nonprofit insurance companies.

Hidden Action Assume for the moment that there is no hidden information and insurance companies can get to know a complete medical history of patients before they sell them insurance. Now suppose a 50-year-old man, John, who smoked perhaps two cigarettes a day, drank three beers a week, and had a body mass index of 27, bought insurance. By conventional standards, he is low risk and secures a low level of premium. However, having bought the insurance and been assured of medical care, he starts to smoke more, drink more, and switch to an unhealthy diet. Unfortunately, the insurance company cannot monitor these behaviors. Therefore, the contract, which was sold on the basis of original risk, becomes skewed because of the underlying risk that he fell sick, and the required care increases. Relationships of providers with both insurance companies and patients can also potentially suffer from moral hazard problems. One of the most important assumptions in healthcare provision is that doctors and nurses do not consider their own economic well-being while recommending and carrying out treatments. Unfortunately, often there is little recourse to verify if such assumption is violated. Patients lack expertise to question the treatment course ordered. Although insurance companies and the Center for Medicare & Medicaid Services (CMS) have experts to scrutinize a recommended treatment course, the information asymmetry problem is unavoidable. The problem is embedded in the popular fee-for-service (FFS) model of payment, where the medical provider is paid (either directly by the patient or the private or public insurance agency) for medical expenses regardless of their impact on

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patient health. Since the providers get paid for each procedure, and not remission of illness or prevention of relapse, there is incentive to order excessive, often unnecessary, procedures. To be sure, this does not have to be a sinister criminal plan, and it seldom is. The problem lies in the complex web of information asymmetry and incentive systems. When a provider finds out that the patient is covered, the provider may order procedures that are marginally important to protect the patient (and possibly self against any potential malpractice lawsuit), even when there is no benefit personally from those procedures. But it is very difficult for the patient and provider to make an economic decision (in case there are copays) by themselves. Unfortunately, this system has contributed significantly to the escalation of costs throughout the system. Since patients are often protected by a fixed copay, and generally trust their providers, they seldom question recommended tests and treatments. Insurance companies, on the other hand, try to pass on this higher cost to their enrollees in terms of higher and higher premiums. (Note how higher premiums affect individuals who did not seek much medical care, creating an indirect burden on healthier individuals.) In fact, it is widely recognized by now that the most threatening and overarching problem in the U.S. healthcare sector is escalating cost.

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Cost—The Main Problem

While mechanisms such as copays and differential contracts solve some of the informational asymmetries, they do not address the fact that health care in the United States remains enormously expensive, particularly compared to other industrialized countries. The difference is even more remarkable when we compare some of the standard health outcome indicators across these countries. Despite spending more money per capita, the U.S. often falls behind other industrialized countries in terms of

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Chapter 9 Healthcare Costs: Follow the Money Total Health Expenditure (THE) % Gross Domestic Product (GDP)-2014

% of GDP spent on healthcare

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health outcomes. Additionally, there is a vast amount of disparity within the U.S. in terms of those health outcomes, both in terms of geography and race and ethnicity. To illustrate some of the points that depict the comparisons, consider FIGURE 9-1, which shows the total health expenditure (THE) for top 10 industrialized countries as percentages of their gross domestic product (GDP) in 2014. Note, first of all, that not only does the U.S. spend the highest proportion among all 10 countries, it outspends the next highest spending country, Sweden, by more than five percentage points. There is also a remarkable similarity between the other (mostly European) countries as far as the percentage of THE in GDP is concerned. Finally, note that these are the highest spending countries by this metric, so some of the advanced countries such as the United Kingdom or Australia, whose numbers are slightly less than 10%, are not even in the graph (OECD, 2017). It can be argued that spending more money is not a bad outcome per se. It is true that humankind has made tremendous progress in reducing and virtually eliminating many diseases,

and medical science has improved and extended lives for many. If this improvement has come at a high cost, that may be acceptable. It may be useful to think about it in a more personal way: If improving your health makes you substantially happier, then you may want to spend 15% of your income on health. Unfortunately, for the United States, the higher spending often does not translate into better health outcomes. There are many ways to measure health outcomes, but some of them are universally accepted to important goals across countries and cultures. Infant mortality rate (IMR) is one of them. It measures how many babies lose their lives during the first year of their birth per 1,000 live births. Globally, health professionals strive to keep this ratio as low as possible. While infant health is obviously unpredictable, systemically high rates of IMR point to deficiencies in the health delivery system (see FIGURE 9-2) (World Bank, 2017). Figure 9-2 represents data for infant mortality rates for those 10 highest countries that were represented in Figure 9-1. The graph shows a remarkable fact—in spite of spending the

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Cost—The Main Problem Infant mortality rates in countries that spend highest proportions of GDP on health

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highest proportion of its national income on health, the U.S. has the worst outcome among the industrialized countries shown in the figure in terms of IMR. Although such trends can be seen in other important health outcomes such as life expectancy, such anomalies are (fortunately) not seen across the board. In fact, the U.S. excels in certain areas of health outcomes, particularly innovations. There is more to this story. So far, the data suggest that some health outcomes in the U.S. compare poorly with other advanced countries in the world. In addition, however, significant inequality exists within the U.S., both across various regions and across different socioeconomic and demographic groups. There is a growing literature on various socioeconomic determinants of health that traces differences in health outcomes to these variables. Although beyond the scope of this chapter, excellent discussions about race, region, and social determinants can be found in the works of Williams (1999) and Williams, Neighbors, and Jackson (2003). FIGURE 9-3 plots the IMRs of two U.S. states, Mississippi and Alabama, and three countries that span continents and are much poorer than the U.S. We can see that some states in the U.S. perform much worse than countries that are

FIGURE 9-3  Infant mortality rates for selected countries and states in the United States Data from Kaiser Family Foundation. (2018). Infant Mortality Rate (Deaths per 1,000 Live Births). Retrieved from http://kaiserf.am/2snoFoo

much poorer (Sri Lanka’s per capita income is 7% of the United States). Therefore, the disconnect between national spending and health outcomes, both in comparison to the performances of other industrialized countries and between states in the U.S., is quite clear. The general consensus is that the U.S. spends too much on health care and no matter how that bill is shared, as an economy, it would soon struggle to pay that bill. And this heightened spending has not been accompanied with

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a steady and uniform improvement in some of the basic health outcomes over the years. Although it is not easy to identify a single source of cost escalation, let us take an accounting approach and look at the different sectors that constitute the overall healthcare economy. Then we can examine the nature of cost inflation in each of them. According to Fidelity Research, the Healthcare sector had a market capitalization of 5.08 trillion dollars, about 20% of the total market capitalization in the U.S. stock market, as of April 17, 2018. The sector consists of six industries (in decreasing order of market capitalization): Pharmaceuticals, Biotechnology, Health Care Equipment & Supplies, Health Care Providers & Services, Life Sciences Tools & S­ ervices, and Health Care Technology (Fidelity Investments, 2018). Pharmaceuticals rank 5th in the overall industry-level ranking for market capitalization. The above estimates do not include the hospital sector, which according to CMS estimates, was a little more than a trillion dollars in 2015 (CMS, 2015). It is difficult to identify a single factor or sector that is responsible for the cost escalation. It is somewhat easier to see for publicly traded profit-driven pharmaceutical and insurance companies (categorized under the managed care sector). Executives are driven by the company’s bottom line and often such objectives are at odds with patients’ welfare. Obviously, there is a public recognition of this conflict and a variety of government regulations are in place to protect patients’ interests. Unfortunately, at the same time, these companies have armies of lobbyists to cut down such regulations. According to a bipartisan Center for Responsive Politics analysis of all lobbying expenditures as found in U.S. Senate Office of Public Records, more than 500 million dollars were spent on lobbying for the healthcare sector in the United States in 2016, a more than 40% increase compared to 2006 (Center for Responsible Politics, 2016). Cost escalation also comes from the not-for-profit section of the healthcare sector. According to the CMS, not only are hospital costs rising, the rates of increase are also

going up over the years (2015). From an economist point of view, rising cost is not necessarily a bad thing if it is also accompanied by better quality; but in this case, even before getting into the quality issues, what is more disturbing is the lack of transparency and efficiency. In a long article published in Time magazine, Steven Brill pointed out a widespread practice in the hospital industry of using a protocol called the Chargemaster to bill patients (2013). Admittedly, healthcare products cannot be priced in the same way as, for example, a laptop or haircut, but the pricing scheme appeared almost completely arbitrary, where generic over-thecounter medicine is charged with hundreds of percentages of mark up. Hospitals run as notfor-profit institutions saved vast amounts of money in federal, state, and local taxes with a loose mandate of community engagements, particularly in densely populated poor urban areas, but the proportions of their budget devoted to charity remained less than 2% to 3% in most of the cases. While there was no profit to be distributed to the shareholders, evidence suggests that these hospitals lavishly spent on facilities and on their top doctors and executives (Brill, 2013). Fortunately, the cost problem is being widely recognized and initiatives are being taken to address the problem. As previously discussed, one key problem with the FFS payment system is that it rewards quantity of service provided, rather than quality—escalating costs while not necessarily improving care. To address this issue, the Center for Medicare & Medicaid Innovation, formed as part of the ACA, started an initiative called Bundled Payments for Care Improvement (BPCI). The idea is to improve quality and lower cost by reducing fragmented care. For example, using a definition of “episode of care” as an inpatient stay at a hospital for a patient, under the traditional Medicare payment system, hospitals and doctors are paid separately for their services provided for the same patient. But in the BPCI system, under one model, the payments are still based on FFS, but are retrospective in nature, bundled together, and

Cost—The Main Problem

reconciled against a “target” price. Under yet another model, “CMS makes a single, prospectively determined bundled payment to the hospital that encompasses all services furnished by the hospital, physicians, and other practitioners during the episode of care, which lasts the entire inpatient stay” (CMS, 2014). There is no denying the fact that as medical spending has increased over the years, so has the overall quality of care, both in the U.S. and worldwide. Fifty years ago, an average American was expected to live for 70 years (commonly known as life expectancy). Today they can expect to live 9 more years. Many diseases like plague and smallpox that have historically claimed millions of lives have now been eliminated. Vaccines have improved preventive health enormously. Even some more recent challenges such as human immunodeficiency virus (HIV) have been met with some success—people with HIV have been managing their lives through medications that were not available just a few years ago. Death rates from acquired immunodeficiency syndrome (AIDS) have also been falling steadily. The number of AIDS-related fatalities fell from 1.9 million in 2005, the year of peak mortality, to 1 million in 2016 (UNAIDS, 2017). These benefits need to be weighed against increased costs. Economists have long recognized the vital role that the pharmaceutical industry plays in this field. Discovery of a new drug is a slow, expensive, and most importantly, uncertain process. Billions of dollars of upfront investment are needed to develop drugs—both those that succeed and those that fail. Profit-making private companies need to recuperate not only their research into successful drugs, but also their unsuccessful ones, driving up the prices for the former. On one hand, the patent protection that these drugs enjoy is necessary to incentivize their research, but on the other hand, it offers monopoly rights, meaning that they can charge a price as high as the market can sustain. Another area where rapid improvements have been made is biotechnology and biomedical engineering, including the use of nanotechnology,

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genome editing, and sophisticated cardiovascular devices. The trade-off between imposing price control and setting lower incentives for research spending is present here also. If a company develops a new prosthetic knee that is significantly better than the current state of the art device, should it be allowed to charge as much as it can get from the market? Generally, the question confronting the stakeholders is: Can the increase in benefit justify the cost hyperinflation? This is a complex issue and does not suggest any last word; however, it is worth exploring a bit deeper. One way to assess the “benefit” from healthcare innovation is to measure the life-years saved by a health intervention (sometimes adjusted for quality). Cutler, McClellan, Newhouse, and Remler (1998) examined the cost and benefit of heart attack treatments between 1984 and 1991 using a Medicare dataset. They found that the total cost of treatment (including commodities like beta blockers and services of professionals) increased by 32%. However, in a follow-up study, they found that improvements in the quality of treatment during this period led to heart attack survivors living 8 months extra on average. Using some complex calculations, they concluded that the cost inflation was outweighed by the benefits accrued. While the general argument that one should not merely look at the cost without factoring in the benefit is valid, it does not necessarily mean that all cost increases have been associated with increased quality and benefit. For example, Cutler and colleague’s studies used Medicare data, while it is well-known that Medicare reimburses at the lowest rate among all insurers. In fact, according to American Hospitals Association (AHA), hospitals lose money from Medicare reimbursements (AHA, 2013). According a recent Commonwealth Fund report, the U.S. performs well in terms of survival rates after major issues like breast cancer or strokes compared to its peers in the industrialized world (Schoen, Hayes, Collins, Lippa, & Radley, 2014). Moreover, the U.S. does lead in innovation in both pharmaceuticals and

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technological innovation. However, a large part of the innovation comes from the government sector. In fact, the prognosis that price controls may kill all innovation is not necessarily true. A large part of the overall innovation in terms of new drugs, new devices, or new methods, apart from new research insights, come from publicly funded organizations like the National Institute of Health (NIH) and university research labs (Bhattacharya, Hyde, & Tu, 2013).

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Health Policy—ACA and Beyond

At the time of writing this chapter, the United States is undergoing a fierce health policy debate that, although political in nature, touches upon many topics discussed in this chapter. Should there be an “individual mandate,” in the sense that private individuals should be forced to buy a private product by the government? Or is the question misplaced because health care is not like any other private commodity that is bought and sold in the free market? Should government subsidize health care through Medicaid expansion, even though there is some evidence that both doctors and patients can exploit the subsidies by abusing prescription medication? What about the cost? What can policymakers do to control cost yet not create disincentives for innovations? The Patient Protection and Affordable Care Act (ACA), President Barack Obama’s 2010 signature healthcare reform, has been the most significant change in the health policy landscape in this century. However, it will be worthwhile to step back and look at some of the most consequential changes in health policy in the post–World War II era. During the war, in order to control rampant wartime inflation, there was a wage freeze, even for most productive employees. In order to bypass this regulation, employers sought to offer health coverage in lieu of wage income and both labor unions and regulators agreed with the War Labor Board exempting employer-paid health benefits from wage controls and income

tax. This temporary arrangement became popular and remained in place even after the war, finally being formalized in Internal Revenue Service (IRS) code in 1954. However, this arrangement left out one group of adult populations who were not in the job market—the elderly. Despite an earlier push by the Truman administration in 1949 to start a German-style national social insurance program, which was stopped by intense lobbying from various groups including the American Medical Association, there was little option for the retired and their spouses to find private insurance. This led to the second major development in the healthcare landscape beginning 1965, when President Johnson signed Social Security Act Amendments into law. It established Medicare, a health insurance program for the elderly, and Medicaid, a health insurance program for the poor. Looking at these developments through the lens of some economic insights previously discussed, one observation is that employer-sponsored health insurance can mitigate both adverse selection and moral hazard problems to a large extent. When individuals are signing up for one of the insurance plans provided by their employees, they are not selecting the plan based on their health, a problem that is more relevant in the open insurance market, but they are selecting on the basis on their employment contract, of which health benefits are only a part. For large employers, there is likely to be a mix of various types of risk profiles. Obviously, this gets more difficult the smaller the employer gets, as there is likely to be less risk diversity and lower bargaining power for the small business. However, a less transparent problem with this arrangement comes from its tax policy aspects. Pretax funding of employer-sponsored insurance premiums has been one of the driving forces behind cost escalation and passive subsidization provided by the federal government. It has also contributed to a slower increase in nominal wage growth in the U.S. How does this happen? Let us first look at the problem from the employer’s viewpoint. Suppose the employer contemplates a fixed additional amount to the employee cost, either in

Health Policy—ACA and Beyond

extra wage, or in extra benefit. At the margin, an extra dollar in wage would mean around 9 cents more in payroll taxes, whereas an extra dollar in benefits would entail no such additional expense. Likewise, for the employee, it is better to take the extra dollars in benefit. Obviously, one cannot get paid only in benefits. But there is strong evidence that inflation-adjusted wages have remained flat for many workers whereas benefits have increased. The problem is that a more generous health benefit may lead to system-wide cost increases. And despite the best efforts of insurance companies, the moral hazard problems coming from the providers in terms of unnecessary tests and procedures can fuel what can potentially become an upward spiral—generous tax-free benefits leading to higher cost leading to higher premiums leading to more wage-benefit substitutions—all funded by the federal government in terms of foregone tax payments. It is worth noting that beyond the tax consequences of premium payments substituting wage income, increase in cost affects insurance companies also. Insurance companies worry about escalating cost for their own bottom line. Sure, they can pass on some increased cost as higher premium, but as with any other business, they always strive to lower their cost, in this case payments to healthcare providers. This brings us to another major health policy change in the last 50 years or so—the emergence of health maintenance organizations (HMOs) and managed care. Starting in the aftermath of the Great Depression and during the World War II, Henry Kaiser, an industrialist, and an entrepreneur-doctor, Sidney Garfield, MD, teamed up to provide insurance to thousands of workers who worked in the shipyards of Kaiser-owned companies. Although the contract was standard—workers paid premiums for potential future treatments—there was a feature rather unique for the time. The care was provided by doctors and nurses who were also hired by the Kaiser companies at Kaiser-owned facilities, but care provided outside of this network was not covered. Kaiser could keep the costs down because the doctors had fixed payments and no

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incentives to order unnecessary procedures. After the war, even though the Kaiser factories had much fewer workers, when such vertically integrated plans were offered to the public, it became both popular and profitable. U.S. health care is still dominated by HMOs. This brings us to the first decade of the 21st century. The healthcare landscape was the following—the majority of Americans were getting insurance from their employers. The elderly and disabled Americans were covered by Medicare. And some qualified poor families and children received care from Medicaid, depending on the generosity of the states they lived in. Finally, some Americans bought coverage directly from the individual insurance market offered by the insurance companies. This left a large number of Americans uninsured, who were not old enough, not poor enough, and not fortunate enough to have a job that offered affordable health benefits. The individual insurance market was very expensive because of the adverse selection problem. It was probably too expensive for many healthy Americans to enroll. At the end of 2010, as many as 79 million Americans were either uninsured or underinsured, defined as those who were insured, yet spent a high share of their income on medical care (Schoen, Hayes, Collins, Lippa, & Radley, 2014). Then came the landmark legislation of ACA in 2010. The mainstay of the law was circumventing the adverse selection problem in the individual insurance market. It created both employer and individual mandates, where individuals had to buy insurance, or pay a tax penalty. For qualified patients, it offered generous subsidies. It also capped both premium out-of-pocket amounts. Finally, it tried to curb the cost escalation to some extent by imposing a Cadillac tax—whereby employer-sponsored health benefits whose value exceeds specified thresholds—would be subject to an excise tax of 40%. (Note: The actual implementation was first delayed until 2020 and it remains uncertain if it will ever take effect). ACA also sought to expand Medicaid significantly by allowing some individuals and families without children

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to be covered. Such expansion, including subsidies, was planned to be funded by a couple of new taxes.

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Conclusion

At the time of writing this chapter, the U.S. Congress has tried and failed to repeal ACA. It has, however, successfully eliminated the individual mandate through the tax reform legislation. How that will have an impact on financing the rest of the ACA is still unknown at this time. It is worthwhile to look at that process through the lens of market principles and following the money. ACA was mainly built on free market principles. It explicitly tried to solve the adverse selection problem by mandating that individuals need to buy insurance. This was an unusual policy stance—government forcing private individuals to buy private goods. However, it is clear that health care is different from all other private goods, so needs special treatment. Moreover, any repeal effort that does not include the individual mandate is likely to fall prey to the adverse selection problem and rising premiums knocking many of the newly insured people off insurance once again. The same is true for the employer mandate also. The Medicaid expansion was straightforward. The effect of Medicaid expansion on health outcomes and health services use is mixed. Results from the famous Oregon experiment suggest that while use of health services increased for Medicaid enrollees, the outcomes were not significantly better. However, other studies that compare expansion with nonexpansion states show that Medicaid expansion improved outcomes (Miller & Wherry, 2017). Unfortunately, the role of ACA in dealing with the major problem of cost escalation is still unclear (Weiner, Marks, & Pauly, 2017). The two areas where ACA tried to control cost are Medicare and the “Cadillac Tax” (expensive employer-sponsored premiums). Even though the largest impact of ACA was on the individual market, the share of that market in the overall

healthcare sector is only 6%. With Medicare, it had a slew of cost-saving regulations like reduced payment rates and cutting down administrative clutter. With the Cadillac Tax, it sought to undo some of the damages done by the blanket tax break on expensive employer-sponsored health insurance premiums. (Note: A more efficient tax policy would be to scale back some of the tax breaks, but the political economy of taxation is often driven by politics and not economics). In the individual markets, the idea was that various insurance companies would compete with each other in the individual insurance markets or exchanges, as they were called, driving down the premiums and copays. To be clear, the politics surrounding ACA is complex and it is impossible to evaluate this piece of health policy without getting into all the turmoil that its implementation and continuation faces until today. However, it was largely built on economic insights and the failure to repeal it shows that such insights can actually be embedded into a resilient health policy.

Discussion Questions 1. 2. 3. 4.

In what ways can health care be different from other consumer purchases? Provide examples for both goods and services. Critically evaluate the statement: “High and growing cost remains the most important challenge in the U.S. health care sector.” Briefly discuss two major health policy changes that took place in the U.S. over the last five decades. What are the challenges of a market-driven healthcare system and how can public and private insurance markets control premiums and co-payments?​

References American Hospital Association (AHA). (2013). Setting the record straight on TIME’s article “bitter pill.” Retrieved from http://www.aha.org/content/13/settingrecordstraight .pdf (accessed August 2, 2017). Arrow, K. J. (1963). Uncertainty and the welfare economics of medical care. American Economic Review, 53, 941–973.

References Baicker, K., & Finkelstein, A. (2011). The effects of Medicaid coverage—learning from the Oregon experiment. New England Journal of Medicine, 365(8), 683–685. Becker’s Hospital Review. (2014, March 17). 8 statistics on hospital capacity. Retrieved from http://www .beckershospitalreview.com/patient-flow/8-statistics -on-hospital-capacity.html (accessed August 2, 2017). Bhattacharya, J., Hyde, T., & Tu, P. (2013). Health economics. Basingstoke, UK: Palgrave Macmillan. Brill, S. (2013, February 20). Bitter pill: Why medical bills are killing us. Time, 181(8), 16–55. Centers for Medicare & Medicaid Services (CMS). (2014). Bundled Payments for Care Improvement (BPCI) initiative: General information. Centers for Medicare & Medicaid Services. Retrieved from http://innovation.cms.gov /initiatives/bundled-payments/ (accessed August 6, 2017). Centers for Medicare & Medicaid Services. (2015). National health expenditures 2016 highlights. Retrieved from https:// www.cms.gov/research-statistics-data-and-systems /statistics-trends-and-reports/nationalhealthexpenddata /downloads/highlights.pdf Center for Responsive Politics (2016) Health sector profile. Retreived from https://www.opensecrets.org/lobby /indus.php?id=H&year=2016 (accessed August 2, 2017). Cutler, D. M., McClellan, M., Newhouse, J. P., & Remler, D. (1998). Are medical prices declining? Evidence from heart attack treatments. The Quarterly Journal of Economics, 113(4), 991–1024. Fidelity Investments. (2018). Health Care Snapshot. Re­ trieved from https://eresearch.fidelity.com/eresearch /markets_sectors/sectors/sectors_in_market.jhtml?tab =industries§or=35 Grossman, M. (1972). On the concept of health capital and the demand for health. Journal of Political Economy, 80(2), 223–255. Lafortune, G., & Moreira, L. (2015). Trends in supply of doctors and nurses in EU and OECD countries. OECD Indicators. Paris, France: OECD Publishing.

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Miller, S., & Wherry, L. R. (2017). Health and access to care during the first 2 years of the ACA Medicaid expansions. New England Journal of Medicine, 376(10), 947–956. Newhouse, J. P., Manning, W. G., Morris, C. N., Orr, L. L., Duan, N., Keeler, E. B., & Brook, R. H. (1981). Some interim results from a controlled trial of cost sharing in health insurance. New England Journal of Medicine, 305(25), 1501–1507. Organisation for Economic Co-operation and Development (OECD). (2017). Health expenditure. Retrieved from http:// www.oecd.org/els/health-systems/health-expenditure.htm Schoen, C., Hayes, S. L., Collins, S. R., Lippa, J., & Radley, D. (2014). America’s underinsured: A state-by-state look at health insurance affordability prior to the new coverage expansion. New York, NY: The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/publications/fund -reports/2014/mar/americas-underinsured (accessed August 2, 2017). United Nations Programme on HIV/AIDS (UNAIDS) (2017) Fact sheet—Latest statistics on the status of the AIDS epidemic. Retrieved from http://www.unaids.org /en/resources/fact-sheet (accessed September 25, 2017). Weiner, J., Marks, C., & Pauly, M. (2017). Effects of the ACA on health care cost containment. LDI Issue Brief, 24(4), 1. Williams, D. R. (1999). Race, socioeconomic status, and health: The added effects of racism and discrimination. Annals of the New York Academy of Sciences, 896(1), 173–188. Williams, D. R., Neighbors, H. W., & Jackson, J. S. (2003). Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health, 93(2), 200–208. World Bank. (2017). World development indicators 2017. Washington, DC: Author. © World Bank. Retrieved from https://openknowledge.worldbank.org/handle/10986 /26447. License: CC BY 3.0 IGO.

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CASE STUDIES

CASE STUDY Quality-Based vs. Quantity-Based Incentive Payment Approaches: MACRA and MIPS Olga S. Kagan and Veronica D. Feeg The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), a bipartisan legislation signed into law on April 16, 2015, established the Quality Payment Program. The Quality Payment Program: (a) repealed the Sustainable Growth Rate (SGR) formula that was in effect in which Medicare physician payment rate calculations were based on fee-for-service reflected in increased enrollment and changes in physician fees; (b) changed the way that Medicare rewards clinicians for value over volume; (c) streamlined multiple quality programs under the new Meritbased Incentive Payment System (MIPS); and (d) gave bonus payments for participation in eligible alternative payment models (APMs) (CMS, 2016a). “These changes were designed to stimulate provider delivery of services rewarded for quality of services based on outcomes rather than quantity of services in the fee-for-service reimbursement methods. This new program streamlines current pay for reporting and pay for performance programs with a single system where you can be rewarded for better care. You’ll be able to practice as you always have, but you may receive higher Medicare payments based on your performance” (CMS, 2016b, p. 1). The Quality Payment Program is a new way to pay clinicians, as well as offer clinicians tools and resources to help provide patients participating in Medicare the best possible care. The Quality Payment Program takes a comprehensive approach to payment by basing consideration of quality on a set of evidence-based measures that were primarily developed by clinicians, thus encouraging improvement in clinical practice and supporting by advances in technology that allow for the easy exchange of information. The Quality Payment Program also offers special incentives for those participating in certain innovative models of care that provide an alternative to

fee-for-service payment (CMS, 2017a). Under the Quality Payment Program, clinicians are rewarded for giving high-quality and high-value care in one of two ways: (1) the Merit-based Incentive Payment System (MIPS), or (2) advanced alternate payment models (APMs). Providers can choose, if they are eligible, one of these payment systems (clinician participation in either of these programs is based on practice size, specialty, location, or patient population). If they decide to participate in MIPS, they will earn a performance-based payment adjustment if they participated in the Quality Payment Program in 2017 or if they bill Medicare more than $30,000 in Part B allowed charges a year and provided care for more than 100 Medicare patients a year. Clinicians participating in MIPS, including physicians, physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and a group that includes such clinicians, will earn a performance-based payment adjustment to their Medicare payment. This payment adjustment is based on a MIPS final score that assesses evidence-based and practice-specific quality data in the following four categories: (1) quality, (2) cost, (3) improvement activities, and (4) advancing care information. Based on eligibility, each participating provider who submits payment data for Medicare reimbursement has been tasked to submit a plan of selected outcome measures that target select patient groups in the practice to be paid for their performance of meeting goals. This pay-for-performance approach weights the reimbursements that will incentivize quality over quantity. FIGURE 9-4 provides an example of the advice provided to clinicians by the Centers for Medicare & Medicaid Services (CMS) for the timing of participating in the payment process.

Quality Control To answer the question about how the Quality Payment Program will change providers’ Medicare payments, the response from CMS is that it depends on the data submitted by March 31, 2018. For example, for 2019, based on 2018 data, Medicare payments will be adjusted up, down, or not at all. This will continue over the subsequent years, taking into account new definitions and

Case Study

Performance Year 2017

2018 feedback available

Adjustment January 1, 2019

Performance: The first performance period opens January 1, 2017 and closes December 31, 2017. During 2017, record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can join and provide care during the year through that model.

Send in performance data: To potentially earn a positive payment adjustment under MIPS, send data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, 2018. In order to earn the 5% incentive payment by significantly participating in an Advanced APM, just send quality data through your Advanced APM.

Feedback: Medicare gives you feedback about your performance after you send your data.

Payment: You may earn a positive MIPS payment adjustment for 2019 if you submit 2017 data by March 31, 2018. If you participate in an Advanced APM in 2017, then you may earn a 5% incentive payment in 2019.

FIGURE 9-4  Timing of participating in the payment process Data from Centers for Medicare & Medicaid Services. (n.d.). Quality Payment Program. Retrieved from https://qpp.cms.gov/

conditions modified over time by CMS. Payment incentives are estimated to give providers an increase in Medicare reimbursements when they optimize their services and minimize their frequency or former fee-for-service visits and tests. With this new measurement system, payment is based on performance measures (scores) and participation, with expectation that the system will be phased in over subsequent years to change all Medicare payments based on this approach. Electronic health records (EHRs) and CMS electronic tools are available to assist providers with calculations. Additionally, nonparticipation of providers can result in negative incentives for Medicare payments. In simple terms, providers are rewarded for quality and adjusted negatively for failing to comply when the program is fully implemented.

Phased-In Scoring for Payments The Quality Payment Program was slated to phase in since the enactment of MACRA in 2015. Phase-in guidance has been made available to clinicians with tools to establish measures and ease of reporting. The following is a CMS interpretation of two payment paths available to technicians: 1. Pick your pace in MIPS: If you choose the MIPS path of the Quality Payment Program, you have three options (FIGURE 9-5). 2. Participate in the advanced APM path: If you receive 25% of Medicare payments or see 20% of your Medicare patients through an advanced APM in 2017, then you earn a 5% incentive payment in 2019. The cycle of the program is shown in FIGURE 9-6.

CASE STUDIES

Submit March 31 2018

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Not participating in the quality payment program: If you don’t send in any 2017 data, then you receive a negative 4% payment adjustment.

CASE STUDIES

–%

0%

Test: If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment.

+%

Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment and may even earn the max adjustment.

+%

Full: If you submit a full year of 2017 data to Medicare, you may earn a positive payment adjustment.

FIGURE 9-5  Pick your pace for MIPS plan Data from Centers for Medicare & Medicaid Services. (n.d.). Quality Payment Program. Retrieved from https://qpp.cms.gov/

2017

2018

+/– 4%

+/– 5%

+/– 7%

+/– 9%

2019

2020

2021

2022

FIGURE 9-6  Advanced APM path program cycle Data from Centers for Medicare & Medicaid Services. (n.d.). Quality Payment Program. Retrieved from https://qpp.cms.gov/

Deadlines and Changes Over Time Several changes have already been added to the implementation of the Quality Payment Program. These changes are made as notifications and updates on the CMS website. For example, the new deadline was established of December 31st for the performance period for the submission of reweighting applications beginning with the 2017 performance period. The definition of hospitalbased MIPS-eligible clinician was revised to include covered professional services furnished by

MIPS-eligible clinicians in an off-campus outpatient hospital. Additional points were announced: Complex patients bonus. Clinicians can earn up to five bonus points for the treatment of complex patients (based on a combination of the Hierarchical Condition Categories [HCCs] and the number of dually eligible patients treated). Small practice bonus. Five points are added to any MIPS-eligible clinician or small group in a small practice (defined as 15

Case Study or fewer eligible clinicians), as long as the MIPS-eligible clinician or group submits data on at least one performance category in an applicable performance period.

Changes Beyond Adjustments

stool that supports our healthcare system, remain fundamentally and ideologically different. What is clear is that as the arguments shift in public support and policy, cost often remains a driver in decision making in publicly funded health care. One should follow the money to understand more broadly the underlying policy changes that lie ahead.

Case Study Questions 1. What does the Medicare change in payments to providers mean in terms of delivery of services? 2. How does the Quality Payment Program impact on payment to nurses and other providers who provide services to Medicare patients? How do you think quality will be improved? 3. What ways can clinicians choose to participate in the Quality Payment Program? 4. Based on the current ruling, and final score calculations for 2017 transition year and 2018 MIPS performance year score, what would you anticipate will occur in the future? 5. How likely do you believe that Medicare financial incentives planned for quality improvement and cost reduction will be repealed or modified in the current administration and why?

References AANA (2017). 2018 MIPS cost performance category fact sheet. Retrieved from https://www.aana.com/docs/default -source/ofs-aana-com-web-documents-(all)/2018_mips _cost_fact_sheet_version_1.pdf?sfvrsn5177740b1_2 Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services. (2015). The Medicare Access & CHIP Reauthorization Act of 2015 path to value. Retrieved from https://www.cms.gov/Medicare /Quality-Initiatives-Patient-Assessment-Instruments /Value-Based-Programs/MACRA-MIPS-and-APMs /MACRA-LAN-PPT.pdf Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services. (2016a). Medicare value-based Programs: MACRA, MIPS, and APMs. Retrieved from https://www.cms.gov/Medicare /Quality-Initiatives-Patient-Assessment-Instruments /Value-Based-Programs/MACRA-MIPS-and-APMs /MACRA-MIPS-and-APMs.html Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services. (2016b). MIPS APMs in the Quality Payment Program fact sheet. Retrieved from https://www.cms.gov/Medicare/Quality

CASE STUDIES

Despite the adjustments made to the Quality Payment Program in year 2, including more flexibility, new incentives for participation, and free hands-on technical assistance with full implementation in year 3, U.S. Secretary of Health and Human Services Alex Azar proposed reduction or elimination of MIPS reporting requirements to the Centers for Medicare & Medicaid Services (Reid, 2018). This response was formulated based on clinicians’ citing requirements to be burdensome and expensive, taking time away from patient care. Suggestions include using claims data and patient surveys to grade doctors in the program instead of having to report patient data by MIPS-participating clinicians. Another proposal is to introduce a voluntary value program in which physicians could be assessed in a group. Paul Ginsburg from the Brookings Institution and a member of the Medicare Payment Advisory Commission (MedPAC) believes that the reporting requirements under MIPS are ineffective at improving care because doctors can choose the quality measures to be graded on by the government. MedPAC, a congressional advisory board that has 17 members, approved a proposal in January calling on the U.S. Congress to replace MIPS with a voluntary value program in which physicians could be assessed in a group (Reid, 2018). However, until further decisions are made, the current ruling stands. MIPS-participating clinicians who receive a high score would be eligible for bonus payments from Medicare, while those who score poorly would be penalized. Clinicians who do not submit any data automatically will receive the lowest score. At this time, it is uncertain how the pendulum will swing with challenges to underlying politics of pro- and antiregulatory groups that impact how healthcare services are paid for by the government. The principled development of incentivizing quality while decreasing costs will continue in debates at the federal, state, and local levels; however, the approaches will differ. At the same time, the arguments for access, often called the “third leg” of the cost-quality-access

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CASE STUDIES

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-Payment-Program/Resource-Library/MIPS-APMs-in -the-Quality-Payment-Program.pdf Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services. (2017a). Quality Payment Program year 2: Final rule overview fact sheet. Retrieved from https://www.cms.gov/Medicare /Quality-Payment-Program/resource-library/QPP-Year -2-Final-Rule-Fact-Sheet.pdf Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services (2017b). Quality Payment Program: Executive summary. Retrieved from https:// www.cms.gov/Medicare/Quality-Payment-Program /Resource-Library/QPP-Year-2-Executive-Summary.pdf

Centers for Medicare & Medicaid Services (CMS), HHS (2017c). Quality Payment Program: Merit-Based Incentive Payment System (MIPS): Episode-based cost measure field test reports fact sheet. Retrieved from https://www.cms.gov/Medicare /Quality-Initiatives-Patient-Assessment-Instruments /Value-Based-Programs/MACRA-MIPS-and-APMs/Cost -Measures-Field-Test-Fact-Sheet.pdf Reid, J. (2018, February 15). HHS may nix reporting requirements for value-based care program, Azar says. Morning Consult. Retrieved from https://morningconsult.com/2018/02/15 /hhs-may-nix-reporting-requirements-for-value-based -care-program-azar-says/

CHAPTER 10

Private Health Insurance Market Dr. Joyce A. Hahn

OVERVIEW Like other developed countries in the world, in the United States there are both private and public health insurers. What makes the U.S. healthcare system unique has been the dominance of private insurers. Private health insurance creates access to health services and thus improves health by protecting individuals from financial loss due to the high cost of medical expenditures. Health insurance covers a broad range of benefit plans that reflects the ways in which health insurance is organized to pay for a wide array of health services. The health insurance plan not only specifies how and where the healthcare services will be provided, but also functions as the claims processor by managing payment of funds to the providers of the healthcare services. The employer-based private healthcare insurance model gained dominance during the Second World War. An implicit “social contract” was developed between the government, employers, and employees to offer health insurance as an employment benefit. With wages frozen, companies had limited financial resources to offer employees. Health insurance benefits provided a competitive advantage when recruiting and retaining employees. Companies were further encouraged to offer health insurance as an employee benefit as expenditures for healthcare expenses were exempted from income tax. This practice laid the groundwork for employer-based health insurance plans (Zhou, 2009). This model has resulted in the U.S. being one of the only industrialized nations that does not offer universal coverage through some combination of private and public enrollment. The consequence of an employer-based system of health insurance where employers are not mandated to provide coverage is that employers can choose who to cover and whether or not to provide coverage at all. As healthcare costs have risen there has been a steady decline in the percentage of Americans covered by employer-based insurance policies. As the number of uninsured grew, the federal government felt the political momentum for reform that resulted in the passage of the Patient Protection and Affordable (continues) © Anthony Krikorian/Shutterstock

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OVERVIEW

(continued)

Care Act (ACA). The ACA has served to bring healthcare insurance to those workers not covered by employer-based plans and the uninsured Americans. This chapter will provide an overview of the private health insurance industry in the U.S. beginning with the historical evolution of private insurance and managed care, the identification of the key federal laws and their impact on the insurance industry, and the rise of consumer-driven health care and the empowerment of the healthcare consumer. The impact of the ACA will be examined at this dynamic time in healthcare history.

OBJECTIVES ■■

■■ ■■ ■■ ■■ ■■

▸▸

Explain the historical evolution of private health insurance and managed care into a healthcare industry. Identify the key federal laws and their impact on the insurance industry. Identify the key federal laws that protect individuals enrolled in private insurance. Understand consumer-driven health care and the empowerment of the healthcare consumer. Examine the impact of the Affordable Care Act (ACA) on the private insurance industry. Explore the emerging opportunities for nursing practice within the private insurance market.

History of U.S. Health Insurance Reform

The first insurance plans became available in the United States during the Civil War. These early accident insurance plans covered personal injury related from travel by rail or steamboat. These first plans paved the way for more inclusive plans, which covered illness and injury and were the precursor to disability plans. The first group policy giving comprehensive benefits was offered by Massachusetts Health Insurance of Boston in 1847. These first group plans working with healthcare providers would serve to be the predecessors to the fee-based contracts of today’s modern health insurance plans (Zhou, 2009). Prior to the 1920s Americans distrusted the quality of medical care received in hospitals and patients were treated at home by their families and attended by family physicians. Medical advances such as the development of X-ray technology, blood pressure monitoring devices and

the identification of disease-causing organisms served to increase confidence in the healthcare system. By the late 1920s, the cost of health care began to rise given the increased use of technologically based services being provided in medical facilities (Economics History Association, n.d.). The economic reality of the Great Depression brought home the impact of rising healthcare costs. Hospitals faced falling revenues as individuals could not afford the cost of care. Health insurance was created to finance their costs. In 1929, Dr. Justin Ford Kimball of Baylor University in Texas introduced a medical insurance plan called the Baylor Plan to allow teachers to prepay $.50/month for 21 days of semi-private hospitalization at Baylor Hospital. Rather than have each hospital compete for employer contracts, the American Hospital Association (AHA) hired Rufus Rorem to promote hospital prepayment and seek the necessary enabling legislation to create a special class of nonprofit corporations that could sell hospital insurance. In 1934, New York became the

Health Insurance Plans

first state to offer such hospital insurance coverage. These plans were promoted by the AHA. In 1938 the Blue Cross Commission of the AHA began a formal approval process for plans and only those endorsed plans could use the Blue Cross symbol and name (Massachusetts Association of Health Plans, n.d.). This was the origin of Blue Cross, which was a hospital-driven insurance plan. The American public welcomed Blue Cross as a hospital-driven insurance plan but now pressured employers for a medical insurance plan to cover physician costs. Blue Shield was established as physicians were pressured to offer an insurance product and was organized under the auspices of the American Medical Association (Blue Cross Blue Shield, 2017; Zhou, 2009). The financial successes of Blue Cross and Blue Shield as health insurance companies spurred the development of additional private insurance companies. By the 1960s these additional private insurance competitors controlled more than 50% of the healthcare insurance market, decreasing the domination of Blue Cross and Blue Shield. The success of the competing private plans resulted from their lower costs. Blue Cross offered a service contract—a fixed quantity of service for a fixed price. Private insurers offered indemnity plans—a cash amount towards a particular medical service. Ultimately Blue Cross was forced to offer indemnity plans in order to remain competitive. Starting in the 1930s, an alternative way of organizing and financing healthcare delivery was introduced called a health maintenance organization (HMO). Henry Kaiser, an American entrepreneur who owned shipyards and factories on the west coast, began to offer his employees the opportunity to prepay for health care for a few cents a day (Kaiser Permanente, n.d.). This unique employer-based health insurance system not only evolved into the largest HMO in the world, it also established the foundation for many government and private healthcare payment innovations that followed (Kaiser Permanente, n.d.). In addition to Kaiser, which was organized by a major business, HMOs were organized in

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other parts of the country by other stakeholders. Group Health Cooperative in Puget Sound, Washington was organized by members of the Grange, the Aero Mechanics Union, and local supply and food cooperatives. The Health Insurance Plan of Greater New York (HIP) is an example of a government-managed care plan organized when Fiorello LaGuardia was mayor of New York City (HealthPlanOne, 2016). Within the HMO paradigm, patient care is coordinated by a primary doctor who cares for the patient and determines if referral to a specialist within a provider network is required (HealthInsurance.org, 2018). HMO enrollees are entitled to comprehensive and continuous service for a fixed payment. Until the 1970s, HMOs comprised a limited part of the market meeting stiff competition from local medical societies. In 1970, the federal government recognized the potential of HMOs as a way to control costs and improve the quality of care. In the 1980s, the same potential was recognized by the private insurance industry. What had been organized under the umbrella of nonprofit organizations like Kaiser was now being virtually organized by the private insurance industry. The term managed care replaced the term health maintenance organization in the lexicon. What is important about the growth of managed care in the late 1980s is that it was a progressive strategy to provide access, a business strategy to control costs, a government strategy to control costs and achieve access, and a political strategy to avoid national health insurance.

▸▸

Health Insurance Plans

Today over 150 million Americans rely on their employers or the Health Insurance Exchange Marketplace for health benefits. Employers provide health insurance as a benefit package for employees. Citizens not covered by employer-sponsored plans can purchase health insurance directly from the Health Insurance Marketplace. The Health Insurance Marketplace is a key provision of the Affordable Care

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Act that operates as a service to help citizens shop for and enroll in affordable health insurance. The federal government has oversight of the Marketplace through a website (available at www.healthcare.org), which offers health plan shopping, enrollment services, and call centers (Centers for Medicare & Medicaid, n.d. a). These private health insurance plans are varied,

offering traditional indemnity insurance, or a variety of models that fall under the heading of managed care plans such as a health maintenance organization (HMO), preferred provider organization (PPO), or point-of-service (POS) plan. Examples of some historical key innovative approaches to healthcare insurance are provided in TABLE 10-1.

TABLE 10-1  Historical Timeline of Payment Reform Efforts Year

Reform

Goal

Sponsor

1929

Blue Crossa

Designed to reimburse hospitals for expenditures.

American Hospital Association (AHA)

1935

Social Securityb

Passed during the Great Depression providing old-age benefits and increased federal assistance for public health services; a provision to include national health insurance was omitted due to physician opposition.

President Franklin D. Roosevelt

1939

Blue Shielda

A plan for physician reimbursement for healthcare services.

American Medical Association (AMA)

1965

Title XVIII of the Social Security Act – Medicarec

Provides health insurance to individuals over age 65, and under age 65 with permanent disabilities.

President Lyndon B. Johnson

1965

Title XIX of the Social Security Act – Medicaidb

Covers health expenditures for impoverished Americans.

President Lyndon B. Johnson

1973

Health Maintenance Organization Actb

Predecessor of managed care.

President Richard M. Nixon

1985

Consolidated Omnibus Budget Reconciliation Act (COBRA)d

Provides continued coverage for healthcare costs when coverage from an employer-based group health plan ends due to job loss.

President Ronald Reagan

1993

National Health Security Actb

Proposed universal healthcare coverage for all Americans. Never voted on by Congress.

President William Clinton

Health Insurance Plans

Year

Reform

Goal

Sponsor

1993

Family Medical Leave Act (FMLA)b

Allows employees up to 12 weeks of leave for the birth of a child, adoption, or family illness.

President William Clinton

1996

Health Insurance Portability and Accountability Act (HIPAA)b

Prohibits insurance companies from denying healthcare coverage for preexisting conditions.

Senator Edward Kennedy; Senator Nancy Kassenbaum

1997

State Children’s Health Insurance Program (SCHIP)b

Initiative that funds healthcare coverage for children from low-income families whose family income is too high to qualify for Medicaid.

Senator Edward Kennedy; Senator Orrin Hatch

2003

Medicare Prescription Drug Improvement & Modernization Actc

Medicare Part D, provides a prescription plan for the elderly.

President William Clinton

2010

Affordable Care Act (ACA)e

Provides healthcare coverage for all Americans beginning January 2014.

President Barack Obama

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Data from [1] Blue Cross Blue Shield (2017). The history of the Blue Cross Blue Shield System. Retrieved from http://www.bcbs.com/about-the-association/; [2] Sultz, H.A. & Young, K.M. (2014). Health Care USA: Understanding its Organization and Delivery. 8th Ed. Maryland: Aspen Publishers; [3] Neuman, T. (2009). Medicare 101 Tutorial. Retrieved from: http:/kff.org/interactive/medicare- 101-tutorial; [4] SASid. (2007). Cobra Law Information. Retrieved from http://www.cobrainsurance.com/COBRA_Law.htm; [5] US  Dept. of Labor (2015). Monthly Labor Review; April, 2015. The National Compensation Survey and the Affordable Care Act in health care data. Retrieved from https://www.bls.gov/opub/mlr/2015/article/the-national-compensation-survey-and-the -affordable-care-act-preserving-quality-health-care-data.htm

Indemnity Insurance Indemnity insurance plans make a fixed cash payment toward a particular medical expense based on what services are covered and what reimbursement method is used by the insurance company. An insured person makes the decision when and from whom to seek health services. The provider, if services are covered under the health plan, submits a claim with the insurer retrospectively after services have been provided for payment. With this model of healthcare delivery, the individual carries the risk for covering the cost of his or her care. Deductible and coinsurance fees can still apply.

Indemnity insurance is also known as fixed benefit insurance or fee-for-service (FFS) insurance (Aetna, 2017; Fernandez, 2011; United HealthCare, 2017).

Health Maintenance Organization Healthcare service delivery and financing are integrated under managed care. In the original health maintenance organizations (HMOs), individuals joined group practices where their insurance premiums provided the budget to cover the cost of operating the group. Physicians were

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typically salaried so their costs were known. Costs were controlled within the managed care organizations by restricting enrollee access to in-network providers who agreed to accept a discounted fee-for-service payment. HMOs typically won’t cover out-of-network care except in an emergency. An HMO can require their enrollees to live or work in its service area to be eligible for coverage. Enrollees need primary care physician approval to access specialty care, a process known as gatekeeping. Precertification is required for routine in-hospital care. Disease management or care management coordinates care for enrollees with certain medical conditions. A distinguishing feature of the managed care approach is the emphasis on preventive health and the quality assurance processes (Fernandez, 2011, Centers for Medicare & Medicaid, n.d. b).

Preferred Provider Organization A preferred provider organization (PPO) plan offers individuals a hybrid insurance policy that combines the benefits of indemnity and managed care. The PPO will enter into contractual arrangements with providers and creates provider networks. If a patient uses a preferred provider, the cost of services is heavily discounted. If a patient uses out-of-network providers, PPO insurers will cover a portion of out-of-network providers charge depending on the plan. PPOs have an out-of-pocket deductible for the enrollee (U.S. Bureau of Labor Statistics, 2002).

Point-of-Service Plan A point-of-service (POS) plan is another hybrid insurance policy that loosens the gatekeeping restrictions imposed by HMOs. The “point of service” reflects the ability for enrollees to decide which provider they will see without receiving prior authorization from a primary care provider. Rules are generally similar to an HMO with the ability to see an out-of-network provider for a fee (U.S. Bureau of Labor Statistics, 2002).

Consumer-Driven Health Plan The consumer-driven health plan (CDHP) is one of the most recent innovations in the insurance market that seeks to control costs by empowering healthcare consumers to make personal decisions about their coverage. As healthcare expenditures and insurance plan premiums increase, both employers and employees were seeking alternatives to high-cost insurance coverage. The theory behind consumer-driven plans is twofold. First, there is an overuse of services because individuals do not know the cost of services and do not carry substantial financial risk in terms of being responsible for paying for services. Second, healthcare consumers are becoming better educated in terms of their knowledge of personal healthcare services and costs. Because consumers are at risk, they will make more cost-effective decisions about the care they receive. One concern, however, is that patient care is typically driven by physicians and patients do not have adequate information to discern between cost and quality. A CDHP is a combination of a high-deductible plan with a pretax payment account, as described in TABLE 10-2.

High-Deductible Health Plan A high-deductible health plan (HDHP) has a lower premium, a higher deductible, coinsurance, and out-of-pocket maximums for the insured to pay before receiving coverage. The insured will pay out of pocket for care, excluding the preventive care allowed under ACA, until the deductible is met. Once the deductible is met the plan will pay for benefits that are based on the coinsurance level. These plans provide catastrophic coverage guarding against major medical cost. The lower premiums translate into cost savings for both the employer and the employee. An important feature that distinguishes the HDHP from a traditional plan is the ability for the enrolled person to open a health savings account (HSA) that can be used to pay for the medical expenses incurred

Health Insurance Plans

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TABLE 10-2  Comparison of Pretax Savings Plans Pretax employee contribution allowed

Employer contribution allowed

Rollover allowed

Account must be linked with HDHP

Health savings account (HSA)

Yes

Yes

Yes

Yes

Health reimbursement arrangement (HRA)

No contribution allowed from the employee

Yes

Yes

No

Flexible spending account (FSA)

Yes

Yes

No

No

Type of account

HDHP 5 high-deductible health plan. Data from US. Department of Labor (2010) Bureau of Labor Statistics. Compensation and Working Conditions. Consumer-Driven Health Care: What is It and What does it mean for employees and employers? Retrieved from https://www.bls.gov/opub/mir/cwc/consumer-driven-health-care-what-is-it-and-what -does-it-mean-for-employees-and-employers.pdf

under the deductible. HDHPs are considered consumer-driven health plans allowing the consumer control over healthcare spending (Health Insurance Resource Center, n.d.).

Health Savings Account Health savings accounts (HSAs) were created by the U.S. Congress in 2003 so that individuals covered by high-deductible health plans (HDHP) could receive tax advantages for money saved to cover personal medical expenses. Funds placed in an HSA are not subject to federal income tax or payroll taxes at the time of deposit and are referred to as pretax dollars. An HSA is the account holder’s individual account and can be used to pay for qualified medical and pharmacy expenses. The account can be funded by the employer or employee with pretax dollars up to a statutory limit that varies yearly. An HSA plan includes a deductible, but enrollees can use their HSA to pay for out-of-pocket expenses before they meet the deductible. All deposits to an

HSA become the property of the policyholder, regardless of the source of the deposit. Funds deposited but not withdrawn each year will carry over into the next year. If the policyholder ends their HSA-eligible insurance coverage, he or she loses eligibility to deposit further funds, but funds already in the HSA remain available for use (U.S. Department of the Treasury, 2013; Congressional Budget Office, 2016).

Health Reimbursement Arrangement The health reimbursement arrangement (HRA) account can only be funded by the employer. No pretax dollars from the employee can be added to the account. Money in the HRA can only be used for medical expenses. Any unused funds will roll over from one year to the next. It is not necessary for an employee to be enrolled in a high-deductible health plan (HDHP) to participate (U.S. Bureau of Labor Statistics, 2010).

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Flexible Savings Account A flexible spending account (FSA) allows employees to arrange with their employer to set aside pretax dollars from their paycheck for out-of-pocket medical expenses. These expenses could include insurance copayments and deductibles, and qualified prescription drugs and medical devices. There is no carryover of unused FSA funds, meaning if you don’t use it, you lose it (Congressional Budget Office, 2016).

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Employer-Sponsored Health Insurance

Employer-sponsored health insurance covers over 150 million nonelderly individuals of the U.S. population. The ACA employer responsibility provision requiring health insurance coverage for companies employing over 50 full-time employees is not seen as causing major changes in work hours or hiring in the employer market. Larger firms report they have looked ahead to the cost of providing health insurance when the ACA final provisions take place in 2020. Smaller firms are relying on their employees finding less expensive options on the Health Insurance Marketplace (Kaiser Family Foundation, 2016). Employers negotiate and choose their own employee health insurance plan offerings; thus, there is no uniformity between plans. Plans have differing copays and deductibles, for example some differing benefits such as prescription coverage. Employer-sponsored family coverage premiums reached $18,142 in 2016, representing a 3% rise in premiums over the 2015 average. The average cost for single-person coverage in 2016 was $6,435, which was not statistically significant from the 2015 cost. Workers’ salaries since 2015 saw an average increase of 2.5% and reported inflation increased 1.1%. Since 2011 family coverage premiums have increased 20%, and since 2006 family premiums increased 58% (Kaiser Family Foundation, 2016).

Employer-sponsored health insurance is financed both through the employers who shoulder the larger burden of the premium and employees who pay the remainder of the premium. As the cost of health insurance has risen, employers have shifted a larger percentage of the costs of plans onto workers. Workers on average are now paying $5,277 toward their family coverage and $1,129 for single coverage premiums, according to the Kaiser Family Foundation Health Research & Educational Trust 2016 Employer Health Benefits Survey: Health Plan Administration. To further control the cost of health insurance, employers are increasing cost sharing for services. Employees are experiencing higher plan deductibles and larger copayments at the time of healthcare provider service. These higher costs have served to fuel the political debate about the shortcomings of the insurance changes by ACA. Insurance premiums and deductibles continue to rise and the American public is contacting their congressmen to voice their displeasure and concern and ask for help. Health insurance plans are administered by private and nonprofit companies; some well-known plans are Aetna, Cigna, United HealthCare, and Blue Cross Blue Shield. Employers send premiums directly to the insurance company, a system known as group market health insurance. The premium is a set fee for the employer based on estimates of the costs that will be incurred by a particular group of employees. The cost of the premium is typically divided between the employer and the employee with employees paying an ever-increasing percentage due to deductibles and copayments. The insurance company provides underwriting, claims processing, payments to providers, and negotiating agreements with providers. Many larger companies, in an effort to contain costs, choose to be self-insured. When a health plan is self-insured, companies negotiate agreements with providers, and the employer sets aside funds to pay for health benefits directly. These plans are administered by an intermediary (can be a private health insurance company),

Laws and Regulations Impacting the Provision of Health Insurance

which handles the enrollment, claims processing, and negotiating health provider contracts (Congressional Budget Office, 2016).

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Health Insurance Exchange Marketplace

Individuals who cannot access health insurance through their employer can purchase individual insurance plans through the Health Insurance Exchange Marketplace created under the ACA. This marketplace covers the self-employed, part-time workers, and those individuals unable to obtain insurance through an employer. These plans are administered by private insurance companies, with individuals assuming responsibility for the full cost of their premium. The ACA is designed to address some of the problems in both the employer and the individual health insurance market as a way to ensure that a greater number of individuals have the opportunity to purchase health insurance at an affordable cost (Fernandez, 2011).

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Laws and Regulations Impacting the Provision of Health Insurance

Health insurance regulations address the benefits that must be offered, the individuals to whom the insurance is made available, and the insurers’ responsibilities to the plan enrollees. The U.S. federalism system makes the regulation of the health insurance market quite complicated. In most cases, health insurance regulation is the primary responsibility of the states, as established in the 1945 McCaran-Ferguson Act. Individual states have established standards and regulations. Fully insured plans (that is, employer-sponsored plans) are subject to state insurance requirements. Self-insured plans

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are not subject to state insurance regulation. State insurance regulations typically require a richer set of benefits such as prenatal care and well-child care than are offered by the companies that self-insure. Because these companies are not regulated they have the flexibility to change the package of benefits whenever it is financially advantageous. All health insurance plans are subject to federal laws. There are three federal laws that have significant impact on how health insurance is provided: 1. 2. 3.

Employee Retirement Income Security Act of 1974 (ERISA, P.L. 93-406) Health Insurance Portability and Accountability Act of 1996 (HIPAA, P.L. 104-191) Patient Protection and Affordable Care Act (PPACA, P.L. 111-148)

ERISA As federal law, ERISA sets minimum standards for employer-sponsored benefits. Companies that self-insure are subject to regulation under ERISA because the services are defined as an employer-sponsored benefit. This law requires health plans to provide the participants with the information regarding the plan features, participant rights to establish a grievance with an appeals process, and adequate disclosure of the plan’s financial activities. ERISA preempts state laws that relate to employee benefit plans. Self-insured health plans are exempt from state laws under ERISA because health care is defined as an employer benefit and not insurance (U.S. Department of Labor, n.d. a).

HIPAA This federal act is an amendment to ERISA providing protections for working Americans and their families who have preexisting medical conditions. The provisions in HIPAA established federal requirements for private and public employer-sponsored health plan insurers.

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This legislation permits individuals to continue health insurance after a loss or change of jobs. Additional HIPAA provisions address patient privacy of identifiable medical information and electronic transmission of health information (U.S. Department of Labor, n.d. b).

ACA This healthcare reform act includes private insurance provisions mandating new requirements on individuals, employers, and health plans; restructures the private health insurance market; sets minimum standards for health coverage; and provides financial assistance to individuals and small businesses in certain circumstances. ACA legislation supports innovative medical care delivery models and expands the Medicaid program (Centers for Medicare & Medicaid, n.d. a).

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The Health Reform Changes Impacting Private Insurers

The ACA and the healthcare provisions of the Health Care and Education Reconciliation Act (HCERA) combined were signed into law by President Obama on March 23, 2010. On June 28, 2012, the U.S. Supreme Court, in the case of National Federation of Independent Business v. Sebelius, rendered a final decision to uphold the healthcare law (Supreme Court of the United States, 2012). Significant private health insurance market reforms within ACA are intended to improve consumer protections including oversight of premiums, access, coverage, and clearer communication between the insurers and the enrollee. The ACA requires all Americans to have health insurance, known as the individual mandate, or face penalties. Insurance can be obtained in several ways. Individuals can purchase insurance through state or federal exchanges. Individuals

who cannot afford the cost of insurance can apply for a federal subsidy. Insurance is also available through employers. The ACA does not mandate employers to provide employees with insurance coverage but does impose penalties on employers that have at least 50 full-time equivalent employees and do not provide coverage to pay a penalty (Chaikand, Fernandez, Newsom, & Peterson, 2010). In addition, eligibility for federal programs, such a Medicaid and State Children’s Insurance Program (SCHIP), has been expanded under ACA.

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ACA and Its Impact on Employers

Under the ACA, large employers will be subject to penalties—$2000 per year multiplied by the number of employees minus 30 (Kaiser Family Foundation, 2013a)—if they do not offer minimum and affordable health coverage. Their employees will be eligible to purchase insurance through state exchanges. Employers are only required to cover full-time employees; employers that currently offer a health plan to their parttime employees (working less than 30 hrs/week) may decide to drop part-time eligibility for insurance plans. Similarly, employers that currently sponsor retiree health plans may choose to terminate these plans, sending this group into the state health insurance marketplace. It is not known how many large employers will opt to pay the penalty and direct their employees to the insurance exchanges. Small employers, many of whom did not previously offer health insurance, are not subject to penalties. To encourage small business to purchase health insurance for their employees, employers with 50 to 100 employees can purchase coverage through the Small Business Health Options Program. Employers with fewer than 25 employees are eligible for a tax credit to offset the cost of insurance. All the changes under the ACA apply to new insurance plans. Some of the changes do

ACA and Its Impact on Employers

not impact older plans that are called grandfathered plans. If the private insurance plan was in existence before the ACA became law on March 23, 2010, it is a grandfathered plan. This is important because persons covered under such plans do not have the same level as protection as do persons in plans organized after that date. A grandfathered plan only changes status when a major change such as reducing benefits or increasing out-of-pocket costs occurs. Insurance plans must inform the enrollees if they are grandfathered and provide them with contact information to ask questions. Twenty-three percent of companies that offered employees health insurance benefits in 2016 offered at least one grandfathered health plan in 2016 and 23% of covered employees were enrolled in a grandfathered health plan

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(Kaiser Family Foundation, 2017). Consumer coverage protections can be seen in BOX 10-1.

Group Plans and Individual Plans That Are Not Grandfathered Group plans and insurers are prohibited from excluding coverage for preexisting health conditions. They may not put lifetime limits on essential health benefits (EHB), which include emergency services, hospitalization, maternal and newborn care, mental health and substance abuse disorder services, preventive and wellness services, chronic disease management, and pediatric services, to include oral and vision care. Plans can only charge a higher premium based on individual or family insurance, age, tobacco

BOX 10-1  Consumer Protections Under ACA All health plans must: ■■ ■■ ■■ ■■

■■

End lifetime limits on benefits. End arbitrary cancellation of health coverage. Cover adult children up to age 26. Provide a Summary of Benefits and Coverage (SBC), a short, easy-to-understand summary of what a plan covers and costs. Hold insurance companies accountable to spend your premiums on health care, not administrative costs and bonuses.

Grandfathered plans DON’T have to: ■■ ■■ ■■ ■■

Cover preventive care for free. Guarantee your right to appeal. Protect your choice of doctors and access to emergency care. Be held accountable through rate review for excessive premium increases.

In addition to the above, grandfathered individual health insurance plans (the kind you buy yourself, not the kind you get from an employer) don’t have to: ■■

End yearly limits on coverage or cover you if you have a preexisting health condition.

Data from U.S. Department of Health and Human Services (2017b). What if I have a grandfathered health insurance plan? Retrieved from https://www .healthcare.gov/what-if-i-have-a-grandfathered-health-plan/

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use, and geographic rating area (set by each state). Group and individual market plans must provide insurance to everyone who applies, and they must guarantee the ability to renew health insurance regardless of changes in health or the amount of health services that will be required (Mach, 2013).

Private Insurers and the State Health Insurance Marketplaces/ Private health insurers can also sell their insurance products on the state Health Insurance Exchanges, which are marketplaces where individuals who are not covered by employer sponsored plans and small businesses with fewer than 100 employees can choose affordable, comprehensive health coverage that meets or exceeds a set of minimum benefit standards. The state exchange insurance plans must be offered at four tiers designed from the lowest premium (bronze) to the highest premium (platinum). Government-sponsored premiums and subsidies will be available to make coverage affordable (Hahn, Sheingold, & Ott, 2013).

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Private Insurance Industry Response to ACA

ACA and Its Impact on the Cost of Health Insurance Many provisions of the ACA have made health insurance coverage more affordable to individuals, including premium and cost-sharing subsidies depending on income and rate restrictions on health plans for individuals and small businesses. Newer innovative benefit designs were developed by health plans and are also designed to control costs. These include wellness programs to encourage healthy living and financial incentives to enhance patient engagement

in their healthcare choices (O’Connor, 2013). The expansion of coverage under ACA has included both healthy persons and persons who are less healthy but could not afford health care. It also includes persons whose employers terminated coverage because it did not meet the minimum requirements set by the ACA and persons who had policies that did not meet the minimum benefit standards set by law. As a result, some persons experienced higher premium costs. Private insurers, citing financial reasons, have been withdrawing from state Health Insurance Exchange Marketplaces, leaving some states with minimal insurer participation. Health insurance premiums on the exchanges are expected to rise faster in 2017 than in previous years due to financial insurer loss and the phasing out of the ACA reinsurance program (Kaiser Family Foundation, 2017). The ACA reinsurance program worked as part of a risk reduction for private insurers, transferring funds to the exchange insurance plans with higher-cost enrollees to provide incentive not to charge higher premiums. Concerns surrounding the financial stability of the health exchanges and private insurers were raised following the initiation of the Health Insurance Marketplace Exchanges. Analysis of premiums and claims data reported insurer financial performance worsened in 2014 and 2015 with the opening of the exchange marketplace (Kaiser Family Foundation, 2017; S & P Global Market Intelligence, 2017). The analysis demonstrates improvement in financial stability in 2016 and early 2017. This additional data provides the evidence demonstrating the individual health exchange market has been stabilizing and private insurers are recovering financially.

Private Insurers Initiatives to Transform Health Care The private insurer industry around the country has been responding to ACA, becoming

Opportunities for Nursing

proactive and adjusting business models to move from underwriting risk to managing populations. They are changing from insurance carriers to consumer health solutions companies. Insurer websites are describing best practices and their goals of improving access to high-quality, affordable care. Personalized care providing care coordination through accountable care organizations (ACOs) and medical homes is highlighted. Insurers are also empowering consumers with online and mobile device apps to gain access to extensive provider networks, which demonstrates technological advances. Apps are available for physicians meant to assist doctors with meaningful use, workflow management, and clinical support (Divall, Camosso-Stefinovic, & Baker, 2013). Wellness and prevention programs to include stress-reduction programs, free cholesterol screening, hypertension education and monitoring, and tobacco cessation programs are being reimbursed. Patient satisfaction is the ultimate goal.

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Health Insurance Legislative Changes on the Horizon

Providing health insurance to all Americans has continued to be a bipartisan debate in the U.S. Congress. Repeal of the ACA was at the forefront of Republican promises in the 2016 presidential election. Americans find themselves discussing whether health care is a personal right in the United States. Multiple Republican bills to repeal and replace ACA (known as Obamacare) have been presented and defeated in Congress. It is a certainty that health insurance coverage will change in our future, as it has always evolved in the past. Just what the new direction of health insurance coverage will look like is unknown. Nurses advocating for consumers can and will help shape the dynamics of healthcare insurance reform.

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Opportunities for Nursing

The evolving healthcare policy environment is a remarkable opportunity for nursing to demonstrate the quality and value of nursing. Nurse leaders, nurse practitioners, and nurse researchers are in a unique position to demonstrate clinical outcomes, identify wasteful practices, and eliminate inappropriate care (Hahn, Sheingold, & Ott, 2013). Nurse executives have the opportunity to lead their organizations into becoming accountable care organizations (ACOs), utilizing quality improvement outcomes based on evidence-based care (Cady, 2012). Researchers will find the current healthcare environment presents an opportunity to validate nursing’s value to healthcare delivery by demonstrating links between quality patient outcomes and care coordination strategies. Nursing case managers will find employment opportunities in private insurance companies as nurse coordinators and navigators, as well as transition to care coaches assisting patients and families through the continuum of care. There will also be a role for nurses to become involved with the design and implementation of health information technology in their workplace as consumers and healthcare providers embrace electronic technology (Paradis, Wood, & Cramer, 2009). The continued development of new care delivery models will impact and accelerate policy change to remove barriers to nursing practice and increase access to care for the underserved populations. These evolving roles are explained in more detail on TABLE 10-3. Nursing has a tradition of providing voice and leadership in the healthcare reform arena from the perspective of both the patient and the consumer (Hahn, Sheingold, & Ott, 2013). Nurses are in the position to advocate to ensure the inclusion of the nursing profession in new healthcare policy models for the delivery of care. Our unique professional insights, evidence-based research, and individual experiences are key to improving both access to care and improving the quality of care.

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TABLE 10-3  Nurse Employment Opportunities Opportunities for nurses in the private insurance industry

Scope of role

Nurse coordinator

Responsible for interprofessional coordination of skilled nursing care. Also serves as a patient advocate, and facilitates communication between all stakeholders. Champions healthcare quality by supervising compliance with the Minimum Data Set (MDS) and Resident Assessment Instrument (RAI) requirements.a

Nurse navigator

Facilitates patient empowerment as a coach, tutor, and direct care provider. Skilled in overcoming system barriers to comprehensive care with a variety of interprofessional team members.b

Transitions coach

Provides encouragement to patients and caregivers to become more active during the process of transitions of care. It is a model that primarily facilitates effective care transitions by working with patients and caregivers to improve the patient to provider communication and self-management skills.c

Nurse informaticist

Usually is registered nurse (RN) with graduate degree. Constructs, executes, and administers data systems that support healthcare quality through electronic medical records (EMR) and analysis of outcomes. Often delivers educational programs to clinicians and monitors trends.d

APRN nurse entrepreneur

Advanced practice nurse (APRN) responsible for development of nurse-managed clinics and new business ownership models of independent practice.e

Sources: aAmerican Association of Nurse Assessment Coordination, 2011; bDesimini et al., 2011); cThe Care Transitions Program, n.d.; dNelson, 2013, eSharp & Monsivais, 2014. Data from American Association of Nurse Assessment Coordination (2011). Defining the role of nurse assessment coordinators: Beyond paperwork and reimbursement. Retrieved from: http://www.aanac.org/docs/white-papers/the-role-of-the-nurse-assessment-coordinator- (april-2011).pdf?sfvrsn=2 ; The Care Transitions Program®. Retrieved from: http://www.caretransitions.org/definitions.asp; Desimini, E., Kennedy, J., Helsley, M., Shiner, K., Denton, C., Rice, T., Stannard, B., Farrell, P., Marmerstein, P., Lewis, M. (2011). Making the case for nurse navigators: Benefits, outcomes and return on investment. Oncology Issues. September/October. 26-33; Nelson, B. (2013). Health information technology: Where do nurses fit in? Advance Healthcare Network For Nurses. Retrieved from: http://nursing.advanceweb.com/Student-and-New- Grad-Center/Career-Counseling/Health-Information-Technology-Where-Do-Nurses-Fit-In.aspx.

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Quality Patient Care and Care Coordination Strategies

The current healthcare reform environment provides the opportunity for nurses to participate as leaders in care coordination promoting

positive quality patient health outcomes. The ACA contains provisions that support measurement of effective patient care transitions, health delivery redesign with payment innovations to foster evidence-based transitional care, integrated models holding providers accountable across patient episodes of care, and establishment of public reporting and payment disincentives for avoidable hospital readmissions

Quality Patient Care and Care Coordination Strategies

(Naylor & Sochalski, 2010). Master’s prepared nurses, that is, advanced practice nurses (APRNs), have been proposing and researching innovative transitional models of patient care that focus on primary care, chronic care management, care coordination, and wellness. The Transitional Care Model (TCM) developed by Naylor and researchers at the University of Pennsylvania has been successful in demonstrating positive outcomes related to the triad of patient access to care, quality of care, and cost (University of Pennsylvania School of Nursing, 2013). Naylor, who is Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative Director and a professor at the University of Pennsylvania School of Nursing, designed the evidence-based research Transitional Care Model (TCM) to enhance the quality of life for patients and their families. The model involves care by APRNs serving as primary care coordinators to reduce hospital readmissions and promote positive health outcomes (Robert Wood Johnson Foundation, 2013). The APRN will perform an in-hospital assessment of the patient and collaborate with the patient’s care team, resulting in an evidence-based discharge plan of care that is designed to meet the expectations of the patient, caregiver, and health providers. Beginning with a visit within the first 24 hours after hospital discharge, the transitional care nurse (TCN) makes regular home visits and is available through telephone support through an average of 2 months after discharge. The TCN facilitates continuity of medical care between the hospital and primary care providers in the community. Patient and family engagement is a cornerstone of this model connecting the patient, family caregivers, and healthcare providers as members of the care team (Robert Wood Johnson Foundation, 2013; University of Pennsylvania School of Nursing, 2013). Naylor reported increased patient satisfaction, physical functioning, and quality of life with the use of the TCM model (Naylor et al., 2009). Improved healthcare quality outcomes at lower cost have been demonstrated in National Institutes of Health (NIH) trials to include a drop in

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readmission rates within 6 weeks by 57% (­Naylor et al., 1994), and a 50% reduction in readmission rates within 6 months (Naylor et al., 1999). Dr. Naylor and her team of researchers partnered with Aetna Corporation and Kaiser Permanente Health Plan to translate research into practice. Throughout research and practice testing, the model has proven to provide improved quality of care at lower cost by reducing the number of hospital readmissions. The TCM was the basis for a new Medicare benefit for hospital discharge planning (University of Pennsylvania School of Nursing, 2017). The TCM model can be viewed as a necessary component to be embedded within the organizational ethics for healthcare facilities. The integral role nurses play in all aspects of care transitions positions the nursing profession to be leaders in healthcare organizational ethics. Participation in the movement of transitional care is the opportunity for nurses to move beyond ethical moral distress and utilize their professional role to articulate, advocate, and integrate transitional care into practice on behalf of their patients (Naylor & Berlinger, 2016). For decades, another dynamic nursing leader has been setting the example of expert care coordination while meeting the needs of childbearing women in the urban healthcare arena. Ruth Watson Lubic is credited with establishing two certified birth centers, the Maternity Center Association in New York City and the Family Health and Childbirthing Center in Washington, DC. Prenatal and labor and delivery care are provided at these centers for low-risk pregnancies. The cost savings are significant for childbearing woman, reducing the Cesarean rate in 2005 compared with the rest of the city (15% versus 28%) and significantly lowered the rates of premature and low-birth rate infants. This resulted in $1.2 million in cost savings. Such a nurse-driven innovation, if expanded to a nationwide model, could potentially save almost $13 billion for Medicaid-funded deliveries (Nickitas, 2011). Dr. Lubric’s legacy lives on in DC with the Family Health and Childbirthing Center, demonstrating a Cesarean section

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rate of 18%, which is significantly below the national average of 32%, and a 5% premature infant rate, below the national average of 11%, in 2015 (Community of Hope, 2017).

Reimbursement Tied to Patient Outcomes Healthcare reimbursement currently is tied directly to patient outcomes. Nurses have taken the lead in many organizations to identify and improve patient care outcomes, thereby increasing reimbursement rates for their healthcare institutions. The American Association of ­Critical-Care Nurses (AACN) reported that critical care nurse–led innovations at 42 hospitals nationwide not only significantly improved the patient clinical outcomes, but demonstrated financial savings that totaled more than $28 million annually (AACN, 2015). The AACN developed and implemented a 16-month leadership academy for critical-care nurses that resulted in the positive patient clinical outcomes. This initiative demonstrates the value in empowering and investing in leadership training for the bedside nurse to improve quality patient outcomes, which has direct financial gains for the healthcare institution.

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Conclusion

Private insurers continue to hold the largest insurance market share with over 150 million Americans participating in private health plans. For most Americans healthcare insurance remains a benefit from their employers. Key federal legislation has shaped the healthcare industry; the most recent healthcare reform legislation known as the Affordable Care Act (ACA) is changing the way private insurers conduct business. Consumer empowerment and legislative reforms are instrumental in changing private insurer business models from underwriting risk to managing populations. The ACA is providing new opportunities for nurses to demonstrate quality outcomes through evidence-based practice and

research and provide patient services as navigators and clinical coordinators, and for advanced practice nurses to provide and bill for patient care. Future legislative change is expected to impact the dynamics of healthcare reform and the private insurance industry.

Discussion Questions 1.

2.

3.

4.

Describe the difference between employer-sponsored health insurance plans and individual health insurance plans obtained on the Health Insurance Exchange Marketplace. Explain some of the consumer protection features of the ACA that all health plans must include. What are some of the exceptions for the “grandfathered plans”? Conduct an Internet search of the insurance marketplace for your own state. What are some of the features that you and your family will benefit from the most? Describe the new nursing opportunities and roles that are evolving in the dynamic healthcare environment and the impact on patient access and quality.

References Aetna. (2017). Indemnity plans. Retrieved from https://www .aetna.com/insurance-producer/health-plans-insurance /indemnity-plans.html American Association of Critical Care Nurses (AACN). (2015). AACN clinical scene investigator program generates clinical, fiscal results. Retrieved from https:// www.aacn.org/nursing-excellence/csi-academy/csi-news /aacn-clinical-scene-investigator-program-generates -clinical-fiscal-results American Association of Nurse Assessment Coordination (AANAC). (2011). Defining the role of nurse assessment coordinators: Beyond paperwork and reimbursement. Retrieved from http://www.aanac.org/docs/white -papers/the-role-of-the-nurse-assessment-coordinator -(april-2011).pdf?sfvrsn=2 Blue Cross Blue Shield. (2017). The history of the Blue Cross Blue Shield System. Retrieved from http://www.bcbs .com/about-the-association/ Cady, R. F. (2012). Healthcare reform after the Supreme Court ruling: Implications for nurse executives. JONA’s Healthcare, Law, Ethics, and Regulation, 14(3), 81–84.

References Centers for Medicare & Medicaid Services (n.d. a). Glossary: Affordable Care Act. Retrieved from https://www .healthcare.gov/glossary/affordable-care-act/ Centers for Medicare & Medicaid Services (n.d. b). Health insurance plan & network types: HMOs, PPOs, and more. Retrieved from https://www.healthcare.gov /choose-a-plan/plan-types/ Chaikind, H., Fernandez, B., Newsom, M., & Peterson, C. L. (2010). Private health insurance provisions in the Patient Protection and Affordable Care Act (PPACA). Congressional Research Service. Report R40942. Retrieved from http:// www.fas.org/sgp/crs/misc/R43048.pdf COBRAinsurance.com. (2007). COBRA law information. Retrieved from http://www.cobrainsurance.com/COBRA _Law.htm Community of Hope. (2017). Annual report 2015. Retrieved from https://www.communityofhopedc.org/sites/default /files/COH_2015AnnualReport_Web_0.pdf Congressional Budget Office. (CBO). (2016). Private health insurance premiums and federal policy. Retrieved from https:// www.cbo.gov/sites/default/files/114th-congress-2015-2016 /reports/51130-Health_Insurance_Premiums.pdf Desimini, E. M., Kennedy, J. A., Helsley, M. F., Shiner, K., Denton, C., Rice, T. T., Stannard, B., Farrell, P. W., Marmerstein, P. A., & Lewis, M. G. (2011, September/ October). Making the case for nurse navigators: Benefits, outcomes, and return on investment. Oncology Issues, 26–33. Divall, P., Camosso-Stefinovic, J., & Baker, R. (2013). The use of personal digital assistants in clinical decision making by health care professionals: A systematic review. Health Informatics Journal, 19(1), 16–28. Retrieved from http:// journals.sagepub.com/doi/10.1177/1460458212446761 Economic History Association. (2017). Health insurance in the United States. Retrieved from https://eh.net/encyclopedia /health-insurance-in-the-united-states Fernandez, B. (2011). Health insurance: A primer. Congressional Research Service. Report RI.32237. Retrieved from http:// www.fas.org/sgp/crs/misc/R43048.pdf Hahn, J. A., Sheingold, B. H., & Ott, K. M. (2013). Demystifying state health insurance marketplaces. Nursing Economics, 31(3), 119–127. HealthInsurance.org (2018). What is a health maintenance organization? Retrieved from https://www.healthinsurance .org/glossary/health-maintenance-organiztions-hmos/ Health Insurance Resource Center. (n.d.) High-deductible health plan (HDHP). Retrieved from https://www.healthinsurance .org/glossary/high-deductible-health-plan/ HealthPlanOne (2017). Health insurance plan (HIP). Retrieved from http://www.healthplanone.com/health insurancecarriers/hip/ Kaiser Family Foundation. (2009). Medicare 101 tutorial. Retrieved from http:/kff.org/interactive/medicare-101 -tutorial Kaiser Family Foundation (2013a). Employer responsibility under the Affordable Care Act. Retrieved from http://kff.org

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/infographic/employer-responsibility-under-the-affordable -care-act/ Kaiser Family Foundation (2013b) Percent of private sector establishments that offer health insurance to employees. Retrieved from http://kff.org/other/state-indicator/percent -of-firms-offering-coverage/ Kaiser Family Foundation (2016). 2016 employer health benefits survey: Health plan administration. Health Research & Educational Trust (HRET). Retrieved from http://kff .org/private-insurance/report/20132016-employer-health -benefits/ Kaiser Family Foundation (2017). Individual insurance market performance in early 2017. Retrieved from http:// www.kff.org/health-reform/issue-brief/individual -insurance-market-performance-in-early-2017/ Kaiser Permanente. (2013). About us: Our history. Retrieved from http://share.kaiserpermanente.org/article/history -of-kaiser-permanente/ Mach, A. L (2013, April 23). Overview of private health insurance provisions in the Patient Protection and Affordable Care Act (ACA). Congressional Research Service Report. Retrieved from https://fas.org/sgp/crs /misc/R43048.pdf Massachusetts Association of Health Plans (MAHP) (n.d.). Blue Cross and Blue Shield: A historical compilation. Retrieved from http://www.mahp.org/issues/BCBS%20mutualization /Blue%20Cross%20History%20Compilation.pdf Monitini, L. (2012, October 9). A tale of two keynotes: Futurist Joe Flower and Aetna’s Mark Bertoli. [Blog post]. Retrieved from http://thehealthcareblog.com /blog/2012/10/09/a-tale-of-two-keynotes-futurist -joe-flower-and-aetna%E2%80%99s-mark-bertoli/ National Federation of Independent Business v. Sebelius, 557 U.S. 519 (2012). Naylor, M. D., & Berlinger, N. (2016). Transitional care: A priority for health care organizational ethics. The Hastings Center Report, 46(S1), 39–42. Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B., Mezey, M., Pauly, M., & Schwartz. J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. Journal of the American Medical Association, 28(7), 613–620. Naylor, M. D., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial. Annals of Internal Medicine, 120(12), 999–1006. Naylor, M. D., Feldman, P. H., Keating, S., Koen, M. J., Kurtzman, E. T., Maccoy, M. C., & Krakauer, R. (2009). Translating research into practice: Transitional care for older adults. Journal of Evaluation in Clinical Practice 15(16), 1164–1170. Naylor, M. D., & Sochalski, J. A. (2010, November 4). Scaling up: Bringing the transitional care model into the mainstream. The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/Publications/Issue -Briefs/2010/Nov/Scaling-Up-Transitional-Care.aspx

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Nelson, B. (2013). Health information technology: Where do nurses fit in? Advance Healthcare Network For Nurses. Retrieved from http://nursing.advanceweb.com/Student -and-New-Grad-Center/Career-Counseling/Health -Information-Technology-Where-Do-Nurses-Fit-In.aspx Nickitas, D. M. (2011). Nurses. In D. M. Nickitas, D. J. Middaugh, & N. Aries (Eds.) Policy and politics. Sudbury, MA: Jones & Bartlett Learning; p. 93. O’Connor, J. T. (2013). Comprehensive assessment of ACA factors that will affect individual market premiums in 2014. Milliman Report. Retrieved from http://www .ahip.org/MillimanReportACA04252013/ Paradis, M., Wood, J., & Cramer, M. (2009). A policy analysis of health care reform: Implications for nurses. Nursing Economics, 27(5), 281–287. Robert Wood Johnson Foundation (2013). The transitional care model. The future of nursing. Retrieved from http:// www.nursing.upenn.edu/media/transitionalcare/Pages /default.apx Sharp, D. B., & Monsivais, D. (2014). Decreasing barriers for nurse practitioner social entrepreneurship. Journal of the American Association of Nurse Practitioners, 26(10), 562–566. S & P Global Market Intelligence. (2017). The U.S. ACA individual market showed progress in 2016, but still needs time to mature. Retrieved from https://www .globalcreditportal.com/ratingsdirect/renderArticle .do?articleId=1828594&SctArtId=421970&from=CM&nsl _code=LIME&sourceObjectId=10047007&sourceRevId =5&fee_ind=N&exp_date=20270408-00:16:31 Sultz, H. A., & Young, K. M. (2014). Health care USA: Understanding its organization and delivery. 8th ed. Frederick, MD: Aspen Publishers. The Care Transitions Program. (n.d.). What is a transitions coach? Retrieved from https://caretransitions.org /what-is-a-transitions-coach/ The Commonwealth Fund. (2016a). 2017 premium changes and insurer participation in the Affordable Care Act’s health insurance marketplaces. Retrieved from http:// www.kff.org/health-reform/issue-brief/2017-premium -changes-and-insurer-participation-in-the-affordable -care-acts-health-insurance-marketplaces/ The Commonwealth Fund (2016b). New Commonwealth Fund survey: Most ACA enrollees who have used their plans are getting health care they previously would have gone without; wait times for doctor appointments similar to other insured Americans. Retrieved from http://www.commonwealthfund.org/publications/press -releases/2016/may/aca-tracking-survey-access?omnicid =rsscmnw&utm_source=feedblitz&utm_medium =FeedBlitzRss&utm_campaign=thecommonwealthfund

United HealthCare. (2017). Fixed hospital and doctor and medical insurance. Retrieved from https://www.uhone .com/insurance/supplemental/indemnity-insurance /what-is-indemnity-insurance University of Pennsylvania School of Nursing. (2013). Transitional Care Model. Philadelphia, PA: Penn State Nursing. Retrieved from http://www.nursing.upenn .edu/media/transitional care/Pages/default.aspx U.S. Bureau of Labor Statistics. (2002). Definitions of health insurance terms. National Compensation Survey. Retrieved from http://www.bls.gov/ncs/ebs/sp/healthterms.pdf U.S. Bureau of Labor Statistics (2010). Consumer-driven health care: What is it, and what does it mean for employees and employers? Retrieved from https://www .bls.gov/opub/mlr/cwc/consumer-driven-health-care -what-is-it-and-what-does-it-mean-for-employees-and -employers.pdf U.S. Department of Health and Human Services. (n.d. a). Glossary: Flexible spending accounts. Retrieved from https://www .healthcare.gov/glossary/flexible-spending-account-FSA/ U.S. Department of Health and Human Services. (n.d. b). What if I have a grandfathered health insurance plan? Retrieved from https://www.healthcare.gov /what-if-i-have-a-grandfathered-health-plan/ U.S. Department of Labor. (2013a). Health plans and benefits: Employment Retirement Income Security Act. Retrieved from http://www.dol.gov/dol/topic/health-plans/erisa .htm#doltopics U.S. Department of Labor. (2013b). Health plans and benefits: Health Insurance Portability and Accountability Act. Retrieved from http://www.dol.gov/dol/topic/health -plans/portability.htm U.S. Department of Labor. (2015, April). The National Compensation Survey and the Affordable Care Act in health care data. Monthly Labor Review. Retrieved from https://www.bls.gov/opub/mlr/2015/article/the -national-compensation-survey-and-the-affordable -care-act-preserving-quality-health-care-data.htm U.S. Department of the Treasury. (2013). Resource pages: Health savings accounts (HSAs). Retrieved from http:// www.treasury.gov/resource-center/faqs/Taxes/Pages /Health-Savings-Accounts.aspx White House. (2013). A more secure future: What the new health care law means for you and your family. White House blog: Barack Obama. Retrieved from http://www .whitehouse.gov/healthreform/healthcare-overview Zhou, K. (2009). The history of medical insurance in the United States. Yale Journal of Medicine and Law, 6(1), 38–39.

Case Study

CASE STUDY

Commercial Insurance Credentialing for the Enterprising Nurse Practitioner: Lessons Learned Dr. Wesley Cook, President, District Primary Care, LLC In 22 states and the District of Columbia (DC), nurse practitioners (NPs) enjoy full practice authority (FPA). A leader in the FPA movement, DC provides a tremendous opportunity for enterprising NPs. Enchanted by DC’s confidence in NPs, I formed District Primary Care (DPC) as a limited liability company in the summer of 2016. An aging population, a trend away from hospital-centered care for the chronically ill, and heightened public demand for in-home care provided the perfect niche for my talents and preferences (Iglehart, 2013; Sharp & Monsivais, 2014; Sharp, 1999). Because DPC provides primary care services to geriatric patients who are facility- or homebound and are in the poorer sections of town, the business model would have been unsuccessful without accepting reimbursement from both public and commercial insurance products. Medicare and Medicaid are both publicly and commercially administered, depending on the plan type. This case study shares the lessons I learned along the way.

Lesson 1: Contract Negotiation Requires Keen Awareness of Key Jurisdictional Barriers Commercial payers have often followed the Centers for Medicare & Medicaid Services’ (CMS) lead when establishing policies for reimbursement and determination of medical necessity, but not

always (Buppert, 2012, 2017). The Balanced Budget Act of 1997 affords NPs provider status with direct reimbursement for services provided to Medicare beneficiaries at 85% of the annual physician rate schedule. Medicaid also directly reimburses NPs for serviced provided to its beneficiaries, but reimbursement is uneven due to jurisdictional-level regulatory oversight for Medicaid programs (Kaiser Family Foundation, 2012). However, given the private nature of commercial insurance, it remains the commercial payer’s prerogative to establish their own policies so long as they meet regulatory requirements. Lack of scope-of-practice parity and variation in local insurance regulations complicate business-planning efforts by creating an uneven market (Buppert, 2012, 2017; Watson, 2015). Without universal FPA, commercial payers may justify uneven policies, denying provider credentialing at will (Buppert, 1998). When the reimbursement rate is reduced or denied unless NP claims are submitted under a physician’s name, potential customer base and revenue generation are both compromised (Buppert, 2017; Chilton, 2002; Watson, 2015). It is imperative to know the insurance regulations and scope of practice barriers to commercial insurance credentialing so that when contracts are negotiated, the NP is equipped with the necessary information to disabuse any false assertions from the payer regarding the NP role and its legal entitlements (Buppert, 2012, 2017).

Lesson 2: Know the Fullness of Provider Status Available to the NP Confounding the unevenness of NP reimbursement amongst commercial payers is the lack of NP representation on commercial payer advisory boards and credentialing panels (Chilton, 2002). The lack of parity in NP scope of practice and reimbursement furthers the tradition of physician-controlled credentialing amongst commercial payers (Buppert, 2017). NPs are also unevenly recognized as primary care providers across commercial payers, leaving NPs as higher cost out-of-network or specialist providers (Buppert, 2012; Chilton, 2002; Watson, 2015). CareFirst (2013), a Blue Cross Blue Shield subsidiary, seems to have pioneered the NP primary care providers as recognized leaders of

CASE STUDIES

This case study highlights an APRN nurse entrepreneur’s journey to establish an independent nurse practitioner practice inclusive of commercial (private) insurance company reimbursement. The lessons learned are explained to provide future APRN independent practitioners the opportunity to benefit from the experiences presented.

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CASE STUDIES

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their patient-centered medical homes. Some commercial payers remain firm in not allowing NPs to be primary care providers. Practice ownership is demanding of time and mental energy, but it is imperative that NP-practice owners continue to work with commercial payers, gaining access to advisory boards and credentialing panels to heighten the profile of the NP in the physician-saturated environment (Buppert, 2017; Chilton, 2002). Procuring the extent of provider status afforded in writing will also help the NP-entrepreneur to create a business and marketing plan around those services for which reimbursement has been contractually guaranteed.

Lesson 3: Delegated Contract Negotiation Requires the Active Participation of the NP Owner A credentialing firm was enlisted to assist with the cumbersome task of credentialing. This firm was entrusted with contract negotiation but not signatory privileges. The firm promised clear communication and transparent processes. They advised that many times, applications can take up to 6 months to be approved by public and commercial payers alike. It slowly became clear that I had entrusted the management of a process to those who were not managing the process after 3 months of poor communication with many payers. Reports were difficult to read; excuses were myriad. The Medicaid application had been lost entirely, having not been monitored by the project manager. This placed significant delays on key revenue. Even worse, the credentialing contractor had not taken seriously any effort to negotiate on my behalf or involve me as impasses were met. Commercial payer credentialing has been streamlined substantially by CAQH ProView, a central, secure, online repository of standard credentialing information from which commercial payers draw requisite information. However, not all payers use the central repository, and some who do still require a separate application. Thus, this part of the process remains cumbersome but administrative, justifying delegation. However, the president of any given company retains ultimate responsibility for the oversight of business operations, even those administrative tasks delegated to those believed competent, so it is imperative for the NP-practice owner to

supervise the process. Securing legal counsel is also invaluable in negotiation as attorneys are well versed in argumentation and negotiation strategies that are not typically part of the core NP curriculum. The public payers are straightforward, and I was able to easily provide management for Medicare and Medicaid credentialing. Additionally, after leaning on the firm to report progress more frequently and specifically, modifying directives per such reporting, CareFirst, Humana, and Aetna contracts were finalized. United HealthCare stated that they were closed to all individual providers, even though DPC was established as a practice entity. Cigna would not empanel nurse practitioners, explaining all claims must be tied to a physician. Always have legal counsel approve contractual language in prior to signing. This ensures that areas that should be negotiated have not been ignored. Payers do not always understand NPs as more than physician-extenders or mid-level providers. Presenting the business case inclusive of quality data will often do more to assist with commercial payer credentialing than any impassioned case made without these key data.

Lesson 4: Seeing Patients Prior to Contract Acceptance May Prove Detrimental Overly trusting the credentialing firm also proved detrimental to reimbursement itself. They did not request retroactive dating for claims generated prior to contract finalization. They maintained that it could not be negotiated after the contract. Everything is negotiable; to accept the contracting party’s assertion otherwise is to accept a lose–win contract. While the start dates for retroactive claims with public payers and some commercial payers were successfully appealed, DPC suffered a financial loss of approximately $10,000 in unpaid claims generated on inactive dates. Hold off on directly reimbursable patient care until the credentialing process is complete, unless written agreement to pay from a date prior to the contract start is procured. Given the impoverished situation of many of DPC’s patients, the unreimbursed claims were written off as bad debt; attempting collection from those who believed they were being seen by an in-network provider seemed practically impossible and morally unsound.

Case Study

Lesson 5: Maintain Business Viability with a Systemized Approach to Credentialing Maintenance

payer credentialing, and I am enriched daily by both business and clinical aspects of my practice. Owning a practice is serious business, and it is all too easy to become enamored with the freedom of charting one’s own course to the detriment of business interests. Credentialing is a cumbersome process, commercial-payer credentialing, all the more. But, if the NP is to compete in the marketplace, pursuing and procuring commercial-payer provider status is essential. Without the ability to directly bill, NP entrepreneurs lose business opportunities because beneficiaries will choose lower cost, in-network providers. As NPs gain and maintain full practice authority across the country, commercial-payer provider status remains a significant barrier to scope-of-practice parity even in areas where full practice authority is enjoyed. Cumbersome as it may be, NPs are wise to pursue commercial-payer provider status in any practice setting, pairing with attorneys and professional organizations where necessary to resolve issues of obstruction (see BOX 10-2).

BOX 10-2  Practice Pearls for Nurse Practitioners Seeking Provider Status with Commercial Payers Lesson 1: Contract Negotiation Requires Keen Awareness of Key Jurisdictional Barriers ■■

■■

Hire an attorney to guide you through the process of understanding your rights as an NP business owner, payer contract negotiating, and credentialing firm hiring. Set aside a copy of your local insurance regulations so that you may use them to appeal rejections, if applicable.

Lesson 2: Know the Fullness of Provider Status Available to the NP ■■

■■

Reach out to your local nurse practitioner professional organization for any credentialing resources or contacts they may have. Keep records of which payers allow PCP status, as well as any procedural prohibitions for NPs; if you are allowed per your jurisdictional scope of practice, challenge the policy in writing with the assistance of an attorney.

Lesson 3: Delegated Contract Negotiation Requires the Active Participation of the NP Owner ■■

Consult a business guide* tailored for NPs, as you: •• Hire an attorney. •• Focus inquiries to and determine priorities for your attorney, who is likely paid by the hour. (continues)

CASE STUDIES

There are additional layers for remaining credentialed with commercial payers. Each has its own timeline for recredentialing, different requirements for peer review, quality assurance, and prior authorization. A systemized approach is required for both the requisite tasks of maintaining good standing and pushing the policy envelope. When claims are denied because they have not been coded with a requisite modifier or the diagnosis codes do not match the evaluation and management codes, a system needs to be established so the NP does not lose income-producing time untangling often-confusing claim denials. DPC now has a practice manager and a biller who deftly manage this process. While DPC remains a fledgling business, it is viable and growing. The work of caring provides rewards worth the frustrating labyrinth of

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BOX 10-2  Practice Pearls for Nurse Practitioners Seeking Provider Status with Commercial Payers

(continued)

CASE STUDIES

•• Map out your credentialing plan. •• Hire and evaluate a credentialing firm, if not self-credentialing. •• Learn key knowledge for the NP entrepreneur:   

NP reimbursement overview. NP practice ownership considerations. Appeal provider-status rejection with the assistance of your attorney. Rejection is not a final ruling if you have not appealed at least once . . . or thrice.

Lesson 4: Seeing Patients Prior to Contract Acceptance May Prove Detrimental ■■

■■

Expect credentialing to take 3 to 6 months. Accept it. The speed of the insurance company’s credentialing staff is a rate-limiting aspect of the process you have no control over. Know the policy for retroactively submitting claims prior to the contractual start date. Do not see patients with that insurance until you are officially credentialed unless you have in writing that claims will be paid retroactive to the date of the contract; you will not be paid.

Lesson 5: Maintain Business Viability with a Systemized Approach to Credentialing Maintenance ■■

Keep record of who the decision makers are, how often they meet, when any closed panels are expected to open, and any written policies you procure during the process. Place this in the file with your contract so that you may be equipped to gain a better contract during recredentialing, if possible.

* Suggested business guides: Buppert’s Nurse Practitioner Business Practice and Legal Guide or Grossman & O’Brien’s How to Run Your Nurse Practitioner Business: A Guide for Success.

Case Study Questions 1. Identify key barriers for NPs credentialing with commercial payers. 2. Discuss the role of legal counsel in negotiating and appealing commercial-payer contracts. 3. Describe the value of NP quality and efficacy data in commercial insurance negotiations and appeals.

References Balanced Budget Act of 1997, Pub. L. No. 105-33, § 4511, 111 Stat. 442-113 (1997). Buppert, C. (1998). Reimbursement for nurse practitioner services. The Nurse Practitioner, 23(1), 60–64, 67. Buppert, C. (2012). Most payers now reimburse NPs, but the details differ. Journal for Nurse Practitioners, 8(9), 743–745.

Buppert, C. (2017). Nurse practitioner’s business practice and legal guide (6th ed.). Burlington, MA: Jones & Bartlett Learning. CareFirst. (2013). Blue Cross Blue Shield’s patient-centered medical home program: An overview. Retrieved from https://member.carefirst.com/carefirst-resources/pdf /pcmh-program-overview.pdf Chilton, L. (2002). Breaking down insurance barriers: The Mississippi nurse practitioner network. Advance for Nurse Practitioners, 10(9), 45–46. Grossman, S., & O’Brien, M. B. (2010). How to run your nurse practitioner business: A guide for success. New York, NY: Springer Publishing Company. Iglehart, J. K. (2013). Expanding the role of advanced nurse practitioners—risks and rewards. New England Journal of Medicine, 368(20), 1935. Kaiser Family Foundation. (2012). Medicaid benefits: Nurse practitioner services. Retrieved from http://www.kff .org/medicaid/state-indicator/nurse-practitioner-services

Case Study

Watson, M. (2015). Basic principles to consider when opening a nurse practitioner-owned practice in Texas. Journal of the American Association of Nurse Practitioners, 27(12), 683–689. doi:10.1002/2327-6924.12274

CASE STUDIES

/?currentTimeframe50&sortModel5%7B%22colId %22:%22Location%22,%22sort%22:%22asc%22%7D Sharp, D. B., & Monsivais, D. (2014). Decreasing barriers for nurse practitioner social entrepreneurship. Journal of the American Association of Nurse Practitioners, 26(10), 562–566. doi:10.1002/2327-6924.12126 Sharp, N. (1999). NP ownership of home care, long-term care, assisted living, and community care. The Nurse Practitioner, 24(12), 51–59. doi:10.1097/00006205-199912000-00005

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CHAPTER 11

Medicare: Protector to Innovator Brigitte S. Cypress

OVERVIEW Medicare is America’s second largest entitlement program, behind Social Security, signed into law by President Lyndon Johnson in 1965. The program provides healthcare insurance for the retired and disabled population, including younger adults with permanent infirmities. Medicare faces many issues and challenges today—and in the years to come—despite the creation of the Affordable Care Act (ACA) of 2010. The uncertainty of the current political climate, coupled with the controversies of the ACA, will continue to create debate and tensions among policymakers in the United States Congress, healthcare providers, consumers, and beyond. The situation heightens the need for serious consideration of reform now and in the future.

OBJECTIVES ■■ ■■

■■ ■■ ■■

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Understand the evolution of the passage of Medicare, including its timelines and milestones. Summarize the current Medicare structure, including who is eligible, its four components, and the changes with the implementation of the Affordable Care Act. Have an overview of Medicare spending and its effect on future Medicare projections. Analyze and understand how we pay for Medicare and its effect on consumers and providers. Discuss the Medicare’s Quality Improvement Organizations (QIOs) and their role in improving health quality of Medicare beneficiaries. Describe the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) of 2015 and its current and future impact to clinicians and providers. Provide a future outlook of Medicare and discuss strategies how to move forward for better patient, family, provider, and healthcare outcomes.

© Anthony Krikorian/Shutterstock

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Introduction

For the last 10 years, Americans have witnessed the intense and tumultuous debate over the future of their healthcare system. The passage of the Patient Protection and Affordable Care Act of 2010 (ACA) ushered in a new era in health law and policy. The Affordable Care Act guarantees access to health care for more than 30 million people, creates new incentives to change clinical practice to foster better coordination and quality, and changes the payment system to reward value. It also gives more information to physicians to make them better clinicians and make patients more value-conscious consumers. After multiple legal challenges and Congressional efforts that ultimately failed to repeal the law, the ACA was established by the end of the Obama administration. The law has since been vulnerable related to its length and complexity, and divisive and heated debates have led to massive confusion about its impact. There is also the continuous pressures of the “repeal and replace” chorus of angry and misinformed voters. The ACA is not only historic and transformational, but profoundly troubling for some and controversial for many (Manchikanti, ­Caraway, Parr, Fellows, & Hirsch, 2011). With the new political climate and the 2016 election of President Donald Trump, dynamic uncertainty again pervades the national debate. The unpredictability that the national debate surrounding American health care produces will certainly affect policy, legislation, and, consequently, patient and family outcomes. Healthcare providers must adequately address current issues such as their inability to push organizations and entities into adopting more efficient practices. Other important aspects like improvement in coverage and affordability and incentives toward reducing financial excess and waste should be addressed. Eliminating gaps in delivery of high-ranking services should also be a high priority. Medicare is moving quickly to bring about effective changes on reimbursement and finances, as it faces increasing financial spending and swelling enrollment.

In fiscal year 2017, the Office of the Actuary of the Centers for Medicare & Medicaid Services (CMS) has estimated that gross current law spending on Medicare benefits will total $709.4 billion. Medicare will provide health insurance to 58 million individuals who are age 65 or older, disabled, or have end-stage renal disease (ESRD) (U.S. Department of Health and Human Services [USDHHS], 2017b). Much of the recent growth in spending over the past two decades among Medicare beneficiaries is attributable to rising spending on chronic conditions, specifically, diabetes, hypertension, kidney disease, mental disorders, and arthritis. Spending has also increased in outpatient care and for prescription drug therapy, but less for inpatient care (Thorpe, Ogden, & Galactionova, 2010). The $709.4 billion Medicare benefits spending for 2017 is itemized as follows: (a) Part A: $202.1 billion gross fee-for-service spending; (b) Part B: $192.9 billion gross fee-for-service spending; (c) Part C: $204.7 billion gross spending; and (d) Part D: $109.7 billion gross spending (U.S. Department of Health and Human Services, 2017b). Medicare Part A pays for inpatient hospital, skilled nursing facility, home health related to a hospital stay, and hospice care. Medicare Part B pays for physician, outpatient hospital, end-stage renal disease, laboratory, durable medical equipment, certain home health, and other medical services. Medicare Part C, the Medicare Advantage program, pays plans a capitated monthly payment to provide all Part A and B services, and Part D services, if offered by the plan. Medicare Part D offers a standard prescription drug benefit. Reducing and slowing the rise in health spending is among the nation’s top health policy priorities. On April 16, 2015, President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) into law. The Congressional Budget Office (CBO) projects the total Medicare spending to increase from $708 ­billion to $1.4 trillion from 2017-2027. Net Medicare spending is projected to grow modestly as a share of the federal budget and the nation’s economy over the next 10 years (­ Congressional Budget Office, 2017).

Evolution of the Passage of Medicare: Timeline and Milestones

The rate of growth of Medicare spending over the long term is predicted to exceed the rate of growth in federal revenues and the overall economy. Thus, much political attention has focused on improving Medicare as imperative for restraining spending increases (Thorpe, Ogden, &­ Galactionova, 2010). Medicare must find new approaches to help restrain the growth in healthcare costs. But how can the government program provide health insurance for most of the people age 65 or older at a time when their healthcare needs tend to explode? This is particularly true for “baby boomers” who continue to enter their retirement years with more complex, chronic health problems and comorbidities than previous generations. When the last of the iconic generation reaches age 65 in less than 8 years, more than 80 million people will be eligible for Medicare coverage. The demands on Medicare increase at a time when the ratio of people paying into the program versus those receiving benefits is at an all-time low and getting worse. How can Medicare improve coverage and reimbursement without limiting access to beneficial services for a great number of people? The increase in the number of people eligible for benefits paired with the rising costs of health care and longer lifespans threaten the program’s sustainability. It could force the current presidential administration and the United States Congress to come up with a plan to reduce costs, either by cutting benefits, raising taxes, or some other policies that change the basic promise made to aging Americans. This raises a serious question: Should the worry be for the current situation or for the long term?

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Evolution of the Passage of Medicare: Timeline and Milestones

Prior to the 1960s (between 1901 and 1909), President Theodore Roosevelt advocated for the passage of social insurance. He believed that a

233

strong country required healthy people. He also favored the passage of health insurance legislation that would come from the states, rather than the federal government, and cover only the working classes. President Roosevelt had an unsuccessful run for another term in 1912. By 1935, Congress passed the Social Security Act of 1935 during the first of President Franklin Roosevelt’s four terms. This epochal piece of legislation contained old-age insurance, unemployment compensation, and maternal and child health, but not health insurance. The U.S. Surgeon General Thomas Parran proposed in 1937 that national health insurance first cover Social Security beneficiaries. By 1939, the Federal Security Agency was created to administer federal organizations dealing with health, education, and social insurance, including the Social Security Board, Public Health Service, and Office of Education. After the Social Security Board called for beneficiary health insurance, President Harry Truman publicly lent his support to national health insurance in 1945 (­ Centers for Medicare & Medicaid Services, 2017e). In 1965, President Lyndon Johnson said that Medicare would protect Americans by not allowing illness to drain their savings so they might enjoy dignity in their later years. During this time, only about half of older Americans had any health insurance and only about one in four older Americans had protection against the high cost of hospitalization (Centers for Medicare & Medicaid Services, 2017d, 2017g). Medicare and Medicaid were enacted as Title XVIII and Title XIX of the Social Security Act, providing hospitalization, post-hospital extended care, and home health coverage to almost all Americans age 65 or older (Centers for Medicare & Medicaid Services, 2017b, 2017d). To implement the Health Insurance for the Aged (Medicare) Act, the Social Security Administration (SSA) was reorganized and the Bureau of Health Insurance was established on July 30, 1965. This bureau was responsible for the development of health insurance policy. The creation of Medicare in 1965 ensured the dignity of Americans as they reached old age at that time, just as President

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Chapter 11 Medicare: Protector to Innovator

Johnson promised. This was a truly memorable accomplishment for many millions of seniors and people with a disability who have since then counted on the program. On July 1, 1966, Medicare was implemented and more than 19 million individuals enrolled (Centers for Medicare & Medicaid Services, 2017e). In the early 1970s, Medicare eligibility was extended to individuals under age 65 with long-term disabilities and to individuals with end-stage renal disease (ESRD). Medicare was given additional authority to conduct demonstration programs by 1972. Also in 1972, lawmakers extended coverage to people receiving Social Security Disability Insurance payments for 2 years and people with ESRD. For beneficiaries whose primary or secondary diagnosis is amyotrophic lateral sclerosis (ALS), the 2-year waiting period was waived. The Health Maintenance Organization (HMO) Act provided start-up grants and loans for the development of HMOs in 1973. HMOs meeting federal standards relating to comprehensive benefits and quality were established and under certain circumstances had the right to require an employer to offer coverage to employees. The Medicare statute was also amended to provide for HMOs to contract to provide Medicare benefits to beneficiaries who choose to enroll. By 1977, the Health Care Financing Administration (HCFA) was established to administer the Medicare and Medicaid programs (Centers for Medicare & Medicaid Services, 2017e). The 1980s ushered in the broadened coverage of Medicare home health services. Medicare supplemental insurance, also called “Medigap,” was brought under federal oversight. The Tax Equity and Fiscal Responsibility Act of 1982 made it easier and more attractive for health maintenance organizations to contract with the Medicare program providing for Medicare payments on a full-risk basis. In addition, the Act expanded the Agency’s quality oversight efforts through peer review organizations (PROs). An acute care hospital inpatient prospective payment system (IPPS) for the Medicare program, based on patients’ diagnoses, was adopted to replace

cost-based payments in 1983. Under the IPPS, each case is categorized into a diagnosis-related group (DRG). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. The Medicare hospice benefit was established as an option for beneficiaries to receive all-inclusive care to relieve pain and manage symptoms in a home setting rather than an institutional setting. Further, in 1986, the Emergency Medical Treatment and Labor Act (EMTALA) required hospitals participating in Medicare that offer emergency services to provide appropriate medical screenings and stabilizing treatments. The Medicare Catastrophic Coverage Act of 1988 was enacted, which included the most significant changes since enactment of the Medicare program, improved hospital and skilled nursing facility benefits, covered mammography, and included an outpatient prescription drug benefit and a cap on patient liability. By 1989, the Medicare drug benefit and other enhancements of Medicare coverage in the Medicare Catastrophic Coverage Act of 1988 were repealed after higher-income seniors protested new premiums. A new Medicare fee schedule for physician and other professional services, a resource-based relative value scale, replaced charge-based payments (Centers for Medicare & Medicaid Services, 2017e). Additional federal standards for Medicare supplemental insurance were enacted by 1990. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was passed in 1996. It created the Medicare Integrity Program, which dedicated funding to program integrity activities and allowed HCFA to competitively contract for program integrity work. By 1997, The Balanced Budget Act of 1997 (BBA) made changes to Medicare including: (a) establishing an array of new Medicare managed care and other private health plan choices for beneficiaries, offered through a coordinated open enrollment process; (b) expanding education and information to help beneficiaries make informed choices about their health care; (c) requiring the Health Care Financing

Evolution of the Passage of Medicare: Timeline and Milestones

Administration (HCFA) to develop and implement five new prospective payment systems for Medicare services (for inpatient rehabilitation hospital or unit services, skilled nursing facility services, home health services, hospital outpatient department services, and outpatient rehabilitation services); (d) slowing the rate of growth in Medicare spending and extending the life of the trust fund for 10 years; (e) providing a broad range of beneficiary protections; (f) expanding preventive benefits; and (g) testing other innovative approaches to payment and service delivery through research and demonstrations (Centers for Medicare & Medicaid Services, 2017e). In 1988, Medicare.gov was launched to provide updated information about Medicare. The first annual Medicare & You handbook was mailed to all Medicare beneficiary households in 1999. The Ticket to Work and Work Incentives Improvements Act of 1999 (TWWIIA) expanded the availability of Medicare and Medicaid for certain disabled beneficiaries who return to work. The Balanced Budget Refinement Act of 1999 (BBRA) increased payments for some Medicare providers and increased the amount of ­Medicaid disproportionate share hospital (DSH) funds available to hospitals in certain states and the District of Columbia (Centers for Medicare & Medicaid Services, 2017e). The herald of the new millennium further increased Medicare payments to providers and managed healthcare organizations, reduced certain Medicare beneficiary copayments, and improved Medicare coverage of preventive services through the Benefits Improvement and Protection Act (BIPA) of 2000. U.S. Secretary of Health and Human Services Tommy Thompson renamed the HCFA the Centers for Medicare & Medicaid Services (CMS) in 2001 (Centers for Medicare & Medicaid Services, 2017e). By 2003, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) created a new optional outpatient prescription drug benefit, effective in 2006. Medicare consists of two separate but coordinated trust funds: hospital insurance (HI, or Part A) and supplementary medical insurance (SMI). The SMI trust fund

235

comprises two separate accounts: Part B account and the Part D account. Almost all persons who are age 65 and over or disabled and who are entitled to HI are eligible to enroll in Part B and Part D on a voluntary basis by paying monthly premiums (Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2015). For the period prior to 2006, MMA created a temporary prescription discount card program. Beneficiaries with incomes less than 150% of the federal poverty level (FPL) became eligible for subsidies under the new Part D prescription drug program. MMA also required beneficiaries with higher incomes to pay a greater share of the Part B premium beginning in 2007. Enrollment started for Medicare prescription drug coverage by 2005. Medicare prescription drug coverage (Part D) began Medicare for 39 million beneficiaries. Numerous MMA provisions were implemented, including several new preventive services for Medicare beneficiaries, the year after in 2006 (Centers for Medicare & Medicaid Services, 2017e). The Patient Protection and Affordable Care Act (ACA) was signed into law by President Barack Obama on March 23, 2010. For the first time, health insurance companies were prohibited from denying or charging more for coverage based on an individual’s health status. This allowed for the expansion of the Medicaid program and subsidies for insurance purchased through state-based marketplaces to ensure that private insurance is affordable. The ACA also provided a variety of other insurance reforms, such as new preventive benefit requirements and prohibitions on dollar limits, and expanded Medicare drug and preventive services benefits. Also in 2010, people exposed to environmental health hazards within areas under a corresponding emergency declaration became Medicare eligible (Manchikanti, Caraway, Parr, Fellows, & Hirsch, 2011). By 2011, 3.6 million people with Medicare saved $2.1 billion on their prescription drugs. More than 25.7 million beneficiaries in original Medicare received at least one preventive service following a cost-sharing waiver

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Chapter 11 Medicare: Protector to Innovator

in the Affordable Care Act. Further in 2013, an estimated 37.2 million Medicare beneficiaries received at least one free preventive service, including an estimated 26.5 million people with original Medicare. The Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA) of 2015 changed the way Medicare pays physicians. It replaced the Sustainable Growth Rate (SGR) methodology with a method that is more predictable and speeds up participation in alternative payment models. These models encourage quality and efficiency. MACRA also extended CHIP for 2 years, through fiscal year 2017 (Centers for Medicare & Medicaid Services, 2017e).

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Current Medicare Structure

Medicare celebrated its golden anniversary in 2015. The program now provides insurance coverage for almost 58 million Americans, accounts for 20% of the nation’s healthcare spending, and 4% of the GDP (Rettenmaier & Saving, 2016; Thorpe, Ogden, & Galactionova, 2010). Eligible Medicare beneficiaries include individuals age 65 and over who are eligible for Social Security payments, those under 65 with a disability who receive Social Security cash payments, and people of all ages with ESRD. A summary

of the general Medicare enrollment from 2015 to 2017 is presented in TABLE 11-1. The distribution of the number of people receiving Medicare (Parts A–D) is shown in TABLE 11-2. As of 2015, the average benefit per enrollee total was $12,559 divided into: Part A: $4,978; Part B: $5,441, and Part D: $2,141 (Centers for Medicare & Medicaid Services, 2017a).

The Four Components of Medicare Basic Medicare consists of Parts A and B and an optional Part D. This is also known as “original Medicare.” Part A is basically hospital insurance after a pre-occurrence deductible is met ($1,288 in 2016) for a hospital stay of 1 to 60 days, and $161 daily co-insurance for days 21 to 100 in a skilled nursing facility (SNF) (U.S. Department of Health and Human Services, 2017e). This helps to cover 80% of inpatient care as well as skilled nursing facilities, hospice, and home healthcare services. If a person or spouse of 10 years or more has been working 40 quarters (10 years of full-time job), he or she has been already paying into Medicare Part A. If he or she is turning age 65 and currently working and wants to wait to take Social Security (SS) benefit, enrollment in Medicare Part A is needed. If the person is receiving SS benefit already, enrollment to Medicare Parts A and B is automatic. The premium for Part B is deducted from the

TABLE 11-1  General Medicare Enrollment* (Years 2015–2017) Category Age 65 and over Disabled Total Beneficiaries

2015

2016

2017

2017 +/– 2016

46.0

47.7

49.3

+1.7

9.0

9.0

9.0

+0.0

55.0

56.7

58.4

+1.7

* Persons in millions; numbers may not add up due to rounding. Source: Reproduced from Centers for Medicare & Medicaid Services Office of the Actuary. (2016). HHS FY 2017 budget in brief. Retrieved from https://www.hhs.gov/about/budget/fy2017/budget-in-brief/cms/medicare/index.html#parts

Current Medicare Structure

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TABLE 11-2  Distribution of Number of People Receiving Medicare in 2015* Total Medicare Beneficiaries

55.3

Aged

46.3

Disabled

9.0

Part A (Hospital Insurance, HI) Beneficiaries

54.9

Aged

46.0

Disabled

9.0

Part B (Supplementary Medical Insurance, SMI) Beneficiaries

50.7

Aged

42.5

Disabled

8.2

Part C (Medicare Advantage) Beneficiaries

17.5

Part D (Prescription Drug Benefit) Beneficiaries

41.8

* Parts A–D in millions; totals may not add up due to rounding. No data available for year 2016. Source: Reproduced from National Committee to Preserve Social Security & Medicare. (2017). Fast facts about Medicare. Retrieved from http://www.ncpssm .org/Medicare/MedicareFastFacts

SS benefit check each month. This deduction is $121.80 per month (as of 2016) or more depending on your income (U.S. Department of Health and Human Services, 2017e; Schaeffer & Schaeffer, 2015). If one is turning age 65, working, and covered under the employer’s group health plan, nothing should be done unless told by the employer to enroll in Medicare Parts A and B. If unsure, the person can also switch from employer coverage to a Medicare Ad­ vantage (Part C) or Medigap plan (­ Schaeffer & Schaeffer, 2015). Medicare Part B is simply medical insurance. It generally covers 80% of the cost of services after an annual deductible of $166 (as of 2016). The standard monthly Part B premium is $121.80 as of 2016. However, approximately 70% of beneficiaries were held harmless from increases to the

Part B premium in 2016 compared to 2015, because the SS cost of living adjustment for 2016 is 0%. Therefore, these beneficiaries will continue to pay the 2015 premium amount of $104.90. The Bipartisan Budget Act prevented an even higher premium from going into effect for the 30% of beneficiaries who are not held harmless. Some beneficiaries pay a higher Part B premium based on their income: Those with annual incomes above $85,000 (single) or $170,000 (married) pay from $170.50 to $389.80 per month as of 2016 (U.S. Department of Health and Human Services, 2017e). Part B aids with the cost of physician visits, end-stage renal disease, laboratory, durable medical equipment, certain home health, and other medical services (ambulatory surgery services, some preventative care like immunizations, blood works, X-rays, and some diagnostic

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Chapter 11 Medicare: Protector to Innovator

screenings) that do not require a hospital stay. Part B coverage is voluntary, and about 91% of all Medicare beneficiaries are enrolled in Part B (U.S. Department of Health and Human Services, 2017e). It does not cover any care outside of the United States or cost of help with daily activities like bathing, eating, getting dressed, or any care of eyes, teeth, or hearing. A summary of the number of persons served and payments by type of service for Medicare Part A and B is presented in TABLE 11-3 below. If one has no group benefits as an e­ mployee or retiree, there are two options: (1) ­supplement the Medicare benefits with a federally standardized Medigap plan, or (2) replace the ­Medicare benefits with a Medicare Advantage Plan (Part C). Medicare Part C plans pay a capitated monthly payment to provide all Part A

and B services, and Part D services if offered by the plan. Plans can offer additional benefits or alternative cost-sharing arrangements that are at least as generous as the standard Parts A and B benefits under traditional Medicare. In addition to the regular Part B premium, beneficiaries who choose to participate in Part C may pay monthly plan premiums that vary based on the services offered by the plan and the efficiency of the plan (U.S. Department of Health and Human Services, 2017e). Part D is prescription coverage. It offers a standard prescription drug benefit with a 2016 deductible of $360 and an average estimated monthly premium of $41 (U.S. Department of Health and Human Services, 2017e). Some plans do not have a deductible at all (Schaeffer & Schaeffer, 2015). After the initial coverage of

TABLE 11-3  Medicare Part A and B Persons Served and Payments by Type of Service (2015) Persons Served in Millions

Program Payments in Billions

Part A

7.7

$181.9

Inpatient hospital

6.6

$130.0

Skilled nursing facility

1.8

$29.1

Home health agency

1.7

$6.9

Hospice

1.4

$15.9

Part B

33.8

$178.0

Physician/durable medical equipment

33.3

$102.0

Outpatient

25.5

$64,4

Original Medicare

Home health agency

Total (Parts A and B)

2.0

$11.3

34.4

$359.9

Source: Reproduced from Centers for Medicare & Medicaid Services. (2017). CMS Fast Facts. Retrieved from https://www.cms.gov/Research-Statistics-Data-and -Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html

Current Medicare Structure

$2,960, there is a coverage gap until the beneficiary and the Part D provider have spent $4,700 (U.S. Department of Health and Human Services, 2017e). The gap is known as the “donut hole.” Low-income beneficiaries are responsible for varying degrees of cost sharing, with copayments ranging from $0 to $7.40 in 2016 and low or no monthly premiums. The Affordable Care Act makes Medicare prescription drug coverage more affordable by gradually closing the gap in coverage where beneficiaries had to pay the full cost of their prescriptions out of pocket before catastrophic coverage for prescriptions took effect. The “donut hole” will be closed by 2020. The number of beneficiaries enrolled in Medicare Part D is expected to increase by about 4% to 44.5 million this year, including about 12.7 million beneficiaries who receive the low-income subsidy. In 2016, approximately 58% of those with Part D coverage are enrolled in a standalone Part D prescription drug plan, 38% in a Medicare Advantage prescription drug plan, and the rest in an employer plan or the Limited Income Newly Eligible Transition (NET) Plan. Overall, approximately 88% of all Medicare beneficiaries receive prescription drug coverage through Medicare Part D, employer-sponsored retiree health plans, or other creditable coverage (U.S. Department of Health and Human Services, 2017e). A summary of Medicare deductibles, coinsurance, and premiums for the years 2016 and 2017 is shown in TABLE 11-4 below.

Affordable Care Act and Medicare The Affordable Care Act closes the Medicare Part D coverage gap, or “donut hole,” through a combination of manufacturer discounts and gradually increasing federal subsidies (U.S. ­Department of Health and Human Services (2015b, c). When beneficiaries exceed an initial coverage limit of their total drug spending ($3,310 in 2016) until they reach the threshold for qualified out-of-pocket spending ($4,850 in 2016), they are generally responsible for the 5% gap of their drug costs. Prior to the Affordable Care Act, beneficiaries were responsible for

239

100% of their drug costs in the coverage gap. Under the ACA, in 2017, non–low-income subsidy beneficiaries who reach the coverage gap will pay 40% of the cost of covered Part D brand drugs and biologics and 51% of the costs for all generic drugs in the coverage gap. In 2015, more than 5.1 million beneficiaries reached the coverage gap and saved more than $5.4 billion on their medications due to the prescription drug discount program. These savings averaged about $1,054 per person (U.S. Department of Health and Human Services, 2017e). It is argued that the ACA represents the most significant transformation of the American healthcare system since Medicare and Medicaid, but a realistic vision of the future of federal Medicare expenditures will require significant increases in taxation and the estimates themselves are subject to significant uncertainty. As the Chief Actuary of CMS, Paul Spitalnic stated at the end of the 2015 Medicare Trustees Report: The ACA has been successful in reducing many Medicare expenditures to date. Although early indications from some of the alternative payment model demonstrations have been encouraging, there is a strong possibility that certain payment changes will not be viable in the long range. Specifically, the annual price updates for most categories of non-physician health services will be adjusted downward each year by the growth in economy-wide productivity. Sustaining these price reductions will be challenging for health care providers, as the best available evidence indicates that most providers cannot improve their productivity to this degree for a prolonged period given the labor-intensive nature of these services. Absent an unprecedented change in health care delivery systems and payment mechanisms, the prices paid by Medicare for most health services will fall increasingly short of the cost of providing such services. If this

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Chapter 11 Medicare: Protector to Innovator

TABLE 11-4  Medicare Deductibles, Coinsurance, Premiums (Years 2016–2017) Medicare Components

Calendar Year 2016

Calendar Year 2017

Deductible

$1,288.00

$1,316.00

Coinsurance/day

$322.00

$329.00

Coinsurance/LTR day

$644.00

$658.00

Coinsurance/SNF day

$161.00

$164.50

$166.00

$183.00

Maximum deductible

$360.00

$400.00

Initial coverage limit

$3,310.00

$3,700.00

Out-of-pocket threshold

$4,850.00

$4,950.00

Part A

$411.00

$413.00

Part B

$104.90–$389.80

$134.00–$428.60

Part A Inpatient Hospital

Part B Deductible

Part D

Premiums

LTR = lifetime reserve; SNF = skilled nursing facility. * Source: Reproduced from Centers for Medicaid & Medicare Services. (2017). CMS Fast Facts. Retrieved from https://www.cms.gov/Research-Statistics-Data -and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html

issue is not addressed by subsequent legislation, it is likely that access to, and quality of, physicians’ services would deteriorate over time for beneficiaries. Overriding the price updates specified in current law, as lawmakers repeatedly did in the case of physician payment

rates under the SGR formula, would lead to substantially higher costs for Medicare in the long range than those projected in this report (pp. 258–259). Aligned with expenditures and financing, what is Medicare spending like and how is it

How We Pay for Medicare

financed? It is important to have an overview of Medicare spending and to understand how the program is currently financed.

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Overview of Medicare Spending

From the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary, the 2016 annual report of the Boards of Medicare Trustees and the 2016 Medicare baseline and projections, and most recent historical and spending data from the Congressional Budget Office (CBO), Medicare accounted for 15% of the federal budget. Medicare plays a major role in the healthcare system, accounting for 20% of total national health spending in 2014, 29% of retail sales of prescription drugs, 26% of hospital care, and 23% of physician services (Cubanski & Neuman, 2016). Medicare benefit payments totaled $632 billion in 2015: 23% for hospital inpatient services, 12% for the Part D drug benefit, 11% for physician services, and 27% for Medicare Advantage private health plans covering all Part A and Part B benefits. Medicare spending grew 4.5% to $646.2 billion in 2015, or 20% of total national health expenditures (NHE) (Centers for Medicare & Medicaid Services, 2017f). As of 2016, 31% of Medicare beneficiaries are enrolled in Medicare Advantage plans (Cubanski & Neuman, 2016). Slower growth in Medicare spending in recent years can be attributed in part to policy changes that took effect as part of the ACA and the Budget Control Act of 2011 (BCA). The Budget Control Act of 2011 lowered Medicare spending through sequestration that reduced payments to providers and plans by 2% beginning in 2013. The ACA included reductions in Medicare payments to plans and providers and introduced delivery system reforms that aimed to improve efficiency and quality of patient care and reduce costs, including accountable care organizations (ACOs), medical homes, bundled payments, and value-based purchasing initiatives. The average annual growth

241

in total Medicare spending was 4.4% between 2010 and 2015, down from 9% between 2000 and 2010, despite faster growth in enrollment since 2011 with the “baby boom” generation reaching Medicare eligibility age. The average annual growth in spending per beneficiary averaged just 1.4% between 2010 and 2015, down from 7.4% between 2000 and 2010 (Cubanski & Neuman, 2016). Despite the slower growth in spending over the recent years, Medicare disbursement is expected to continue to grow more slowly in the future, and there are signs that it could increase at a faster rate due to rising prescription drug expense, growing enrollment in Medicare, increases in provider payments, and higher growth in input prices for medical care (Cubanski & Neuman, 2016). The Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds in their 2015 annual report further stated: Projections of Medicare costs are highly uncertain, especially when looking out more than several decades. One reason for uncertainty is that scientific advances will make possible new interventions, procedures, and therapies. Some conditions that are untreatable today will be handled routinely in the future. Spurred by economic incentives, the institutions through which care is delivered will evolve, possibly becoming more efficient. While most health care technological advances to date have tended to increase expenditures, the health care landscape is shifting. No one knows whether future developments will, on balance, increase or decrease costs (p. 2).

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How We Pay for Medicare

Medicare’s expenditures are currently paid through a combination of payroll taxes (37%), taxes on Social Security benefits, federal general

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Chapter 11 Medicare: Protector to Innovator

revenues (42%), premium payments from retirees (13%), state transfers, and a few other sources (Rettenmaier & Saving, 2016).

Medicare’s Hospital Insurance Revenue Sources Medicare Part A is financed primarily through a 2.9% tax on earnings paid by employers and employees (1.45% each) (accounting for 88% of Part A revenue). Higher-income taxpayers (more than $200,000/individual and $250,000/ couple) pay a higher payroll tax on earnings (2.35%). Part A is also funded by federal income taxes on Social Security benefits. In 2015, payroll taxes will pay for 87% of Part A’s $276 billion in spending. Federal income taxes on Social Security Benefits will pay for 8% and general revenues and premiums from voluntary enrollees make up the remainder (Cubanski & Neuman, 2016; Rettenmaier & Saving, 2016).

Medicare’s Supplementary Medical Insurance Revenue Sources Medicare supplementary medical insurance (SMI) includes Parts B and D. Part B is financed through general revenues (73%), beneficiary premiums (25%), and interest and other sources (2%). Beneficiaries with annual incomes over $85,000/individual or $170,000/couple pay a higher, income-related Part B premium reflecting a larger share of total Part B spending, ranging from 35% to 80%. The ACA froze the income thresholds through 2019, and beginning in 2020, the income thresholds will once again be indexed to inflation, based on their levels in 2019 (a provision in the Medicare Access and CHIP Reauthorization Act of 2015 [MACRA]). As a result, the number and share of beneficiaries paying income-related premiums will increase as the number of people on Medicare continues to grow in future years and as their incomes rise. Part D is financed by general

revenues (77%), beneficiary premiums (14%), and state payments for dually eligible beneficiaries (10%). As for Part B, higher-income enrollees pay a larger share of the cost of Part D coverage (Cubanski & Neuman, 2016; Rettenmaier & Saving, 2016). The Medicare Advantage program (Part C) is not separately financed. Medicare Advantage plans such as HMOs and preferred provider organizations (PPOs) cover all Part A, Part B, and (typically) Part D benefits. Beneficiaries enrolled in Medicare Advantage typically pay monthly premiums for additional benefits covered by their plan, in addition to the Part B premium (Cubanski & Neuman, 2016).

▸▸

Medicare Quality Improvement Organizations

The Quality Improvement Organizations (QIOs) Program is one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries. It is an integral part of the U.S. Department of Health and Human Services (USDHHS)’ National Quality Strategy for providing better care and better health at lower cost. QIOs, an important resource in CMS, are required under Sections 1152 to 1154 of the Social Security Act. CMS is required to provide a report to the U.S. Congress every fiscal year that outlines the administration, cost, and impact of the QIO Program. Throughout its history, the program has been instrumental in advancing national efforts to motivate providers in improving and measuring quality for better outcomes. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, CMS identifies the core functions of the QIO Program as: (a) improving quality of care for beneficiaries, (b) protecting the integrity of the Medicare Trust

The Future Outlook: The Way Forward

Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting, and (c) protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints, provider-based notice appeals, violations of the EMTALA, and other related responsibilities as articulated in QIO-related law. A QIO is composed of a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare. There are two types of QIOs that work under the direction of CMS: Beneficiary and Family Centered Care (BFCC-QIOs) and the Quality Innovation Network (QIN-QIOs) (Center for Medicare & Medicaid Services, 2017h; U.S. Department of Health and Human Services, 2017d). The current QIOs’ 5-year contract cycle, or 11th Statement of Work, began on August 1, 2014, and provides approximately $580 million in fiscal year 2017 and $4.1 billion over 5 years. In the 11th Statement of Work, there are 14 Quality Innovation Network (QIN) contracts and 5 Beneficiary and Family Centered Care (BFCC) contracts. BFCC-QIOs is the program’s statutory case review work that manages all beneficiary complaints and quality of care reviews, concerns related to early discharge from healthcare settings, and patient and family engagement to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. They also handle cases in which beneficiaries want to appeal a healthcare provider’s decision to discharge them from the hospital or discontinue other types of services. Two designated ­BFCC-QIOs serve all 50 states and three territories, which are grouped into five regions. Since August 2014, nearly 200,000 case reviews have been conducted. Effective January 2016, Beneficiary and Family Centered Care Contract QIOs assumed the initial reviews of short-stay hospital claims under a probe and educate process (Center for Medicare & Medicaid Services, 2017h; U.S. Department of Health and Human Services, 2017d).

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Quality Innovation Network (QIN) contractors have been working to reduce the occurrence of central-line bloodstream infections, hospital readmissions, and adverse drug events. The QIO Program’s 14 QIN (QIN-QIOs) bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality. By serving regions of two to six states each, QIN-QIOs can help best practices for better care spread more quickly, while still accommodating local conditions and cultural factors (Center for Medicare & Medicaid Services, 2017h; U.S. Department of Health and Human Services, 2017d).

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The Future Outlook: The Way Forward

It is established that projection of Medicare costs is highly uncertain, although it has been on a slower upward trajectory now than in past decades. This raises several questions about recent spending growth and future projections: Can the recent slowdown in Medicare spending be sustained and can this be done without adversely affecting access to or quality of care? How are payment and delivery system reforms influencing spending levels? How will future spending be affected by Medicare’s new approaches to physician payment that will be established pursuant to the 2015 law known as MACRA? What steps could be taken to moderate the projected growth in Medicare spending due to the availability of new specialty drugs and medical technology? (Cubanski & Neuman, 2016). Given the magnitude of the fiscal challenges ahead, Medicare needs new approaches to help it move to a more solid financial footing. The USDHHS presented a set of proposals moving forward with Medicare that are the answers to these questions. The President’s Fiscal Year 2017 Budget includes a package of Medicare legislative proposals

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that will save a net $419.4 billion over 10 years. The USDHHS emphasized that this can be done by supporting delivery system reform to promote high-quality, efficient care, improving beneficiary access to care, addressing the rising cost of pharmaceuticals, more closely aligning payments with costs of care, and making structural changes that will reduce federal subsidies to high-income beneficiaries and create incentives for same to seek high-value services. These strategies are divided into six separate headings, namely, payment incentives, care delivery, information, addressing the rising cost of pharmaceuticals, increasing the availability of generic drugs and biologics, and Medicare structural reforms. They are presented in BOXES 11-1 through 11-6 below. These proposals, combined with tax proposals included in the President’s Fiscal Year 2017 Budget, would help extend the life of the Medicare Hospital Insurance Trust Fund by over 15 years (U.S. Department of Health and Human Services, 2017a). There are other changes to Medicare that have been proposed that could help to address the healthcare spending challenges posed by the aging of the population, including restructuring Medicare benefits and cost sharing, eliminating “first-dollar” Medigap coverage, further increasing Medicare premiums for beneficiaries with relatively high incomes, raising the Medicare eligibility age, shifting Medicare from a defined benefit structure to a “premium support” system, and accelerating the ACA’s delivery system reforms (Cubanski & Neuman, 2016). MACRA provides a unique opportunity to transform healthcare delivery from a volume-based Medicare payment system to one focused on high-quality care at a reasonable cost. The law revoked the Sustainable Growth Rate Formula that calculated payment cuts for physicians. It also created a new framework for rewarding physicians for providing higher quality care by establishing two tracks for payment: merit-based incentive payment system (MIPS), and advanced alternative payment models (AAPMs). The Quality Payment Program (QPP) is the umbrella term used to describe the MIPS and AAPM tracks

BOX 11-1  USDHHS Payment Incentives Proposal 2017 Payment Incentives Reform Medicare Advantage Payments to Improve the Efficiency and Sustainability of the Program. Implement Bundled Payment for Post-Acute Care. Expand Basis for Beneficiary Assignment for Accountable Care Organizations to include Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists. Allow CMS to Assign Beneficiaries to Federally Qualified Health Centers and Rural Health Clinics Participating in the Medicare Shared Savings Program. Allow Accountable Care Organizations to Pay Beneficiaries for Primary Care Visits up to the Applicable Medicare Cost-Sharing Amount. Establish a Bonus Payment for Hospitals Cooperating with Certain Alternative Payment Models. Establish a Hospital-Wide Readmissions Reduction Measure. Establish Quality Bonus Payments for HighPerforming Part D Plans. Extend Accountability for Hospital-Acquired Conditions. Implement Value-Based Purchasing for Additional Providers. Source: Data from U.S. Department of Health and Human Services. (2017). HHS FY 2017 Budget in Brief - CMS – Medicare: 2017 legislative proposals. Retrieved from https://www.hhs.gov/about /budget/fy2017/budget-in-brief/cms/medicare/index.html#parts

under MACRA. It consolidates three existing quality reporting programs: Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBPM), and meaningful use (MU), plus it adds a new performance category, called improvement activities (IA), into a single system through MIPS. It also notably required that Social Security numbers be removed from

The Future Outlook: The Way Forward

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BOX 11-2  USDHHS Care Delivery Proposals 2017

BOX 11-4  USDHHS Proposals to Address the Rising Costs of Pharmaceuticals 2017

Care Delivery

Address the Rising Costs of Pharmaceuticals

Expand the Ability of Medicare Advantage Organizations to Pay for Services Delivered via Telehealth. Allow the Secretary to Introduce Primary Care Payments under the Physician Fee Schedule in a Budget Neutral Manner. Source: Data from U.S. Department of Health and Human Services. (2017). HHS FY 2017 Budget in Brief - CMS – Medicare: 2017 legislative proposals. Retrieved from https://www.hhs.gov /about/budget/fy2017/budget-in-brief/cms/medicare/index .html#parts

BOX 11-3  USDHHS Information Proposals 2017 Information Add Certain Behavioral Health Providers to the Electronic Health Record Incentive Programs. Increase Value in Medicare Provider Payments. Eliminate the 190-Day Lifetime Limit on Inpatient Psychiatric Facility Services. Update Medicare Disproportionate Share Formula for Hospitals in Puerto Rico. Adjust Payment Updates for Certain PostAcute Care Providers. Source: Data from U.S. Department of Health and Human Services. (2017). HHS FY 2017 Budget in Brief - CMS – Medicare: 2017 legislative proposals. Retrieved from https://www.hhs.gov /about/budget/fy2017/budget-in-brief/cms/medicare/index .html#parts

Medicare identification cards (Center for Medicare & Medicaid, 2017c; U.S. Department of Health and Human Services, 2017c). MACRA supports the USDHHS goal to reward clinicians for value over volume through MIPS and providing bonus payments for participation in eligible alternative payment models.

Align Medicare Drug Payment Policies with Medicaid Policies for Low-Income Beneficiaries. Accelerate Manufacturer Drug Discounts to Provide Relief to Medicare Beneficiaries in the Coverage Gap. Modify Reimbursement of Part B Drugs. Require Mandatory Reporting of Other Prescription Drug Coverage. Allow the Secretary to Negotiate Prices for Biologics and High-Cost Prescription Drugs. Change the Part D Coverage Gap Discount Program Agreements from Annually to Quarterly. Establish Authority for a Program to Prevent Prescription Drug Abuse in Medicare Part D. Increase Part D Plan Sponsors’ Risk for Catastrophic Drugs. Require Evidence Development for Coverage of High Cost Drugs. Source: Data from U.S. Department of Health and Human Services. (2017). HHS FY 2017 Budget in Brief - CMS – Medicare: 2017 legislative proposals. Retrieved from https://www.hhs.gov /about/budget/fy2017/budget-in-brief/cms/medicare/index .html#parts

MIPS will combine several current quality programs for physicians and healthcare professionals into one comprehensive program starting in 2019. Under MIPS, positive and negative payment adjustments will be made under the Medicare physician fee schedule based on quality performance, resource use, use of electronic health records, and participation in clinical practice improvement activities. These adjustments will be capped at 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and future years. Between 2019 and 2024, Medicare physicians and healthcare professionals can also receive an

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BOX 11-5  USDHHS Proposals to Increase the Availability of Generic Drugs and Biologics 2017 Increase the Availability of Generic Drugs and Biologics Prohibit Brand and Generic Drug Manufacturers from Delaying the Availability of New Generic Drugs and Biologics. Modify Length of Exclusivity to Facilitate Faster Development of Generic Biologics. Establish Transparency and Reporting Requirements in Pharmaceutical Drug Pricing. Source: Data from U.S. Department of Health and Human Services. (2017). HHS FY 2017 Budget in Brief - CMS – Medicare: 2017 legislative proposals. Retrieved from https://www.hhs.gov /about/budget/fy2017/budget-in-brief/cms/medicare/index .html#parts

BOX 11-6  USDHHS Proposals for Medicare Structural Reforms 2017 Medicare Structural Reforms Eliminate Beneficiary Coinsurance for Screening Colonoscopies with Polyp Removal. Increase Income-Related Premiums under Medicare Parts B and D. Encourage the Use of Generic Drugs by LowIncome Beneficiaries. Modify the Part B Deductible for New Beneficiaries. Introduce Home Health Copayments for New Beneficiaries. Source: Data from U.S. Department of Health and Human Services. (2017). HHS FY 2017 Budget in Brief - CMS – Medicare: 2017 legislative proposals. Retrieved from https://www.hhs.gov /about/budget/fy2017/budget-in-brief/cms/medicare/index .html#parts

additional positive adjustment for exceptional performance (Centers for Medicare & Medicaid, 2017c; U.S. Department of Health and Human Services, 2017c). MACRA is a significant piece of healthcare legislation that is expected to have a profound effect on the way U.S. health care is reimbursed. However, surveys show that few physicians are familiar with the legislation and the impact it will have on their practice especially at a time of unprecedented change, intense pricing pressure, and ever more complicated reporting requirements. Why does MACRA matter? For physicians and healthcare professionals who qualify to receive a separate incentive payment for participating in an eligible alternative payment model, MACRA provides a 5% lump sum payment each year from fiscal years 2019 to 2024. To be a “qualifying alternative payment model participant,” a physician or healthcare professional must receive a certain amount of their payments through an entity (such as an accountable care organization [ACO]) that participates in an eligible alternative payment model (U.S. Department of Health and Human Services, 2017c). For clinicians who receive reimbursement under Medicare Part B, MACRA will tie an increasing amount of that payment to quality and value as defined by their Quality Reporting Program (QPP). The program is cost neutral. By 2022, there will be a 18% differential in p ­ ayment made to the top ­performers versus the lowest performers. Medicare intends to publish the data so that it can be used by ­Physician Compare and other third parties to drive patient choice. These data are also likely to drive private payers as they define networks and enter into contract negotiations. Physician Compare is a CMS website designed to help consumers make informed choices about the health care they receive through Medicare. MIPS payment adjustments will follow providers for 2 years if they switch practices. Practices may think twice if a clinician is a low MIPS performer and it may affect their mobility. Providers who fail to engage with MACRA and MIPS

References

will be setting themselves up for significant reductions in Medicare payments. Furthermore, as data from the program are made publicly available, there is a risk that it could drive future patient volumes away from low performers. The same data will be used to define networks and set prices, and for private payers to implement similar quality reporting programs (Center for Medicare & Medicaid Services, 2017c; U.S. Department of Health and Human Services, 2017c).

▸▸

Conclusion

Medicare is a valuable source of health insurance for seniors age 65 and older, as well as younger adults with permanent disabilities. Despite its many benefits and quality improvement programs, Medicare faces many issues and challenges today and in the years to come. Today, Medicare excess healthcare cost growth and demographics are driving the rise in healthcare spending by the increasing number of the elder population. For decades, per-capita healthcare spending has grown more rapidly than the nation’s per-capita gross domestic product. Other critical challenges include how to finance care for future generations without unduly burdening beneficiaries, taxpayers, or the general economy; concerns about the current payment system for private plans; the current structure of prescription drug spending; and how to make health and long-term care more affordable for beneficiaries in light of rising health costs. It is imperative that we change the extent that a growing Medicare spending and cost burden is taxpayer financed. Indeed, most reforms either passed or suggested should also have the goal of improving the health and healthcare experiences and decreasing the costs of all Americans. We can aim higher by supporting the partnerships that are essential today in getting better health care. Like the prevention-oriented health care today, Medicare and Medicaid programs cannot be effective without partnership. New approaches to better care to keep Medicare and Medicaid sustainable

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and to keep it financially secure should also be upheld, given the uncertainty and controversy of the Affordable Care Act in the current political climate. The need is urgent to bring U.S. healthcare costs into a sustainable range for both public and private payers. The demands Medicare places on the rest of the federal budget will force the U.S. Congress to consider some difficult choices as to who should bear the burden of elder healthcare spending. It amplifies the need for serious consideration of reform.

Discussion Questions 1. 2.

3. 4. 5.

6.

7.

Trace the evolution of the passage of Medicare, its timelines, and milestones. Describe the current Medicare structure, including who is eligible, its four components, and the changes with the implementation of the Affordable Care Act. Discuss Medicare spending as it is now and its effect on future Medicare projections. How do we pay for Medicare and what are the effects on consumers and providers? What are Medicare’s Quality Improvement Organizations (QIOs) and their role in improving health quality of Medicare beneficiaries? What is the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) of 2015 and its current and future impact to clinicians and providers? How do you envision Medicare in the future and how should we move forward for better patient, family, provider, and healthcare outcomes?

References Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. (2015). 2015 annual report of the Boards of Trustees of the Federal Health Insurance and Federal Supplementary Medical Insurance Trust Funds. Retrieved from https:// www.cms.gov/Research-Statistics-Data-and-Systems /Statistics-Trends-and-Reports/ReportsTrustFunds /Downloads/TR2015.pdf

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Centers for Medicare & Medicaid Services (CMS). (2017a). CMS fast facts. Retrieved from https://www.cms.gov /Research-Statistics-Data-and-Systems/Statistics-Trends -and-Reports/CMS-Fast-Facts/index.html Centers for Medicare & Medicaid Services (CMS). (2017b). CMS program statistics. Retrieved from https://www.cms.gov /Research-Statistics-Data-and-Systems/Statistics-Trends -and-Reports/CMSProgramStatistics/2015/2015_Main.html Centers for Medicare & Medicaid Services (CMS). (2017c). CMS quality measure development plan: Supporting the transition to the quality payment program 2017 annual report. Retrieved from https://www.cms.gov/Medicare/Quality -Initiatives-Patient-Assessment-Instruments/Value -Based-Programs/MACRA-MIPS-and-APMs/Draft -CMS-Quality-Measure-Development-Plan-MDP.pdf Centers for Medicare & Medicaid Services (CMS). (2017d). CMS’s program history: Medicare and Medicaid. Retrieved from https://www.cms.gov/About-CMS/Agency Information /History/index.html Centers for Medicare & Medicaid Services (CMS). (2017e). Medicare and Medicaid milestones. Retrieved from https://www.cms .gov/About-CMS/Agency-Information/History/Downloads /Medicare-and-Medicaid-Milestones-1937-2015.pdf Centers for Medicare & Medicaid Services (CMS). (2017f). National health expenditure data fact sheet: Historical NHE 2015. Retrieved from https://www.cms.gov/research -statistics-data-and-systems/statistics-trends-and-reports /nationalhealthexpenddata/nhe-fact-sheet.html Centers for Medicare & Medicaid Services (CMS). (2017g). President milestones. Retrieved from https://www.cms.gov/About -CMS/Agency Information/History/Downloads/President CMSMilestones.pdf Centers for Medicare & Medicaid Services (CMS). (2017h). Quality Improvement Organizations. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient -Assessment-Instruments/QualityImprovementOrgs /index.html Congressional Budget Office. (2017). An update to the budget and economic outlook, 2017–2027. Retrieved from https:// www.cbo.gov/publication/52801 Cubanski, J., & Neuman, T. (2016). The facts of Medicare spending and financing. Henry J. Kaiser Family Foundation. Retrieved from http://www.kff.org/medicare/issue-brief /the-facts-on-medicare-spending-and-financing/ Manchikanti, L., Caraway, D., Parr, A. T., Fellows, B., & Hirsch, J. A. (2011). Patient Protection and Affordable Care Act of 2010: Reforming the health care reform for the new decade. Pain Physician, 14, E35–E67.

Rettenmaier, A. J., & Saving, T. R. (2016). Paying for Medicare now and in the future. Retrieved from http://www.ncpa .org/pdfs/sp_medicare_study_options.pdf Schaeffer, D., & Schaeffer, I. (2015). Medicare made 123 easy. Cave Creek, AZ: American Retirement Advisors Inc. Spitalnic, P. (2015). J statement of actuarial opinion. In Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2015 annual report of the Boards of Trustees of the Federal Health Insurance and Federal Supplementary Medical Insurance Trust Funds (Appendix, pp. 258–259). Retrieved from https://www.cms.gov/Research-Statistics -Data-and-Systems/Statistics-Trends-and-Reports /ReportsTrustFunds/Downloads/TR2015.pdf Thorpe, K. E., Ogden, L. L., & Galactionova, K. (2010). Chronic conditions account for rise in Medicare spending from 1987 to 2006. Health Affairs, 29(4), 718–724. U.S. Department of Health and Human Services. (2017a). HHS FY 2017 budget in brief - CMS – Medicare: 2017 legislative proposals. Retrieved from https://www.hhs .gov/about/budget/fy2017/budget-in-brief/cms/medi care/index.html#proposals U.S. Department of Health and Human Services. (2017b). HHS FY 2017 budget in brief - CMS – Medicare: CMS budget overview. Retrieved from https://www.hhs.gov /about/budget/fy2017/budget-in-brief/cms/medicare /index.html#overview U.S. Department of Health and Human Services. (2017c). HHS FY 2017 budget in brief - CMS – Medicare: Highlights of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Retrieved from https://www.hhs.gov /about/budget/fy2017/budget-in-brief/cms/medicare /index.html#macra U.S. Department of Health and Human Services. (2017d). HHS FY 2017 budget in brief - CMS – Medicare: Medicare Quality Improvement Organization. Retrieved from https://www.hhs.gov/about/budget/fy2017/budget-in brief/cms/medicare/index.html#quality U.S. Department of Health and Human Services. (2017e). HHS FY 2017 budget in brief - CMS – Medicare: The four parts of Medicare. Retrieved from https://www .hhs.gov/about/budget/fy2017/budget-in-brief/cms /medicare/index.html#parts

Case Study

CASE STUDY

Steven Baumann After reviewing some of the current literature on what is now known as postoperative cognitive decline or dysfunction (POCD), this case study will consider the case of an older adult surgical patient and one hospital’s efforts to reduce the incidence and severity of delirium to illustrate that more needs to be done to preserve the cognitive status of older adults. It will also offer some recommendations for practice, policy changes, and further research to reduce the incidence and severity of POCD. Thanks to improvements in surgery and anesthesiology, surgical procedures are now routinely being done on persons of advanced age, including those with multiple comorbidities and various vulnerabilities, including those at risk for or in early stages of cognitive decline. In the context of an aging population this translates into increased numbers of older surgery patients, some who undergo multiple surgeries. As a result of this demographic shift and advances in medicine, more surgical procedures are done on persons over age 65 in the United States than on people under age 65 (Inouye et al., 2016). While their survival and postoperative infection rates are carefully monitored by hospitals and various agencies, the frequency and consequences of postoperative delirium (POD) and postoperative cognitive decline or dysfunction (POCD) continue to go unidentified and underreported; therefore, these clinical entities are generally missed by the general public and healthcare financers, all to the detriment of seniors, their caregivers, and society in general. The consequences of POD and POCD are increased rates of disability, decreased quality of life, higher healthcare costs, and increased need for institutionalization (Inouye et al., 2016). In other words, there is an important opportunity to prevent irreversible cognitive decline in later

life and reduce the burden on caregivers and the U.S. economy that is missed. According to Inouye and colleagues (2016) and others (Cavallari et al., 2016; Fong et al., 2015), postoperative delirium (POD) is more common and detrimental to older adult surgical patients than previously thought, and POCD is an irreversible and progressive neurocognitive syndrome. It is estimated that 10% to 25% of older adult surgical patients have postoperative complications; postoperative delirium (POD) is the most frequent (Inouye et al., 2016). Of the patients who have POD, around 40% never return to their preoperative cognitive status (O’Brien, Mohan, O’Hare, Reynolds, & Kenny, 2016). As illustrated by the case below, the traditional care of the older surgical patient is doing them more harm than previously thought. This individual patient case study and hospital-wide case study seeks to inform nurses about POD and POCD, so that they can take a leading role in hospitals and ambulatory surgical sites to change healthcare practice and policy in ways that protect and preserve the cognitive integrity of older adults, and prevent the need for burdensome assistance from their caregivers. In other words, the costs and benefits of surgery in later life need to be recalculated in light of the new information coming out about impact of surgery and anesthesia on cognitive functioning. Older adult patients and their families need to be better informed about these issues and greater efforts needs to be made to minimize the short- and long-term risk that major surgery and anesthesia represents to older adults. Because this might involve delaying or avoiding surgery, such a change may reduce the number of revenue-generating procedures done in hospitals and ambulatory surgical centers; therefore, such information and practice changes may be met with institutional, as well as individual, barriers to change. Healthcare and hospital policy, economics, and technology play an important role in implementing the changes suggested in this case study.

Postoperative Cognitive Decline According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013), delirium is a neuropsychological syndrome characterized by disturbance of attention

CASE STUDIES

Preserving the Cognitive Status of Older Surgical Patients: A Case Study

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and awareness that develops over a short time period. Delirium involves disturbances in cognition and perception that are not better explained by a preexisting dementia. It is estimated that 29% to 64% of hospitalized older adults experience delirium; of these, nearly half had some level of delirium on admission to the hospital (Inouye, Westendorp, & Saczynski, 2014). Postoperative delirium (POD) is a change in mental status that is distinct from withdrawal effects of anesthesia, which are common in the first 24 hours after surgery. Postoperative delirium therefore usually begins 24 to 72 hours after surgery (Silverstein & Deiner, 2013) and it usually associated with multiple etiological factors. Postoperative cognitive decline (POCD) is a relatively newly recognized postoperative complication; because definitions of the phenomenon remain somewhat unclear, its incidence remains uncertain. Like posttraumatic stress disorder (PTSD), POCD follows a specific event, in this case a surgery or multiple surgeries. Also like PTSD, the person’s presurgical mental and medical health are important contributing factors, and some think that POCD represents an unmasking of preexisting cognitive deficits, rather than a new pathology. In either case, POCD represents cognitive decline that is greater and more rapid than is normal cognitive aging, but usually less severe than Alzheimer’s dementia. Postoperative cognitive decline has been described as a biphasic condition, in that postoperative delirium often improves but the improvement is not sustained, and a rather rapid decline follows (Cavallari et al., 2016). Some of the mechanisms that account for POD also contribute to POCD, and conditions are seen as multifactorial geriatric syndromes. Surgery and anesthesia, particularly in older adults, are significant biochemical and physiologic stressors. The presence of suspected biomarkers for dementia (alpha beta, tau, phosphorylated tau, alpha beta40/tau, alpha beta42/tau ratios, and apolipoprotein E-E4 genotype) increases the risk for both POD and POCD (Fong et al., 2015). While the science regarding the prevention of POCD is still evolving, the overlap of POD and POCD suggest that nursing interventions to reduce delirium in the hospitalized patient, particularly those who also had surgery, should also be helpful and important to reduce the incidence and degree of POCD.

Likewise, the characteristics of the surgery, such as its duration and type, and the type and amount of anesthesia used contribute to the risk of POCD in older adults. The following describes a case study of an older male having surgery in which the prevention of POD and POCD was not anticipated or prevented; it is here to illustrate how routine practice needs to be changed in light of the above described new information.

Case Study Mr. Harris is a 72-year-old married white male, who is a retired New York City detective. His medical history includes hypertension, hypocholesteremia, and gastroesophageal reflux disease, each of which is fairly well controlled. He presents to his primary care provider with a complaint of worsening hematuria and dysuria with urinary frequency. He is referred to a urologist, who after doing an ultrasound of the bladder, recommends cystoscopy and bladder polyp removal. Mr. Harris’ current medications are amlodipine (Norvasc) 5 mg daily, pantoprazole (Protonix) 40 mg daily, and simvastatin (Zocor) 20 mg at bedtime. He has no known drug allergies, but he smokes one pack of cigarettes per day, a habit he has had for nearly 50 years. He drinks two cans of beer each night, which is less than he used to drink when he was younger. Just prior to his scheduled cystoscopy and bladder polyp removal, his complete blood count and metabolic panel results are within normal limits.

Routine Preoperative Assessment and Care On the day of the procedure Harris’ only new complaint is that he has not slept for the past two nights, anxious about the procedure and fearful about the possible findings. He has been informed, and is aware from this own internet search, that a biopsy specimen will be tested and that bladder polyps are often cancerous. On examination, his blood pressure is 132/70 mmHg, heart rate is 62 beats per minute, respiration rate is 16 per minute, and his oral temperature is 97.6°F. The pulse oximeter displays his oxygen concentration on room air as 98%. His height is 5’8” (68 in) and his weight is 172 lbs. (78.1 kgs), giving him a BMI of 26.2. On physical examination, there is no heart murmur, jugular venous distention, or peripheral edema. His electrocardiography is normal. His lungs are clear, with no evidence of

Case Study

Mr. Harris’ Postoperative Course Postoperatively continuous bladder irrigation (CBI) is ordered for Mr. Harris requiring that he be admitted to the hospital for his procedures. While Mr. Harris is in the postanesthesia care unit (PACU), he receives two doses of fentanyl 25 mcg via intravenous (IV). As per routine, once medically stable he is transferred to a medical-surgical unit, where he receives an additional dose of ciprofloxacin 200 mg IV, the fentanyl order is discontinued, and he is provided with an order for oxybutynin (Ditropan) 5 mg on an as-needed basis. He receives one dose of oxybutynin at 2:00 p.m.; the evening nurse making her rounds finds him restless and confused, and he says to her, “Why are there strangers in this room.” The nursing staff tries to calm him and decides to move him closer to the nurse’s station and suspends the bladder irrigation. Despite these interventions, Mr. Harris becomes more confused and agitated, and attempts to leave the hospital. His wife is contacted and asked to return to the hospital in the hopes that she can help calm and reorient him, but she fails to do so. The patient is at this point very agitated, so the nurse calls the house physician to evaluate the patient. An order for lorazepam 1 mg stat is provided with wrist restraints. Because of this postoperative delirium complication, Mr. Harris’ stay in the hospital was extended an additional day, and by the second night he is calmer, although he remained mildly confused. He was generally alert and oriented the next afternoon, so he was discharged. While he generally returned to baseline and remained there over the next 3 weeks at home, his wife noticed that he was not the same in the months that followed the procedure and his cognitive status continued to gradually deteriorate over the next 6 months, such that his wife began to suspect he might be in an early stage of dementia. At this point she became afraid to let him drive or leave

him alone at home. Before discussing Mr. Harris’s case further, a hospital-wide effort to reduce delirium will be first be discussed.

South Shore University Hospital The hospital where Mr. Harris was admitted is described here as South Shore University Hospital. It is a 591-bed regional academic medical center in the northeastern United States. Located in a busy suburban area less than 30 minutes from New York City, this hospital offers multiple surgical specialties, offering patients a wide range of surgical interventions performed within its 24 operating rooms, and postoperative levels of care from intensive care to medical-surgical units. It was identified in 2016 that acute delirium, like Mr. Harris’ case, was frequently occurring and creating longer lengths of stay. Older patients who were admitted for routine surgical procedures, who should be home in a day or two, were developing delirium and would end up staying longer, and many of them needed transfer to a subacute rehab setting instead of home. Aside from the disruption in the lives of patients, like Mr. Harris, and their families, there are other risks of adverse events for older adults the longer they stay in the hospital. Preventing POD therefore reduces the risk of other adverse events, including POCD (Blazer, Yaffe, & Liverman, 2015; Xie, 2016). Recognizing that prevention of acute delirium should be a priority goal in any inpatient healthcare setting, South Shore University Hospital administration assembled an interdisciplinary committee, which came to be known as the Delirium Prevention Team. On the team was a geriatrician; the chairs of both the departments of surgery and anesthesiology; the directors of nursing operations, nursing education, laboratory, radiology, and the blood bank; as well as staff nurses, clinical informaticists, and members of the engineering department. Several strategies were discussed and implemented, requiring changes in the operations of multiple departments. The proposed changes were based on a paradigm shift from an individual-level provider-centric model to a patient-centric model, with the specific goal of the prevention of delirium, including POD and POCD. The primary objective in determining which strategies to focus on extended from the understanding that one of the key ways to prevent delirium was to make sure patients would have

CASE STUDIES

wheezing, rhonchi, or rales. His abdomen is soft and nontender; there are bowel sounds in all four quadrants. There are no abnormalities in his gait or restrictions in range of motion. His laboratory results, including liver enzyme tests, creatinine, and BUN, are within the normal range for an older adult male. He is prescribed ciprofloxacin 200 mg via IV to be administered 1 hour preoperatively.

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more regular sleep–wake cycles, with at least 5 hours of uninterrupted sleep. The decision made was to create the midnight to 5:00 a.m. time frame as protected time. Every effort, aside from a clinical emergency, was made not to interrupt the patient during this time. Previously, surgical patients had blood drawn at 4:00 a.m. This time was a tradition at the hospital, to assure laboratory results would be available for the surgical team to make their morning rounds scheduled for 7:00 a.m., and the first case in the operating room could start at 8:00 a.m. After considerable deliberation, it was decided that premade order sets were not adequately individualized; many included 4:00 a.m. blood draws that were not clinically indicated. Many of those blood tests were eliminated or moved to the evening before in order to reduce the number of blood tests drawn early in the morning. Reducing the number of early morning laboratory tests made it possible for those who still needed them to be able to get them done at 5:00 a.m., and they would still receive results on time. The role of the clinical informaticists was to design new electronic order sets, and adjust the electronic medical record to prevent providers from being able to order tests prior to 5:00 a.m., unless critically emergent. Chest X-rays and electrocardiograms were also not being done before 5:00 a.m.—or not at all—as this team also focused on resource utilization and specific clinical indication for tests or procedures. Early morning processes were also streamlined to minimize the disruption to the patient. South Shore University Hospital, for several years, had a quiet time in place at 3:00 p.m. This practice included dimming unit lights and reducing the volume of overhead paging for 1 hour to promote patient rest and sleep. Signs had been hung to encourage quiet time. The Delirium Prevention Team recognized that this practice could reduce sleep at night, so the practice was stopped. Curtains and blinds were kept open during daylight hours. These strategies have been observed to reduce the incidence of delirium. One of the biggest changes and challenges was to get the nurses to not allow patients to sleep during the day, even if they had been up the night before with delirium. The engineering department was an integral part of this team and new strategies. At the time of

the team’s implementation, a grateful family had donated a considerable amount of money to the hospital to renovate one of the patient care units and upgrade the bedside technology for patient use. This included providing tablets and updated televisions in each patient room. The funding was also used to identify lighting equipment that might assist in facilitating a proper sleep–wake cycle. The new lighting would automatically get brighter during the day and dim at night, providing visual cues to both patient and staff for proper wakeful times and sleep times. The team also developed a patient/family brochure that is given to all patients at the time of admission. This brochure explains delirium, the possible causes, the common behaviors, and some advice on what family and friends can do to help. This brochure has enabled the nurse to begin the conversation with the patient and family about delirium, as it can be a very frightening experience for both the patient and the family. South Shore University Hospital required all staff to be educated on delirium, including POD and POCD, and strategies were put in place on hire and on an annual basis, with the goal of preventing acute delirium and potentially reducing the incidence of POCD.

Individual Practice Change Recommendations Returning to the specific case of Mr. Harris, it is important for nurses to be aware of the key role they play in preoperative and postoperative assessment and teaching, and therefore they are in a key position to calculate the risk for POD and POCD and intervene in a way to reduce its incidence and severity. In addition to the above hospital-wide education and changes to improve nighttime sleep and reduce delirium, hospital and home care nurses need new knowledge, tools, and skills to reduce POCD. In the case of Mr. Harris, his need for surgery was not in question, nor is it clear if delirium could have been prevented, but alternative medical and nursing care as described above could have reduced its severity, and perhaps avoided the POCD. Cognitive baseline assessment should be done on all older surgical patients with use of a validated assessment tool, such as the Confusion Assessment Method (CAM). Mr. Harris’s risk for postoperative cognitive delirium and decline was increased by his smoking, alcohol

Case Study

Conclusion This case study is an example of how the traditional approach to surgery can do a disservice to the older adult surgical patient and a paradigm shift involving multiple hospital departments working together is needed to reduce the incidence and severity of POD and POCD.

Case Study Questions 1. What are the nature of barriers that remain to recognition of POD and POCD in older surgical patients and what individual and system-wide changes are needed where you work to help maintain the cognitive integrity of older adults? 2. While this case study did not discuss any of the research currently being

done on changes in surgery and the use of anesthesia, including the use of electroencephalogram during surgery to reduce the amount of anesthesia needed, it does ask the question: What contribution can nursing research make to prevent cognitive decline in older adults? 3. How can nurse educators package innovative nursing educational materials, including virtual simulation, to distribute the knowledge and skills needed by all hospitals and ambulatory surgical centers to make the changes suggested above?

References American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 63(11), 2227–2246. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Blazer, D. G., Yaffe, K., & Liverman, C. T. (2015). Cognitive aging: Progress in understanding and opportunities for action. Washington, DC: National Academies Press. Cavallari, M., Dai, W., Guttmann, C. R., Meier, D. S., Ngo, L. H., & Hshieh, T. T., . . . Alsop, D. C. (2016). Neural substrates of vulnerability to postsurgical delirium as revealed by presurgical diffusion MRI. Brain, 139, 1282–1294. doi: 10.1093/brain/aww010. [Epub 2016, February 26.] Fong, T. G., Hshieh, T. T., Wong, B., Tommet, D., Jones, R. N., & Schmitt, E. M., . . . Inouye, S. K. (2015). Neuropsychological profiles of an elderly cohort undergoing elective surgery and the relationship of cognitive performance with delirium. Journal of the American Geriatrics Society, 63(5): 977–982. doi:10.1111/jgs.13383. Inouye, S. K., Marcantonio, E. R., Kosar, C. M., Tommet, D., Schmitt, E. M., & Travison, T. G., . . . Jones, R. N. (2016). The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients. Alzheimer’s & Dementia, 12, 766–775. http:// dx.doi.org/10.1016/j.jalz.2016.03.005. Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383, 911–922. doi: 10.1016/S0140-6736(13)60688-1. Newman, S., Wilkinson, D. J., & Royse, C. F. (2014). Assessment of early cognitive recovery after surgery using the PostOperative Quality of Recovery Scale. Acta Anaesthesiology Scandinavia, 58, 185–191. O’Brien, H., Mohan, H., O’Hare, C., Reynolds, J. V., & Kenny, R. A. (2016). Mind over matter? The hidden epidemic of cognitive dysfunction in the older surgical patient.

CASE STUDIES

use, stress, fatigue on the day of the procedure, pre- and postoperative pain, use of opioids, age, as well as use of ciprofloxacin and oxybutrin, which are both on the American Geriatric Society (AGS)’s Beers Criteria for potentially inappropriate medication use in older adults (American Geriatric Society, 2015). Mr. Harris lack of sleep prior to his procedure was also a modifiable risk factor for POD and POCD. Disturbance in one’s circadian rhythmicity, which is associated with intrinsic melatonin’s metabolite 6-sulfatoxymelatonin (6-SMT) fluctuating, has been associated with POCD (Wu, Wang, Wu, & Yue, 2014). Newman, Wilkinson, & Royse (2015) also reported those older surgical patients (49.2 vs. 45.2) who have difficulty eating and have lower body temperatures are slower to clear cognitively after surgery. The recognition and management of underlying individual level risk factors is imperative to the prevention of POCD. Ongoing professional educational programs regarding POCD are needed for all members of the healthcare team. Modifiable predictor factors should be targeted for interventions to prevent or preempt POCD. In addition to sleep, improved management of pain, stress, and nutritional status with as little opioid analgesics, benzodiazepine, and antipsychotic medication use as possible is the goal. Nonpharmacological interventions and environmental practices known to reduce delirium should also help reduce the risk of POCD.

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CASE STUDIES

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Annals of Surgery, [Epub ahead of print], PMID: 27537541 doi: 10.1097/SLA.0000000000001900. Silverstein J. H., & Deiner, S. G. (2013). Perioperative delirium and its relationship to dementia. Progress in NeuroPsychopharmacology & Biological Psychiatry. 43, 108–115. doi: 10.1016/j.pnpbp.2012.11.005. Wu, Y., Wang, J., Wu, A. & Yue, Y. (2014). Do fluctuations in endogenous melatonin levels predict the occurrence of postoperative cognitive dysfunction (POCD)?

International Journal of Neuroscience, 124(11), 787–791. doi: 10.3109/00207454.2014.882919. Xie, Z. (2016). The mechanistic studies of postoperative delirium and cognitive dysfunction in rodents. Paper presented at the New York Academy of Science conference on Surgery and Cognition Delirium, Cognitive Decline, and Opportunities to Protect the Brain. New York, NY. Retrieved from http://www.nyas.org/MediaPlayer. aspx?mid=3bcd7e43-962e-4d94-8ba4-a884e5d1f2b8

CHAPTER 12

Medicaid and the Financing of Care for Vulnerable Populations: A Story of Misconceptions Barbara Caress and Nancy Aries

OVERVIEW Unlike any other country, access to health care in the United States is based on key social attributes such as immigration status, income, employment, disability, age, and parentage. This results in tremendous inequities in health insurance entitlement and the level of benefits received. Medicare was a breakthrough, opening eligibility to all elderly persons. At the time, it was assumed that Medicare would be the first step to universal coverage, but this has not happened. Instead there is Medicaid, Medicare’s poorer cousin. Medicaid comes in two variants. Original Medicaid for the very poor—the federal government sets a loose set of parameters regarding services and eligibility and matches the states’ payments for services. Although many people think Medicaid covers all very low-income and vulnerable people, that is not true. Because states determine income cutoffs for eligibility, many persons living in poverty are not eligible. At the same time, original Medicaid is the major source of support for previously non-poor elderly persons and those with disabilities because it covers long-term care services such as nursing homes and home health care that are not covered by Medicare. The second variant is Medicaid offered as part of the Affordable Health Care Act (ACA). Extending income eligibility and setting national standards would have created a more seamless system of financing for America’s low-income population, but the Supreme Court decision in 2012 allowed states to choose whether or not to participate. At this time, 33 states are participating in the Medicaid expansion. The expansion is being actively considered by 3 more states. At the same time, the Trump administration and 11 states are seeking federal approval to impose new barriers to Medicaid enrollment. © Anthony Krikorian/Shutterstock

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Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations

OBJECTIVES ■■

■■ ■■ ■■ ■■

▸▸

Consider why access to health care is more limited in the United States than other industrialized nations. Explain how Medicaid can be a safety net but not cover all persons who live in poverty. Analyze the critical role Medicaid plays in supporting long-term care for the elderly and disabled. Describe how and why original Medicaid and ACA expansion are different. Describe who remains uninsured and why that matters.

Introduction

Unlike other countries, the United States has created a healthcare system in which access to care is based on social criteria. There is private insurance for many employed members of society and their dependents, although a declining percentage (from 71% in 2009 to 66% in 2014) of the workforce receives employer-based health insurance (Long, Rae, Claxton, & Damico, 2016). The elderly are enrolled in government-sponsored Medicare, covering hospitalization in Part A and doctors in Part B. Having worked throughout their lifetimes, these individuals are viewed as deserving of benefits to which they contributed while employed. The government also pays for the most vulnerable, low-income populations who had been eligible for income support. Historically this has included children, some of their parents, the disabled, and the elderly. With the ACA, government-paid (ACA Medicaid) or assisted (ACA marketplace) coverage has expanded. The different modes of health insurance do not ensure that every American has access to health coverage and health services. There are still large groups in the population who are left out because they are uninsured or underinsured (Kaiser Commission on Medicaid and the Uninsured, 2013b). Among the 27.6 million who were still uninsured at the end of 2015, 46% reported that they could not afford it even with ACA subsidies. In fact, 84% of the people paying the tax penalty for failure to have health insurance made less than $50,000 a year. Even with today’s government program, 5.4 million are still uninsured due to their immigration status,

in addition to the 2.6 million who are very low-­ income residents of one of the states that did not expand Medicaid coverage. In the past, to fill some of the gaps in coverage, a number of federal, state, and local programs were developed to ensure that there was some minimal floor of health care for everyone. Most large cities had at least one large public hospital that cared for the poor (Starr, 1982). In the 1960s a large number of community health centers were built in low-income rural areas, and then in economically disadvantaged urban communities (Sardell, 1988). Public health departments organized clinics for persons with communicable diseases, such as tuberculosis (TB) and acquired immunodeficiency syndrome (AIDS), and other programs for special populations and services, such as school-based care or family planning (Rosenbaum, 2011). The patchwork ways in which access to health care has been defined creates disparities in access and quality of care. People with excellent health insurance and limited out-of-pocket obligations can generally get care from a wide range of providers who participate in their network. However, Medicaid recipients and many people insured through the ACA often have access to smaller lists of providers (known as a “narrow” network) due to the low reimbursement rates that result in nonparticipation. And, of course, uninsured people have only as much access as they can afford to pay out of pocket. Where people live also impacts their health outcomes. Academic medical centers tend to be located in urban areas and make it easier for people needing complex care to access these

Health Outcomes in the United States in Relation to 10 Developed Nations

services than persons who live several hours away (Schwamm, 2014). These differences are further aggravated by differences among states. Although disparities exist between rich and poor, white and black, educated and noneducated, urban and rural, a low-income person in a top-performing state on The Commonwealth Fund scorecard may fare better than advantaged populations in low-performing states (Radley, McCarthy, & Hayes, 2017). This chapter will examine how care is financed for vulnerable populations and the consequences of these organizational choices. The chapter begins with a comparison of the United States to other developed nations. Such a comparison is critical to understanding how the choice to make access dependent on social criteria leads to worse health outcomes. Next the chapter will review the original Medicaid program because it is the primary source of care for many low-­income people. It will consider the populations served by original Medicaid, the high costs of Medicaid, and the significance of Medicaid being a federally mandated and state-implemented program. This means there is no one Medicaid program; rather, there are 50 different programs with 50 sets of outcomes. ACA Medicaid is quite different. While still a state option and state administrated, it includes federally established i­ncome and immigration status criteria and a fixed set of coverages. The discussion would not be complete without an examination of the impact of health insurance coverage on the health of the people being served. And the flip side—the effect of being uninsured on well-being.

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Health Outcomes in the United States in Relation to 10 Developed Nations

Most Americans assume that the United States has the best healthcare system in the world. This is true for many people, but it is also true that

257

millions of Americans receive subpar care. To understand the variance that exists in the United States, a good place to begin is by examining the U.S. in comparison to other developed nations. While there are many differences among these healthcare systems, the fact that the U.S. is the only nation to define access to care based on social classifications impacts both access to and affordability of care. A study of health system performance thus becomes a way to demonstrate the extent to which different modes of access have resulted in disparate outcomes. Every year The Commonwealth Fund conducts a survey of 11 developed nations concerning access and affordability of care. TABLE 12-1 highlights some findings from the 2017 survey. First to consider is the percentage of adults who had problems getting medical care due to cost issues. In the United Kingdom, only 1% of respondents reported cost problems compared to 20% of U.S. respondents. In the U.S., 58% reported not seeing a doctor. The next closest response was 22% in Switzerland. The second indicator to consider is outof-pocket spending. In Sweden, only 4% reported having spent more than $1,000 out of pocket. In the United States, 36% of respondents spent more than $1,000 out of pocket. Interestingly, this percentage does not vary greatly between the insured and the uninsured. Americans are confronted with high out-of-pocket expenses because U.S. mandated out-of-pocket limits exclude many common expenses such as eye glasses, dental, and out-of-network care. High spending did not translate into excellent health outcomes. In fact, 21% of American adults suffered from two or more of five common chronic conditions. Adults in the 10 other countries surveyed were healthier. Canada trailed the U.S. by 5 points, 16%, and the next highest, France, had 12% of adults aged 18 to 64 suffering from two or more common chronic diseases. Nor does the extra spending produce exceptionally better treatment results for breast cancer. The U.S. 5-year relative survival rate is tied for first with Norway and Sweden. Lastly and more tellingly, deaths

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Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations

TABLE 12-1  Adult Access and Affordability of Care in the United States and 10 Other Countries Percentage of adults who:

Nation

Had serious problems paying or were unable to pay medical bills

Had $1,000 or more in out-ofpocket medical spending

Had multiple chronic conditions

5-year breast cancer relative survival rate

Mortality amenable to health care*

Australia

5

16

10

88

62

Canada

6

15

16

88

78

France

23

7

12



61

Germany

4

5

8

86

83

Netherlands

7

7

9

85

72

New Zealand

5

7

9

86

78

Norway

8

13

12

89

64

Sweden

5

4

10

89

69

Switzerland

11

46

10



55

United Kingdom

1

4

10

81

85

United States

20

36

21

89

112

* Deaths per 100,000. Data from Schneider, E.C., Sarnak, D. O., Squires, D., Shah, A., & Doty, M. M. (2017). Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund.

from conditions amenable to health care such as diabetes and appendicitis are much higher in the U.S. than in any of the 10 other countries in the survey. The importance of considering the United States in the context of other developed nations

is to demonstrate the variance that exists and to suggest that the differences can be attributed in part to the complexity of the healthcare system in the United States and the limited access to care due, in part, to the inequitable distribution of health insurance.

Populations Served by Original Medicaid

▸▸

Populations Served by Original Medicaid

Original Medicaid was the primary safety net insurer of low-income persons younger than age 65 years who had no other payer for medical care. It was enacted in 1965. The common assumption was that Medicaid was a program for low-income children and, sometimes, their parents. The reality is that original Medicaid overwhelmingly finances care for disabled and elderly people. Health spending for elderly persons is rarely associated with Medicaid because it is mistakenly assumed that their healthcare services are paid by Medicare. Medicare payments, however, stop at the door of acute care recovery. Thus, the long-term care services needed by low-income elderly are paid by Medicaid. The reasons go back to the original alignment of Medicaid in the 1960s with welfare programs. While medicine and Medicare were limited to the treatment of diseases that could be impacted by the intervention of healthcare providers, Medicaid was understood to be part of the social welfare system that covered a range of services that fall at the intersection of medical care and social services. This included nursing homes, intermediate care facilities, mental health facilities, and home health and personal care (Rosenbaum, 2009). When cash support provided by Social Security was not adequate to cover these services they were classified as a health-related service and thus fell under the eligibility guidelines for Medicaid (Brown & Sparer, 2003). Nonelderly disabled people are also an invisible Medicaid population (Vladeck, 2003). This is a heterogeneous group that has traditionally been served by other state agencies but whose care is increasingly paid for by Medicaid. Included in this group are physically disabled children and adults, developmentally disabled

259

adults, the mentally ill, and persons with AIDS and substance abuse problems. Eligibility rules have changed over time to extend services to larger groups of low-­ income people, but the basic structure of the program remains the same. Children are defined as age 18 years and younger. During the past two decades, income eligibility for this group has been expanded. Adults age 19 to 64 years were originally defined as mothers who receive welfare benefits. This group was extended to include more parents of eligible children, pregnant women, and a small number of people who are eligible through the Breast and Cervical Cancer Prevention and Treatment Act of 2000. The original categorization of the aged, blind, and disabled is now broken into two groups: those aged 65 years and older and disabled, and people younger than age 65 years who have physical, mental, or emotional conditions that prevent them from performing the activities of daily living. In 2010, three-quarters of Medicaid recipients were women and children. With ACA expansion, 43% are children and 34% are adults. Less than 10% of enrollees are elderly, and only 14% are disabled. But the percentage of expenditure is not parallel to enrollment. Children represent nearly half of enrollees but account for only 19% of spending. Even adults account for a smaller percentage of spending than enrollment. Looking at TABLE 12-2 it is obvious that the preponderance of Medicaid expenditures is for services to the disabled and elderly. Spending on the disabled is nearly three times greater than the percentage of disabled people who are enrolled in Medicaid. Disabled individuals account for one in seven enrollees and 40% of Medicaid spending. Spending on the elderly is nearly two times greater than the percentage of elderly (9% of all enrollees and 21% of spending). Taken together, the disabled and elderly are less than one-quarter of enrollees but incur almost two-thirds of program spending.

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Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations

TABLE 12-2  Medicaid Enrollment and Distribution of Payment by Enrollment Group, Fiscal Year 2010 Category

Distribution of Medicaid Enrollees by Enrollment Group

Distribution of Medicaid Payments by Enrollment Group

Aged

9%

21%

Disabled

14%

40%

Adult

34%

19%

Children

43%

19%

Total

100%

100%

Enrollees = 66,390,542

Expenditures = $81,507,921,594

Data from Kaiser Family Foundation (2017, January 3). Retrieved from https://www.kff.org/medicaid/state-indicator/medicaid-spending-by-enrollment-group /?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

▸▸

Original Medicaid Is Different Program in 50 States and Washington, DC

Another common misconception about original Medicaid is that knowing how it works in one state can be generalized to the other 49 states and the District of Columbia. This could not be further from the truth. Medicare, like Medicaid, was enacted in 1965 during Lyndon J­ ohnson’s presidency, and is a federally mandated and operated program of health insurance for the elderly. But Medicaid was linked to public assistance and shared responsibility of financing between the federal government and the individual states that varies in proportion. It was never meant to cover all low-income people. The federal program provided states with general guidance about which populations would be eligible for services and the range of services that states were either mandated or given the

option to provide. The implementation of these guidelines was to be determined by the states. It was assumed that states were in the best position to identify exactly who should receive care, what services would be included in the benefits package, and payment rates for services. During the past half century, Medicaid evolved into 51 different programs in populations served, the services provided, and provider payments. Although more than 60 million Americans received Medicaid prior to implementation of the ACA, only by looking at the evolution of state programs can the vast need for health care of low-income persons be understood. Medicaid eligibility is determined in two ways. Broadly, it covers three distinct populations: low-income elderly, disabled people who receive federally assisted income maintenance through Supplemental Security Income (SSI), and low-income families and children who meet the Modified Adjusted Gross Income (MAGI) standards or live in one of the 36 states or the District of Columbia that offer Medicaid to people whose healthcare expenses have almost ­depleted their assets (‘spend-down’) or reside in

Traditional Medicaid Costs and Variation by State

a state that accepts ACA Medicaid expansion for families earning less than 138% of the current poverty threshold. Medicaid also covers some related groups that do not receive cash assistance but whose income puts them close to the poverty level. These groups include children, pregnant women, certain Medicare beneficiaries, and recipients of adoption and foster care services. Such broad eligibility criteria initially resulted in relatively standard eligibility guidelines across states. When Medicaid was first passed, states covered most eligible persons at income cutoffs close to the poverty line. Over the past 50 years, the income cutoffs dropped to very low levels in many states. When Temporary Assistance to Needy Families (TANF) replaced AFDC in 1996, the U.S. Congress required states to implement a new Medicaid eligibility category for low-income families and set the minimum income standard at the same level as had been in effect in state welfare programs. In most states the income level was so low that many parents who worked at low-paying jobs that did not provide health insurance did not qualify for Medicaid. A year later Congress created the State Children’s Health Insurance Program (SCHIP), which expanded eligibility for low-income children. The unequal nature of eligibility for original Medicaid is demonstrated in TABLE 12-3, which shows income eligibility for Medicaid and SCHIP as a percentage of the federal poverty level in 2018. Federal law required that children age 6 to 18 years be covered at the poverty level, or 100%. However, states had the discretion to extend eligibility to more children. Eighteen states funded children at the poverty level, and three states and the District of Columbia set income eligibility for children at 300% of the poverty level. The remaining 29 states fell somewhere in between. The eligibility levels for working parents are starker. Five states (Arkansas, Alabama, Indiana, Louisiana, and Texas) set eligibility at or below 25% of the federal poverty level. The federal poverty level for a household of three in 2018 was $20,790 (Office of the Assistant Secretary for Planning and Evaluation, 2018). ­Twenty-five percent of the federal poverty level

261

for that same family was $4,881. This means that practically no low-income working parents are ­eligible for Medicaid in these five states. Thirteen states set the income eligibility below 50% of the federal poverty level. Twenty-eight states set the income eligibility below 75% of the federal poverty level, and 33 states set the income eligibility below 100% of the federal poverty level. Only 17 states set the eligibility cutoffs at or above the federal poverty level, with Minnesota setting the cutoff at 215% of the poverty level. The tremendous variation among states regarding income eligibility is inversely related to the number and percentage of working parents who were uninsured by state (Schoen et al., 2013).

▸▸

Traditional Medicaid Costs and Variation by State

Medicaid is also expensive. In fiscal year 2012, it covered over 65 million persons at a cost of $421 billion dollars (Kaiser Commission on Medicaid and the Uninsured, 2013a). The costs of Medicaid are covered by federal, state, and local governments. The federal share is based on average per capita income for each state relative to the n ­ ational average. It ranges from 50% in 14 states (including New York, California, and North ­Dakota) to more than 70% in 10 states and the District of ­Columbia (including Mississippi, West Virginia, and Kentucky) (Kaiser Commission on Medicaid and the Uninsured, 2014). As of 2012, the state and local share for all of Medicaid was $183 billion (45%) of total spending (Martin, Harman, Whittle, Catlin, & National Health Expenditure Team, 2014). Despite federal support, Medicaid is often the largest part of state budgets and it is countercyclical, meaning Medicaid enrollment expands when the economy contracts, which puts state legislatures under tremendous pressure to make cuts to the Medicaid budget in times of fiscal austerity as they seek to lower taxes and control state spending (Sommers & Epstein, 2011).

0%

67%

18%

AL 50%

100%

138%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

NE UT WY SD OK NC VA KS GA FL MS ID MO TX

0%

0%

0%

SC

AL

0%

0%

TN

WI

ME

50%

Childless Adults

100%

100%

138%

Reproduced from Kaiser Family Foundation (2018). Medicaid Income Eligibility Limits for Adults in States That Have Not Implemented the Medicaid Expansion, January 2018. Retrieved from https://www.kff.org /medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2018-findings-from-a-50-state-survey/. Accessed 06/29/18.

Notes: Eligibility levels are based on 2018 federal poverty levels (FPLs) and are calculated based on a family of three for parents and an individual for childless adults. In 2018, the FPL was $20,780 for a family of three and $12,140 for an individual. Thresholds include the standard five percentage point of FPL disregard. OK and UT provide more limited coverage to some childless adults under Section 1115 waiver authority.

18%

TX

22%

26%

ID

MO

27%

MS

33%

36%

GA

FL

38%

38%

KS

43%

NC

VA

43%

60%

63% 55% 50%

OK

SD

WY

UT

NE

SC

98%

TN

105% 100%

WI

ME

Parents

TABLE 12-3  Income Eligibility for Medicaid/CHIP as a Percentage of Federal Poverty Level, 2018

262 Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations

Traditional Medicaid Costs and Variation by State

The higher costs of Medicaid can be attributed to the elderly and disabled. In effect, Medicaid is the safety net for middle-class persons who go bankrupt in old age due to the costs of long-term care. As a result, Medicaid is the major institutional payer for nursing homes and home care. In 2012, Medicaid accounted for 46% of nursing home and 73% of home health or personal care expenditures (Centers for Medicare & Medicaid Services, 2014). Medicare spending accounts for a smaller portion of these expenditures because its payments are limited to acute care and the recovery of persons from incidents associated with these acute episodes. Medicaid, however, is more inclusive because it pays for the long-term care of persons with chronic conditions. Medicaid expenditures also reflect the ways that the 50 states have chosen to define covered services and payment rates. Even though the federal government pays the majority of costs, spending decisions are made at a local level. States have discretion about what optional services to provide in addition to those mandated by the federal government and how to structure payment rates. TABLE 12-4 provides data for the five states that pay the least per beneficiary for Medicaid services and the five states that pay the most per beneficiary by enrollment group. There are tremendous variations among payments by the lowest-paying states and the highest-paying states. The difference is least pronounced for children because they do not use a high volume of expensive healthcare services. Nevada paid $1,523 per child while New Mexico spent $5,136 per child. The larger differentials in payments for services can be found among the elderly and disabled. Georgia had the lowest payment for the elderly ($6,162) and Alaska paid four times more ($25,792). The differences are slightly greater in terms of payments for the disabled: Alabama spent $7,020 per beneficiary and North Dakota $33,765. Low payment rates can impact both access to and quality of services. Many physicians do not accept Medicaid patients because the payment is so low (Zuckerman, McFeeters, Cunningham, &

263

Nichols, 2004). In Princeton, New Jersey, almost no physicians take Medicaid patients (Kitchenman, 2014). This means that children who are eligible for Medicaid in that area cannot easily make an appointment for needed care. Likewise, poor payment rates impact working conditions and the quality of care (Grabowski, Angelelli, & Mor, 2004). Interviews with nursing home aides in Mississippi revealed a situation in which the aides, who are low paid, took it upon themselves to bring food to residents and cover for one another while they took soiled sheets to the laundromat so residents would not lie in their own feces (C. Schoen, personal interview, 2013). Although it is assumed that these institutions meet a minimum standard of care because they are reimbursed by Medicaid, they do not. Low payment also results in perverse incentives where program eligibility can overlap. Such is the case for elderly people who are eligible for Medicare and Medicaid due to their financial circumstances. These persons are referred to as dual eligibles. Regulators are less concerned with the overall cost of a person’s care than with controlling the individual budget for which they are responsible. In the case of dual eligibles, Medicare prefers that Medicaid pay, and Medicaid prefers that Medicare pay, even though the federal government pays most of both expenditures. For nursing homes this means that an elderly patient who has been hospitalized is admitted to the nursing home under Medicare, and Medicare is a good payer. When that person becomes a long-term patient, he or she becomes a Medicaid patient after exhausting personal savings and assets. If the same person is hospitalized, he or she becomes a Medicare patient. Some states put a hold on the bed and Medicaid continues to pay the nursing home for the days that the patient spends in the hospital. When that individual returns to the nursing home, he or she once again becomes a Medicaid patient. The incentives are such that nursing homes are not penalized for hospitalizations. In fact, they are often paid when a resident is hospitalized and then they receive the higher reimbursement rate when that

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Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations

TABLE 12-4  Average Per Capita Medicaid Payments by Enrollment Group, Fiscal Year 2014 Five Lowest Spending States State

Children

State

Adults

State

Elderly

State

Disabled

Nevada

$1,523

Arkansas

$1,446

Georgia

$6,162

Alabama

$7,020

Wisconsin

$1,762

California

$1,803

S. Carolina

$7,051

Georgia

$8,999

Florida

$1,822

Alabama

$2,043

Maine

$7,143

Mississippi

$9,697

Louisiana

$1,933

Nevada

$2,222

Florida

$7.281

Tennessee

$9,826

Washington

$1,969

Louisiana

$2,488

Alabama

$7,987

Kentucky

$10,430

Five Highest Spending States State

Children

State

Adults

State

Elderly

State

Disabled

New Mexico

$5,136

Alaska

$6,893

Alaska

$25,792

N. Dakota

$33,765

Alaska

$5,135

N. Dakota

$6,377

N. Dakota

$24,699

Minnesota

$28,854

District of Columbia

$4,442

Washington

$6,018

Delaware

$21,225

Alaska

$28,388

N. Dakota

$4,370

Delaware

$6,011

New York

$20,888

Rhode Island

$25,936

Delaware

$3,977

Tennessee

$5,882

Pennsylvania

$20,787

New York

$24,905

Data from Kaiser Family Foundation, June 9, 2017. Retrieved from https://www.kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee /?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

same resident is discharged back to their care (Schoen, October 20, 2013). Even with generally lower reimbursement rates, people with Medicaid still had much better access to care than the uninsured. There is a growing body of evidence that Medicaid coverage matters. One researcher tracked children in the earliest Medicaid cohort. Looking at the group first enrolled between 1965 and 1970, Andrew

Goodman-Bacon documented extremely meaningful life differences—particularly in longevity and in lifetime earnings. Another study found that age-adjusted mortality in states with more generous eligibility standards was significantly better than the same statistic in states with less inclusive eligibility. A paper published in 2012, comparing adult (20–64 years of age) mortality in three expansion states (Arizona, Maine,

ACA Medicaid

and New York) with neighboring nonexpansion states, found a difference of 19.6 deaths per 100,000. The authors concluded, “Policy makers should be aware that major changes in ­Medicaid—either expansions or reductions in coverage—may have significant effects on the health of vulnerable populations” (Sommers, Baicker, & Epstein, 2012).

▸▸

ACA Medicaid

The expansion of Medicaid is a linchpin of the ACA. With its passage, Congress changed Medicaid from a 50-state checkerboard of eligibility rules to a single national standard for very-low-income legal residents. The ACA ensured that any uninsured adult living in a family with an income less than 138% of the poverty line would be entitled to coverage ($16,643 for an individual and $33,948 for a family of three in 2017). About $1.028 trillion was budgeted to be spent over 10 years to enroll an expected 21.3 million new Medicaid and SCHIP recipients. The federal government was directed to fund 100% of the cost of expansion through 2016, and 90% after that. Depending on the state option, newly eligible people would receive the same benefit package as the state’s traditional Medicaid program or a special expansion package, but in no case may the benefits be less than the 10 essential benefits offered on healthcare exchanges to other ACA participants. The program as described was cut short by a U.S. Supreme Court decision in 2012. Twenty-four states joined a petition filed by Florida challenging the constitutionality of the ACA’s Medicaid expansion. If a state wished to continue to receive the traditional federal funding match for its Medicaid program according the ACA, it was required to accept the expansion—funding, eligibility, and benefit design. In a variety of split decisions, the Supreme Court found that the requirement was a coercive overstep of federal authority and declared that linking current funding with future funding was unconstitutional. Rather than the Medicaid expansion being mandatory,

265

the court made it optional. Each state was permitted to decide whether to participate (Jost & Rosenbaum, 2012). As of June 2018, 33 states plus Washington, DC had opted into the Medicaid expansion, 3 are considering expansion, and 14 have not adopted ACA Medicaid (Kaiser Family Foundation, June 2018) (FIGURE 12-1). The Trump administration has encouraged states to seek waivers that would ­permit new eligibility restrictions for enrollment in ­either traditional Medicaid, ACA Medicaid, or both. As of June 2018, 11 states have sought approval of work requirements—4 have been approved and 7 are pending for both Medicaid and ACA Medicaid. While only an estimated 4–6% of participants would be disqualified by work requirements, there is concern among analysts that these new qualifications and their attendant r­ equired documentation will effectively discourage a significant number of qualified applicants ­(Garfield, Rudowitz, Musumeci, & Damico, 2018). About 12 million people are enrolled in Medicaid. But 2.4 million are caught in a coverage gap (FIGURE 12-2). They are deemed too low income to pay any part of a premium for subsidized private coverage, and they are categorically ineligible for help from the state in which they live. Although the court made expansion a state option, it left in place a number of ACA elements that are designed to impact the way care is provided to both insured and uninsured persons (Hess & Witgert, 2012). Among the most important is new models of integrated care, ­including accountable care organizations (ACOs), Community Care Networks, significantly increased support for community health centers, support for research and publication of quality standards and report cards, substantial support for workforce training, and greater support for the National Health Service Corps (Riley, Berenson, & Carmody, 2012). Since the coverage expansion part of the ACA has been in place for only 4 years, findings about effects are still preliminary. However, some impacts are known on financial security, coverage,

FIGURE 12-1  Status of State Action on the Medicaid Expansion Decision as of June 12, 2018 Reproduced from Kaiser Family Foundation. (2018). Current status of state Medicaid expansion decisions. Retrieved from https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding -medicaid-under-the-affordable-care-act/?activeTab=map¤tTimeframe=0&selectedDistributions=current-status-of-medicaid-expansion-decision&selectedRows=%7B%22wrapups%22:%7B %22united-states%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

care, utilization, affordability, and health outcomes that can be measured. Unpaid medical bills are a leading cause of bankruptcy. While still the case, the number fell by 50% between 2010 and 2016 (St. John, 2017). With 20 million more individuals with health insurance, the nation’s uninsured rate has declined by nearly 20% to 11.7% (Auter, 2017). There is some compelling preliminary evidence that increased access to health care has resulted in better health outcomes (Antonisse, Garfield, Rudowitz, & Artiga, 2017). Despite fears of an overburdened health system, there are no ­reports of negative consequences such as increased wait times for appointments. The sum of the evidence is positive (Mazurenko, 2018).

▸▸

Who Is Left Out

The uninsured in 2017 look very much like the uninsured before the ACA—disproportionately low income, young, and people of color.

The principal difference is that their numbers are much diminished. Most of the 26 million who remain uninsured are low income or near low income. (Congressional Budget Office, 2017). Eight in 10 of the uninsured live in families with incomes below 300% of the poverty line ($61,260 for a family of three). They are divided almost equally among the three income cohorts. First are the 26% who live below the poverty level and would be income eligible for Medicaid. Nearly 3 million of the low-income uninsured are residents of states that did not expand Medicaid. Others are low-income undocumented families who are ineligible for either Medicaid or ACA marketplace subsidies. The second, equally large group (27% of uninsured) live in families with incomes between 100% and 200% of the federal poverty line, and the last group (28%) are members of families between 200% and 300% of the federal poverty standard. While all would be income eligible for federal assistance, half reported that the coverage was too expensive. Some are ineligible because of their immigration status.

Health Insurance and the Health of Vulnerable People

267

Medicaid eligibility thresholds and coverage gaps by state by income for a family of 3 in 2017 $50,000 $40,320 200% poverty

$45,000 $40,000 $35,000 $30,000

$23,190 100% poverty

$25,000 $20,000 $15,000 $10,000 $5,000

Al

ab

am a Te M xa is s so ur Id i ah M is si o ss ip Fl pi or G ida eo rg Ka ia ns a N or Vir s th gin Ca ia O rolin kl ah a om So a U ut h tah Da W kot yo a m N So e ing ut bra h Ca ska Te rol nn ina es W s Ex pa isc ee ns on si io n n st at es

$0

Medicaid

Gap

ACA subsidy

FIGURE 12-2  Medicaid Eligibility Thresholds and Coverage Gaps by State by Income for a Family of Three in 2017 Data from Kaiser Family Foundation. (March 15, 2017). Retrieved from https://www.kff.org/medicaid/fact-sheet/where-are-states-today-medicaid-and-chip/

Three-quarters of the uninsured live in families with at least one full-time worker; another 11% have at least one part-time worker. White Americans are the largest uninsured group (45%) followed by Hispanic (32%), black (15%), and other race (8%) (Kaiser Family Foundation, September 2017).

▸▸

Health Insurance and the Health of Vulnerable People

Since the very early days, local, state, and federal governments have grappled with ways to provide

care for those who cannot afford or cannot access care for themselves. The United States began down the road of universal, one-class care with provisions of the Social Security Act, which not only identified the elderly as a special needs group, but also identified a number of other special needs populations, including mothers and children, the disabled, and the blind. Since 1935 the nation has come a long way in creating a floor for all its citizens, but, as is evident from passage of the ACA, its rocky implementation, and the debate about repeal, there is still a long way to go. As we learn more about the social dimensions of health, good medical services are recognized as one of the best ways to counteract the ravages of poverty, racism, homelessness, and unemployment. Yet many Americans victimized by

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Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations

these scourges are the very people whose access to care is most fragile. The remaining uninsured are disproportionately low income or near low income, nonwhite, the young, and adults with chronic conditions. Only children have nearly universal coverage. With Medicaid and SCHIP covering 40% of American children, their uninsured rate is about 5%. Insurance matters. It makes access possible. In the U.S. today, 54% of the uninsured report no usual source of care, and 20% said they went without needed care due to cost. It reduces financial hardship. And perhaps, most importantly, the uninsured have much worse health outcomes. In 2002 the nation’s Institute of Medicine estimated the lack of insurance caused 18,000 deaths a year. In 2008, the Urban Institute updated the methodology and estimated that lack of insurance was responsible for 22,000 deaths (Dorn, 2008). ­After 3 years of ACA implementation, one in six low-­income or near-low-income (under 200% p ­ overty) adults is still uninsured and vulnerable (Barnett & ­Vornovitsky, 2016). In his very last speech, at the dedication of a new building for the U.S. Department of Health and Human Services (at the time it was the Department of Health, Education, and Welfare), former Vice President and Senator Hubert H. Humphrey said, “The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life, the sick; the needy and the handicapped.” Those words are now inscribed in the portal of the building as a reminder to each of us about what a society owes its citizens.

Discussion Questions 1. 2. 3.

What does it mean to say original Medicaid is 50 different programs? How is ACA Medicaid different than other Medicaid programs? In what ways do financing mechanisms for the care of vulnerable populations contribute to a two-class care system?

4. 5.

Why does insurance matter? Which group or groups of people still have inadequate insurance coverage?

References Antonisse, L., Garfield, R., Rudowitz, R., & Artiga, S. (2017, February). The effects of Medicaid expansion under the ACA: Updated findings from a literature review. Issue Brief. Kaiser Family Foundation. Retrieved from http:// files.kff.org/attachment/Issue-brief-The-Effects-of -Medicaid-Expansion-under-the-ACA-Findings-from -a-Literature-Review Auter, Z. (2017, July 10). U.S. uninsured rate rises to 11.7%: Q2 2017. Gallup Tracking Poll. Retrieved from http://www.gallup.com/poll/213665/uninsured-rate -rises.aspx Barnett. J. C., & Vornovitsky, M. S. (2016, September). Health insurance coverage in the United States, 2015. U.S. Census. Retrieved from https://www.census.gov /library/publications/2016/demo/p60-257.html Brown, L. D., & Sparer, M. S. (2003). Poor program’s progress: The unanticipated politics of Medicaid policy. Health Affairs, 22(1), 31–44. Centers for Medicare & Medicaid Services. (2014). National health expenditures by type of service and source of funds, CY 1960–2012. Retrieved from http://www.cms. gov/Research-Statistics-Data-and-Systems/Statistics -Trends-and-Reports/NationalHealthExpendData /NationalHealthAccountsHistorical.html Congressional Budget Office (CBO). (2017, March 9). American Health Care Act Budget Reconciliation: Recommendations of the House Committees on Ways and Means and Energy and Commerce. Dorn, S. (2008). Uninsured and dying because of it: Updating the Institute of Medicine analysis on the impact of uninsurance on mortality. The Urban Institute. Retrieved from http://www.urban.org/sites/default/ files/publication/31386/411588-Uninsured-and-DyingBecause-of-It.pdf Garfield, R., Rudowitz, R., Musumeci, M., & Damico, A. (2018). Implications of work requirements in Medicaid: What does the data say? Kaiser Family Foundation Issue Brief. Retrieved from https://www.kff.org/medicaid /issue-brief/implications-of-work-requirements-in -medicaid-what-does-the-data-say/ Goodman-Bacon, A. (2016, January 1). The long-run effects of childhood insurance coverage: Medicaid implementation, adult health, and labor market outcomes. NBER Working Paper Series, 22899. Retrieved from http://www.nber .org/papers/w22899.pdf Grabowski, D. C., Angelelli, J. J., & Mor, V. (2004). Medicaid payment and risk-adjusted nursing home quality measures. Health Affairs, 23(5), 243–252. Retrieved from http:// content.healthaffairs.org/content/23/5/243.full

References Hess, C., & Witgert, K. (2012, January 12). Toward meeting the needs of vulnerable populations: Issues for policymakers’ consideration in integrating a safety net into health care reform implementation. Washington, DC: National Academy for State Health Policy. Retrieved from http:// www.nashp.org/sites/default/files/safety.net_.hcr_.pdf Jost, T. S., & Rosenbaum, S. (2012). The Supreme Court and the future of Medicaid. New England Journal of Medicine, 367, 983–985. Retrieved from http://www .nejm.org/doi/full/10.1056/NEJMp1208219 Kaiser Commission on Medicaid and the Uninsured. (2013a). Medicaid enrollment, 2012 data snap shot. Issue Brief. Kaiser Family Foundation. Retrieved from http://kaiserfamilyfoundation.files.wordpress .com/2013/08/8050-06-medicaid-enrollment.pdf Kaiser Commission on Medicaid and the Uninsured. (2013b). The uninsured: A primer—Key facts about insurance on the eve of health reform. Retrieved from http://kaiserfamilyfoundation.files.wordpress. com/2013/10/7451-09-the-uninsured-a-primer-key -facts-about-health-insurance.pdf Kaiser Commission on Medicaid and the Uninsured. (2014). Federal and state share of Medicaid spending: Timeframe 2012. Kaiser Family Foundation. Retrieved from http://kff.org/medicaid/state-indicator/federalstate -share-of-spending/ Kaiser Family Foundation. (n.d.). Status of Medicaid expansion as of June 7, 2018. Retrieved from https://www.kff.org /health-reform/state-indicator/state-activity-aroundexpanding-medicaid-under-the-affordable-care-act /?activeTab=map¤tTimeframe=0&selected Distributions=current-status-of-medicaid-expansion -decision&sortModel=%7B%22colId%22:%22Location %22,%22sort%22:%22asc%22%7D Kaiser Family Foundation. (2017, January 3). Current status of Medicaid expansion decisions. Retrieved from http://www.kff.org/health-reform/slide/current -status-of-the-medicaid-expansion-decision/ Kaiser Family Foundation. (2017, March 15). Where are states today? Medicaid and CHIP eligibility levels for children, pregnant women, and adults. Retrieved from http://www.kff.org/medicaid/fact-sheet/where -are-states-today-medicaid-and-chip/ Kaiser Family Foundation. (2017, June). Medicaid pocket primer. Retrieved from http://www.kff.org/medicaid /fact-sheet/medicaid-pocket-primer/ Kaiser Family Foundation. (2017, June 9). Medicaid spending by enrollment group. Retrieved from http://www.kff.org/medicaid /state-indicator/medicaid-spending-by-enrollment-group/ Kaiser Family Foundation. (2017, September 19) Key facts about the uninsured population. Retrieved from http://www.kff.org/uninsured/fact-sheet/key-facts -about-the-uninsured-population/ Kaiser Family Foundation. (2018). Medicaid income eligibility limits for adults as a percent of the federal poverty level. Retrieved from https://www.kff.org/health-reform

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/state-indicator/medicaid-income-eligibility-limits -for-adults-as-a-percent-of-the-federal-poverty-level /?currentTimeframe=0&sortModel=%7B%22colId %22:%22Location%22,%22sort%22:%22asc%22%7D Kaiser Family Foundation. (2018). Medicaid waiver tracker: Which states have approved and pending section 1115 Medicaid waivers. Retrieved from https://www.kff.org /medicaid/issue-brief/which-states-have-approved-and -pending-section-1115-medicaid-waivers/ Kitchenman, A. (2014, April 23). Profile: Princeton economist makes national mark with insights on health care. New Jersey Spotlight. Retrieved from http://www.njspotlight .com/stories/14/04/19/profile-princeton-economist -makes-national-mark-with-insights-on-healthcare -issues/ Long, M., Rae, M., Claxton, G., & Damico, A. (2016, March). Trends in employer-sponsored insurance offer and coverage rates: 1999–2014. Kaiser Family Foundation. Retrieved from http://www.kff.org/private-insurance /issue-brief/trends-in-employer-sponsored-insurance -offer-and-coverage-rates-1999-2014/ Martin, A. B., Harman, M., Whittle, L., Catlin, A., & National Health Expenditure Team. (2014). National health spending in 2012: Rate of health spending growth remained low for the fourth consecutive year. Health Affairs, 33(1), 67–77. Mazurenko, O., Balio, C. P., Agarwal, R., Carroll, A. E., & Menachemi, N. (2018). The effects of Medicaid expansion under the ACA: A systematic review. Health Affairs, 37(6), 944–950. Office of the Assistant Secretary for Planning and Evaluation. (2018). U.S. federal poverty guidelines used to determine financial eligibility for certain federal programs. Retrieved from https://aspe.hhs.gov/poverty-guidelines Paradise, J. (2017, March 23). Three findings about access to care and health outcomes in Medicaid. Data Note. Kaiser Family Foundation. Retrieved from http://www.kff.org /medicaid/issue-brief/data-note-three-findings-about -access-to-care-and-health-outcomes-in-medicaid/ Radley, D. C., McCarthy, D., & Hayes, S. L. (2017). Aiming higher: Results from The Commonwealth Fund scorecard on state health system performance. Retrieved from https://doi.org/10.15868/socialsector.26933 Riley, P., Berenson, J., & Carmody, C. (2012). How the Affordable Care Act supports a high-performance safety net. New York, NY: The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/Blog/2012 /Jan/Affordable-Care-Act-Safety-Net.aspx Rosenbaum, S. (2009). Medicaid and national health reform. New England Journal of Medicine, 361, 2009–2012. Retrieved from http://www.nejm.org/doi/pdf/10.1056 /NEJMp0909449 Rosenbaum, S. (2011). Medicaid and access to health care—a proposal for continued inaction? New England Journal of Medicine, 365, 102–104. Retrieved from http://dx.doi .org/10.1056/NEJMp1106046

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Sardell, A. (1988). The U.S. experiment in social medicine: The community health center program, 1965–1986. Pittsburgh, PA: University of Pittsburgh Press. Schneider, E. C., Sarnak, D. O., Squires, D., Shah, A., & Doty, M. M. (2017). Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. New York, NY: The Commonwealth Fund. Retrieved from http://www.commonwealthfund .org/interactives/2017/july/mirror-mirror/ Schoen, C. (2013, October 20). Personal interview. Schoen, C., Osborn, R., Squires, D., & Doty, M. (2013). Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Affairs, 32(12), 1–11. Schoen, C., Radley, D., Riley, P., Lippa, J., Berenson, J., Dermody, C., & Shih, A. (2013). Health care in the two Americas. New York, NY: The Commonwealth Fund. Schwamm, L. H. (2014). Telehealth: Seven strategies to successfully implement disruptive technology and transform health care. Health Affairs, 33(2), 200–206. Sommers, B. D., & Epstein, A. M. (2011). Why states are so miffed about Medicaid—economics, politics, and the

“woodwork effect.” New England Journal of Medicine, 363, 2085–2087. Retrieved from http://www.nejm.org /doi/pdf/10.1056/NEJMp1104948 Sommers, B. D., Baicker, K., & Epstein, A. M. (2012, September 13). Mortality and access to care among adults after state Medicaid expansion. New England Journal of Medicine, 367, 1025–1034. St. John, A. (2017, May 2). How the Affordable Care Act drove down personal bankruptcy. Consumer Reports. Retrieved from https://www.consumerreports.org/personal-bankruptcy /how-the-aca-drove-down-personal-bankruptcy/ Starr, P. (1982). The social transformation of American medicine. New York, NY: Basic Books. Vladeck, B. (2003). Where the action really is: Medicaid and the disabled. Health Affairs, 22(1), 252–258. Zuckerman, S., McFeeters, J., Cunningham, P., & Nichols, L. (2004). Changes in Medicaid physician fees, 1998–2003: Implications for physician participation. Health Affairs, W4, 374–384. Retrieved from http://content.healthaffairs .org/content/early/2004/06/23/hlthaff.w4.374.full .pdf+html?sid=570a9424-22cb-4a02-98bb-5cdd10682f02

Case Study

CASE STUDY

Veronica D. Feeg and Jennifer E. Mannin The Affordable Care Act (ACA) of 2010 enacted major reforms intended to expand access for all citizens to insurance, increase consumer protections, emphasize prevention and wellness, improve quality and system performance, expand the health workforce, and curb rising healthcare costs. It expanded Medicaid eligibility in some states and promoted a number of innovative payment and delivery system reforms—including patient-centered medical homes—for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) (Davis, Abrams, & Stremikis, 2011). Along with the new emphasis on Medicaid expansions, and the growing attention to controlling cost and preserving quality that have been examined by policymakers, Medicaid in general and programs for children specifically brace for the impact of the changing regulatory environment and political bickering striving to seek common ground solutions. Policymakers recognize that the shift from Medicaid fee-for-service (FFS) plans to Medicaid managed care is likely to have the most profound impact on low-income children, since children and youth with disabilities and special healthcare needs (CYSHCN) represent 13% to 15% of the U.S. population (Palfrey et al., 2010), and this group must rely on a wide array of physicians and specialty care services (Fox & McManus, 1998).

Shift to Medicaid Managed Care Over the years of moving Medicaid beneficiaries into capitated managed care (MC) plans, policymakers were slower to require low-income CYSHCN to enroll in capitated MC plans due to the uncertainty of the financial incentives in controlling costs and the possibility of adverse effects.

However, advantages have begun to emerge in the availability of care coordination services to assist families in navigating the healthcare system (Rosenbach & Young, 2000) and children with case managers in capitated systems appear to fare better than children in a FFS plan whose families must coordinate care without support (Mitchell & Gaskin, 2004). In the study by Mitchell and Gaskin (2004), the percentage of caregivers who reported problems of access was significantly higher for children in FFS Medicaid (18% to 29%) than it was for children enrolled in the capitated managed care plan. From these studies, the advantages appear to indicate that states who face the high cost of care for CYSHCN can manage their population costs through these MC capitated plans without impact on access. Proponents of this alternative to FFS for Medicaid SSI–eligible children in these times of tumultuous political debate around overhauling Medicaid are pointing to the differences in the value of coordinating care needs of children with complex problems (Mershon, 2016) and the discussions related to how the bills should align incentives, payment structure, and quality measures. Case managers serve families by linking them to necessary health services and community resources that facilitate access to needed services. In a study by Roberto, Mitchell, and Gaskin (2005), children with special needs who receive Supplemental Security Income (SSI) due to disability who are enrolled in FFS Medicaid plans were significantly more likely to encounter an access problem. In another study in Washington DC by Mitchell and Gaskin (2005), children with birth defects, chronic conditions, and/or more limitations of daily living were more likely to enroll in FFS, but more likely to have a general unmet need than children enrolled in the capitated managed plan of Health Services for Children with Special Needs (HSCSN), the comparison group with a partially capitated MC plan. Caregivers whose children were enrolled in HSCSN were significantly less likely to report that their special needs child experienced any unmet need, an unmet need for medical equipment or supplies, an unmet need for prescription drugs, or an unmet need for dental services. They speculated that the case management services available under the plan account for the differences. Case managers are registered nurses, social workers, and other

CASE STUDIES

Alternative Managed Medicaid for Supplemental Security Income (SSI)–Eligible Population of Children with Special Needs in Washington, DC

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Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations: A Story of Misconceptions

CASE STUDIES

health professionals with experience working with CYSHCN. They schedule appointments; arrange for transportation; serve as a link between primary care physicians, specialty providers, and the family; and coordinate services from the District of Columbia (DC) public schools.

Health Services for Children with Special Needs Health Services for Children with Special Needs (HSCSN) is a voluntary Medicaid managed care plan in Washington DC designed specifically for children receiving SSI. Since 1996, the DC has contracted with HSCSN, a nonprofit managed care organization, to administer the program, which differs from other state Medicaid MC plans that carve out certain services to the FFS sector. HSCSN provides a comprehensive set of services to enrollees, including primary and specialty care, mental health treatment, and numerous other family support services through the entire Health Services for Children (HSC) system (Roberto, Mitchell, & Gaskin, 2005). With over 5,000 members today, HSCSN is reimbursed on a per-member, per-month (PM/PM) basis that funds the program to pay providers, the costs of case management and outreach, and other related expenses. HSCSN and DC Medicaid have also established a reconciliation process at the end of each year that is negotiated to share a specified risk if the capitation payments set aside or related direct costs are widely discrepant. Although the plan remains at risk for its administrative expenses, the amount of risk it assumes for direct costs for services has been significantly reduced (Roberto, Mitchell, & Gaskin, 2005). The Health Services for Children (HSC) Health Care System is a unique health system that is committed to helping disadvantaged individuals suffering from disability and/or chronic illness to improve access to health and social services. The system is comprised of HSCSN, HSC Home Care (which includes a residential care health service), HSC Foundation, HSC Pediatric Center, and most recently the National Youth Transition Center (NYTC). In addition to serving individuals and families in the Washington DC area, HSC participates in local, regional, and national projects aimed at improving the future of those with special needs. Beginning as a children’s home accommodating only six children, the Health

Care System today has expanded exponentially to provide services to approximately 6,000 special needs children and families (HSC Health Care System, 2014). HSCSN provides care coordination for individuals who suffer from chronic disabilities and complex medical needs from birth to age 26. Over the past 20 years, HSCSN’s delivery model has evolved in a changing environment, sustaining the commitment and focus on social determinants of health. Today this focus on the social and physical environments that promote good health is comprised of the following model components: (1) a broad scope of Medicaid managed care that incorporates preventive, primary, acute, chronic and long-term care services; (2) family-centered care with a real commitment to care management; (3) continuity of care facilitated by 24-hour access to care coordination; (4) intensive outreach services, including respite care, transportation, and medically necessary home modifications; and (5) integration of health, mental health, and social support. The services are specified in the DC Department of Health Care Finance (see BOX 12-1). Individuals who are currently receiving Supplemental Security Income (SSI), are eligible to receive SSI, are in foster care, or qualify under the Katie Becket waiver may voluntarily choose HSCSN as an alternative to the traditional Medicaid fee-for-service (FFS) plan. This publicly funded managed care model of insurance for children effectively meets the needs of a particularly disadvantaged population in the District of Columbia while keeping costs in balance with services. The plan has pursued prudent growth and operational reinvention to ensure continuing benefit in an ever-changing environment and as a contributing partner with other organizations supporting the disability community (HSC Health Care System, 2014). Recruitment and retention of enrollees is a function of outreach. Each month the Department of Health Care Finance generates a list of those eligible for membership. Outreach sends letters and makes home visits to recruit and retain members. In addition to recruitment and retention, the HSCSN Outreach program offers an array of free services available to all community children and their caregivers. These programs include sports for the children, overnight camping weekends, and support groups for caregivers. One of these

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BOX 12-1  Services Offered to HSCSN Members

Reproduced from Department of Health Care and Finance. (2014). Health Services for Children with Special Needs, Inc. Retrieved from https://dhcf .dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/HSCSN_FACT_SHEET.pdf

programs, the Male Caregivers Advocacy Support group (MCAS) is nationally recognized. Each enrollee is assigned a dedicated care manager who coordinates a wide array of services

including, but not limited to, medical, dental, behavioral, occupational, social, and educational services. HSCSN offers all the Medicaid FFS benefits plus 16 additional coordinated benefits, including

CASE STUDIES

24-hour customer care service Appointment scheduling support Behavioral and development treatment services Dental care Dental and medically necessary orthodontia services Drug and alcohol treatment Doctor visits Early and periodic screening, diagnostic, and treatment (EPSDT) incentive program Early intervention programs Emergency care Family planning Feeding programs Health call telephone link Health education services Healthy living center Home health care Home health nursing and personal care services Hospice care Hospital stays Immunizations Labor and delivery Laboratory and X-ray services Lead testing Mental health services Medically necessary home modifications Medical supplies and equipment Nutritional supplements Parent support program Personal care coordination for all members Physical, occupational, and speech therapy Prenatal care Prescription medicine Outreach services to families and communities Respite care School physicals Transportation to appointments Vision care and glasses Youth and adult wellness Youth athletic program

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CASE STUDIES

168 hours of respite care every 6 months, skilled nursing care, crisis management, appointment scheduling, and transportation. TABLE 12-5 lists the expanded benefits offered by HSCSN as compared

to those benefits offered by traditional Medicaid fee-for-service plans. It is this breadth of services and specialized care coordination that truly sets HSCSN apart from other plans.

TABLE 12-5  Comparison of Medicaid FFS and HSCSN Benefits Medicaid FFS Benefits

HSCSN Benefits: All Services Covered by Medicaid FFS Plus:

Doctor visits

Care coordination planning

Immunizations

Case management

School physicals

Home modification (limited benefit)

Emergency care

Respite care

Hospital stays

Telephone link for health calls

Prescription medications

Feeding programs

Prenatal care

Expanded durable medical equipment and supplies

Labor and delivery

Nutritional supplementation

Vision care and glasses

Home health nursing services

Early intervention school programs

Community-based mental health, behavioral, and developmental treatment services

Family planning

Outreach services to families and communities

Transportation to appointments

Appointment scheduling support

Home health care

Long-term care nursing and facility care

Medical equipment and supplies

Residential treatment

Mental health services

Skilled nursing

Drug and alcohol treatment

Case Study

HSC Health Care System Under the Leadership of Tom Chapman

According to Tom Chapman (2015), recent past president and chief executive officer (CEO) for the HSC Foundation and the HSC Health Care System, social determinants such as poverty, substandard housing, poor nutrition, and undesirable social and environmental conditions are strongly influential factors in many minority communities and may heavily contribute to poor outcomes. Researchers have reported that 15% to 20% of families living below the poverty level in most urban communities are one-third more likely to have a child with special needs in their family (Chapman, 2015), and there are documented disparities in childhood chronic illnesses for Hispanic and black children across many clinical conditions (Berry, Bloom, Foley, & Palfrey, 2010; Chapman & Tait, 2010). As part of his tenure as president and CEO, Tom Chapman influenced the HSC Health Care System’s identity with the issues associated with transitions from institutional to home and community care, from avoidable treatment to prevention, and dependence to independence. As an extension to this, the HSC Foundation has organized many of its programs and those of its 50 partners into a systematic approach to youth transition, launching the National Youth Transitions Center in DC, a partnership with programs designed to provide expert youth transition services. Under Chapman’s leadership for more than a decade, the system has been transformed into the region’s premier special needs human services delivery system for the local community and for its national partners, as all parts of the HSC Health Care System contribute to the well-being of the disadvantaged member stakeholders. He believes

that as the medical miracles of neonatal intensive care units (NICU) increase—those preemies who would not have survived in the past—so too are the challenges of coordinating their multiple needs, especially in low-income communities of families often ill prepared to manage complex responsibilities. His 20 years of leading the care coordination services of HSCSN have taught him that severely, chronically ill children can be 15 times more expensive than TANF (Temporary Aid to Needy Families) beneficiaries. HSCSN members can cost up to $50,000 a year for their total care needs. Despite the societal challenges these children represent, with social, psychological, and transition support they can achieve good outcomes and can thrive in communities. Without services, they will become future economic and social burdens as government dependents. He believes that governments must consider the big picture and long-term consequences as they plan future resource allocation—particularly as the number of children who rely on Medicaid continues to outpace the growth of coverage for those who need it (Chapman, 2015). Studies have identified disparities in services for children who are publicly insured versus children who are privately insured. The findings indicate that this disparity is due to pediatric specialty providers’ nonacceptance of public insurance (Bisgaier & Rhodes, 2011). Concomitantly, in many managed care plans that involve payment capitation, the neediest patients often suffer from a restriction of services due to the high cost of their care (Mitchell, Gaskin, & Kozma, 2008). HSCSN addresses both of these concerns with a capitated system that is both fiscally and medically accountable to the DC government, focusing only on the care coordination of children with complex health and behavioral needs and continuously monitoring the services rendered, member satisfaction, and costs associated with care. As a result, they offer expanded benefits and services, cover more care, and have fewer unmet needs among their enrollees (Mitchell & Gaskin, 2004). As the threats to Medicaid funding grow and states seek fiscally responsible service delivery methods in a compassionate way, and as the managed care Medicaid model with its capitated formulas becomes more prominent in the coming years, it will continue to be important for all healthcare providers who care about their

CASE STUDIES

Courtesy of Thomas W. Chapman

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patients and families to keep a close eye on quality. Members of HSCSN are assessed routinely. Quality outcomes for the plan are measured and reported annually. HSCSN is accredited by the National Committee for Quality Assurance (NCQA), certified according to the Health Effectiveness Data and Information Set (HEDIS), and outperforms others in customer satisfaction according to the Consumer Assessment of Healthcare Providers and Systems (CAHPS). HSCSN is a model program serving a unique population of children with special needs and their families, and as such may serve as a national exemplar from which others may learn. According to Tom Chapman: “We can make the case that HSCSN is a good steward—we are aware of our responsibility to ensure that we make the money go as far as it can. We maximize the benefit of service to people; as we look back at the numbers over 25 or 30 years, we basically have overseen a breakeven close to a 1½% margin program. While it is not an insurance program geared towards being discriminatory about the services we offer, the utilization has come down over the years and I think we’re doing a better job. Access is up, satisfaction is high, and we’re doing a better job” (Personal interview with Chapman, 2017).

Case Study Questions 1. How does a fee for service (FFS) model differ from a managed care (MC) approach to publicly funded services from the patients’ perspective? Are these comparable in the private insurance market? 2. What aspects of service delivery are key considerations for states to finance and/or regulate healthcare systems in the Medicaid system? 3. Which vulnerable groups might be the most severely affected if Medicaid becomes state-only financed with block grants? How might state policymakers offer reductions to financing healthcare delivery through regulation or adjustments in eligibility, preserving their commitment to containing costs while preserving quality? How might the approaches differ for political groups? 4. Consider the following situation: Malcolm is a 2-year-old child who spent his first year of life in the hospital following his premature delivery and multiple complications. What are his long-term needs from a nursing or

health provider point of view? What is the long-term financial impact on a publicly financed health system? Compare the positives and negatives of a managed care (MC) approach with a fee-for-service (FFS) approach related to social impact, clinical aspects of Malcolm’s care, and the public (Medicaid) or private (private insurance) financing ramifications. 5. What advantages are maximized with care coordination underlying healthcare delivery in a capitated system for providers? Families? Payers?

References Berry, J., Bloom, S., Foley, S., & Palfrey, J. (2010). Health inequity in children and youth with chronic health conditions. Pediatrics, 126(6 S3), S111–S119. Bisgaier, J., & Rhodes, K. V. (2011) Auditing access to specialty care for children with public insurance. New England Journal of Medicine, 364(24), 2324–2333. Chapman, T. W. (2017, March 28). Personal interview. Chapman, T. W. (2015, September 11). Guest commentary: Addressing the long-term needs of medical miracles. Modern Health Care, Crain Communications, Inc. Retrieved from http://www.modernhealthcare.com /article/20150911/NEWS/150919978 Chapman, T. W., & Tait, F. (2010). What will open the doors for children and youth with special health care needs from traditionally underserved communities? Pediatrics, 126, S194–S196. Davis, K., Abrams, M., & Stremikis, K. (2011). How the Affordable Care Act will strengthen the nation’s primary care foundation. Journal of General Internal Medicine, 26(10), 1201–1203. Fox, H., & McManus, M. (1998). Improving state Medicaid contracts and plan practices for children with special needs. Future of Children, 8(2), 105–118. HSC Health Care System, Inc. (2014, October). A care coordination model for at-risk children with disabilities. Washington DC: Author. Mershon, E. (2016, July 11). Medicaid overhaul focused on children is pared back. Washington Health Policy Week in Review, New York, NY: The Commonwealth Fund. Retrieved from http:// www.commonwealthfund.org/publications/newsletters /washington-health-policy-in-review/2016/jul/july-11-2016 /medicaid-overhaul-focused-on-children-is-pared-back Mitchell, J., & Gaskin, D. (2004) Do children receiving Supplemental Security income who are enrolled in Medicaid fare better under fee-for-service model or a comprehensive coordination model? Pediatrics, 114(1), 196–204. Mitchell, J., & Gaskin, D. (2005). Factors affecting plan choice and unmet needs among Supplemental Security Income eligible children with disabilities. HSR: Health Services Research, 40(5), Part 1, 1379–1399.

Case Study

Roberto, P., Mitchell, J., & Gaskin, D. (2005). Plan choice and changes in access to care over time in SSI-eligible children with disabilities. Inquiry, 42, 145–159. Rosenbach, M., & Young, C. (2000, June). Care coordination and Medicaid managed care: Emerging issues for states and managed care organizations. Princeton, NJ: Mathematica Policy Research, Inc.

CASE STUDIES

Mitchell, J. M., Gaskin, D. J., & Kozma, C. (2008) Health supervision visits among SSI-eligible children in the D.C. Medicaid program: A comparison of enrollees in fee-for-service and partially capitated managed care. Inquiry, 45, 198–214. Palfrey, J. S., Huntington, N. L., Yusuf, A. Foley, S. M., Nary, D., & Jenkins, R. (2010, December). Viewing services for children and youth with special health care needs through a community lens. Pediatrics, 126(S3), S107–S110.

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CHAPTER 13

Innovation for the Delivery System of the Future: Medical Homes, Accountable Care Organizations, and Bundled Payment Initiatives Dr. Brenda Helen Sheingold

OVERVIEW Healthcare delivery in the United States (U.S.) is evolving away from a fragmented, traditional provider, fee-for-service model in favor of reform that aligns payment incentives to provider quality improvement achievements within delivery systems. The legislative statutes in the A ­ ffordable Care Act (ACA) have been foundational to this transformation by funding the ­development of new healthcare delivery models through research and innovative initiatives. Extensive research has been conducted to identify system improvements that replace fragmented care by linking provider payment and value-driven, coordinated, patient-centered delivery. Data generated from ACA-funded initiatives have demonstrated that significant savings can be realized when healthcare quality is a priority.

© Anthony Krikorian/Shutterstock

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OBJECTIVES ■■

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Identify four healthcare delivery models that support quality-based payment and reimbursement. Identify how alternative payment models (APMs) encourage provider–payer collaboration and provider performance that meets benchmarks regarding quality of care outcomes. Describe four types of bundled payment healthcare delivery models. Describe the role of the Learning and Action Network (LAN) and how it supports the transformation of healthcare delivery in the United States.

Introduction

This chapter presents rapidly evolving models of patient care delivery in the U.S. that are transforming consumer, patient, academic, and payer expectations in the new millennium. These new practice models are accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and bundled payment initiatives. Although variations of these models have existed for some time, passage of the Affordable Care Act (ACA) has accelerated their growth through extensive research and testing programs (Centers for Medicare & Medicaid Services [CMS], 2016; Gilfillan, 2013). The origin of these models is similar because they endeavor to respond to a wide range of healthcare system delivery failures. ACOs build on the health maintenance organization (HMO) concept that seeks to improve quality and reduce cost. The strategic difference is that HMOs shift financial risk to providers while ACOs must also attain quality benchmarks for reimbursement (Frakt & Mayes, 2012). The PCMH model is also foundational to the delivery of health care through the ACA. Historically, this model also focuses on improved quality that aligns with reimbursement. The difference can be found in terms of its focus on health information technology (HIT) and evidence-based practice (EBP) (Arvantes, 2009; Healthcare Information and Management Systems Society & National Committee for Quality Assurance [HIMSS/NCQA], 2010). Additionally, this model employs healthcare teams that are focused or “centered” on the patient needs by offering such services as

flexible, lengthened hours for care, proactive employee telephone calls, and p ­ atient email (Berenson, Devers, & Burton, 2011). Bundled payment initiatives require healthcare organizations to agree to a fixed payment arrangement to cover all costs associated with an episode of care (Baseman, Boccoti, Moon, Griffin, & Dutta, 2016). Payments for healthcare expenditures are provided either prospectively, beginning when a patient requires acute care hospitalization and includes payment for all costs a­ ssociated with the hospitalization, or retrospectively (CMS, 2016). Retrospective bundled payment also ­begins with hospitalization in an acute care facility, but includes financial benchmarks or targets for coverage of post-acute care and costs associated with services such as home health or rehabilitation (CMS, 2016). The overarching goals, such as continuous care, performance-based payment, patient-centered care, and cost ­savings, are shared by the new healthcare delivery models and serve as the core of evolving modern healthcare delivery systems (CMS, 2017b; Meyer, 2012).

▸▸

The Innovation Center: Promoting Care Delivery Models for the Future

The Centers for Medicare & Medicaid Innovation Center (CMMI) was created by the U.S. Congress to test experimental payment and

The Four Major Healthcare Service Delivery Models

quality care delivery models that also contain costs (CMS, 2014a). New initiatives were funded through ACA statutes that expanded services to recipients of Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). The statute provides $10 billion in direct funding in fiscal years 2011 through 2019 to enable organizations to partner with the Innovation ­Center for innovation models testing (CMS, 2014b). Prior to the passage of ACA, ­CMS-funded i­ nitiatives of this type were referred to a “demonstration projects.” Since the Innovation ­Center has been established, the branding of ACO and PCMH initiatives is increasingly referred to as “models” or “innovations” and the term demonstration project is being used less frequently (Berenson & Cafarella, 2012). TABLE 13-1 displays examples of the seven major types of ACO, PCMH, and bundled payment models funded by the Innovation Center. These models are all efforts to address organizational and financial barriers that have prevented the provision of quality patient care.

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Rationale for New Models

The U.S. healthcare system is historically the most expensive in the world, spending more per capita on health care than any other country (Kaiser Family Foundation, 2011). Recent estimates are that national health expenditures per capita in the U.S. were $8,953.00 in 2012, accounting for 17.9% of the gross domestic product (GDP) (Keehan et al., 2012; The World Bank, 2013). Traditionally these estimates have been much higher in the U.S. than in all other nations (Squires, 2012). Despite the higher spending, the U.S. ranks poorly in international comparisons of health system performance (Davis, Schoen, & Stremikis, 2010). In addition, a study released by the National Research Council and the Institute of Medicine in 2013 demonstrated that out of the top 17 Organisation for Economic Co-Operation and Development (OECD) countries, the U.S. ranked last, due in large part to

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repetitious patterns of poor health throughout the entire lifespan (Rubenstein, 2013; World Health Organization, 2000). Determinants of poor health are based upon a variety of factors that include the incidence of chronic disease, maternal and infant mortality, likelihood of death by violence, smoking, food security, and access to dental and medical care (United Health Foundation, 2013). The need to coordinate healthcare delivery in the U.S. is a response to the overall poor health rankings and high costs. While coordinated care has been on the public agenda for a long time, it has not been a priority of those setting policy in Washington (Hoffman, 2003). It became a national priority when the Affordable Care Act (ACA) was passed by the U.S. Congress and signed into law by President Barack Obama in 2010. The new ACA law supports a comprehensive review of healthcare delivery best practices in the U.S., bringing ACO, PCMH, and bundled payment models to the forefront of funded ­research and payment (Baseman et.al., 2016; Gates, Rudowitz, & Guyer, 2014; U.S. ­Department of Health and Human Services ­[USDHHS], 2013a). Payment that is built around the quality and outcome of services delivered, rather than volume of services is referred to as avalue-based purchasing (VBP) program and is the goal for U.S. healthcare delivery in the future (USDHHS, 2016).

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The Four Major Healthcare Service Delivery Models

ACO Model An accountable care organization (ACO), as defined by the ACA, refers to a group of providers and suppliers that coordinate services to improve patient care. More specifically, the American Academy of Family Physicians (AAFP) defines an ACO as “a group of health care providers who agree to take on a shared responsibility for the

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TABLE 13-1  CMS Innovation Center ACO, PCMH, and Bundled Payment Projects Business or Experimental Model

Aim

Accountable Care

Similar care models are designed to incentivize healthcare providers to become accountable for a patient population and to invest in infrastructure and redesigned care processes that provide for coordinated care, and high-quality and efficient service delivery.

Episode-Based Payment Initiatives

Healthcare providers are held accountable for the cost and quality of care beneficiaries receive during an episode of care, which usually begins with a triggering healthcare event (such as a hospitalization or chemotherapy administration) and extends for a limited period of time thereafter.

Primary Care Transformation

Strengthening and increasing access to primary care is critical to promoting health and reducing overall healthcare costs. Advanced primary care practices—also called “medical homes”—utilize a team-based approach, while emphasizing prevention, health information technology, care coordination, and shared decision making among patients and their providers.

Initiatives Focused on the Medicaid and CHIP Population

These are administered by the states but are jointly funded by the federal government and states. Initiatives in this category are administered by participating states.

Initiatives Focused on Medicare–Medicaid Enrollees

Individuals enrolled in both Medicare and Medicaid (the “dual eligibles”) account for a disproportionate share of the programs’ expenditures. A fully integrated, personcentered system of care that ensures that all their needs are met could better serve this population in a high-quality, cost-effective manner.

Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models

By partnering with local and regional stakeholders, CMS can help accelerate the testing of models today that may be the next breakthrough tomorrow.

Initiatives to Speed the Adoption of Best Practices

The Innovation Center is partnering with a broad range of healthcare providers, federal agencies, professional societies, and other experts and stakeholders to test new models for disseminating evidence-based best practices and significantly increasing the speed of adoption.

Source: Reproduced from Centers for Medicare & Medicaid Services Innovation Center (CMS). (2017b). Innovation models. Retrieved from: https://innovation.cms.gov/initiatives/index .html#views=models

The Four Major Healthcare Service Delivery Models

care of a defined population of patients while assuring active management of both the quality and cost of that care” (Bobbitt, 2011). CMS currently provides a variety of ACO financial models, intended to reduce costs and improve the quality and outcomes of care (CMS, 2017a). A key tool for ACOs to achieve these objectives is to coordinate care by sharing medical information and data primarily through an electronic health record (EMR) to reduce redundancy and help control costs (CMS, 2013). Five types of ACOs are defined and summarized with examples in TABLE 13-2. This table illustrates that ACOs are represented by many organizational paradigms and structures. All are an attempt to align financial and practice incentives to insure improved quality and outcomes of patient care. ACOs leverage a wide variety of organizations or integrated care delivery systems and may elect to include a PCMH, which is also known as a primary care medical home and is characterized by the presence of five critical elements or core functions. The Agency for Healthcare Research and Quality (AHRQ) has identified these core functions as follows (AHRQ, 2013): 1. Provides comprehensive care: Organizes care by marshaling a diverse subset of specialists that represent many different professions. Some examples are pharmacists, social workers, nutritionists, physical therapists, occupational therapists, and dentists. This team is usually led by a physician or nurse practitioner. 2. Provides patient-centered care: Delivers care that focuses on establishing a relationship with each patient and their family. It recognizes and considers the cultural, ethnic, and social differences of every patient and incorporates these values into the care that is offered. 3. Provides coordinated care: Supervises key transitions that occur at decisive junctures or care transfer, such as being discharged from the hospital to home, or the introduction of palliative

4.

5.

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care services. Good communication is a requirement of medical homes to achieve effective care coordination. Provides accessible services: Offers appointments that are convenient and flexible to suit patient and family preferences. Also offers 24-hour care, either by telephone or via electronic communication, to reduce overall wait time for patients and families. Provides safe care and quality monitoring: Practices evidence-based care that is routinely analyzed to meet standard benchmarks for quality and safety. Values patient engagement and patient satisfaction. Publicly shares safety data and quality improvement activities.

PCMH Model Patient-centered medical home (PCMH) is a model of care that facilitates the coordination of primary care in a cooperative setting of providers that serve in the interest of the patient and meet most of their healthcare needs (Baseman et al., 2016, HIMSS/NCQA, 2013). The model was originally established in 1967 to provide organized care for pediatric patients, and has since evolved in scope to encompass an extensive range of practice that includes families, clinical specialties, and chronic disease management (American Academy of Pediatrics [AAP], 2013). The original PCMH concept improved access to health care and has progressed due to technological advances. Comprehensive care could only be provided by HMOs that owned their own hospitals and therefore controlled the transfer of patients or by very tight coordination between community health centers (CHCs) and hospitals. Computerization made care coordination possible between providers in diverse locations and helped facilitate the growth of the managed care industry. Combined with the drive to a market-driven health system, organizations have endeavored to control market share, control costs, and address issues of quality through care coordination.

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TABLE 13-2  Snapshot of Accountable Care Organizations in the United States Type

Characteristics

Integrated delivery system

■■ ■■ ■■ ■■

Multi-specialty group practice

■■

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Physician-hospital organizations

■■ ■■ ■■

Independent practice associations

■■

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Virtual physician organizations

■■ ■■ ■■

Examples

Own hospitals. Sponsor health plans. Salary-based specialty practices. Provide extensive population health care.

Eastern Maine Healthcare System, Kaiser Permanente, Geisinger Health System, Henry Ford Health System, Intermountain Health System

Strong affiliation with a hospital (might own one). Contract with multiple health plans. Physician-led coordinated care.

Mayo Clinics (Minnesota, Florida, and Arizona), Cleveland Clinic, Virginia Mason Clinic, Billings Clinic

Subset of a hospital staff. Negotiate with health plans. Cost-effective care coordination.

Advocate Health System, Middlesex Hospital, Detroit Medical Center

Individual physician practices contract with health plans. Care coordination varies. Exchange of protected health information (PHI) varies.

Hill Physicians Group, HealthCare Partners, Monarch Healthcare: A Medical Group, Inc.

Independent small physician practices. Usually located in rural areas. Led by a single physician, foundation, or Medicaid agency.

Community Care of North Carolina, Grand Junction Colorado, North Dakota Rural Cooperative Network, Humboldt County California

Sources: Data from Centers for Medicare & Medicaid Services (CMS). (2017a). Accountable care organizations: General information. Innovation Center; Shortell, S., Gillies, R., & Wu, F. (2010). United States innovations in healthcare delivery. Public Health Reviews, 32(1), 190–212.

The AHRQ has identified two primary approaches to care coordination that are summarized in TABLE 13-3. The ACO and PCMH care delivery models align with the quality improvement and reimbursement incentives required by ACA through VBP (USDHHS, 2016). The Commonwealth Fund has formulated 10 recommendations to support the transformation and alignment of innovative care delivery models and payment:

■■ ■■ ■■ ■■

■■ ■■

Make care coordination a high priority. Identify patients in greatest need of proactive, coordinated care. Train more primary care physicians and geriatricians. Facilitate communication between provi­ ders—for example, through clinical record integration. Engage patients in decisions about their care. Provide better support for caregivers.

The Four Major Healthcare Service Delivery Models

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TABLE 13-3  Approaches to Care Coordination Approach

Examples of Activities

Broad care coordination

■■ ■■ ■■ ■■ ■■

Specific care coordination

■■ ■■ ■■ ■■ ■■ ■■

■■ ■■ ■■

Teamwork Care management Medication management Health information technology Patient-centered medical home Establishing accountability and agreeing on responsibility Communicating/sharing knowledge Helping with transitions of care Assessing patient needs and goals Creating a proactive care plan Monitoring and follow-up, including responding to changes in patients’ needs Supporting patients’ self-management goals Linking to community resources Working to align resources with patient and population needs

Source: Modified, with permission, from Agency for Healthcare Research and Quality. (2017). Care coordination. Retrieved from https://www.ahrq.gov /professionals/prevention-chronic-care/improve/coordination/index.html ■■ ■■ ■■ ■■

Redesign funding mechanisms to meet patients’ needs. Integrate health and social services with physical and mental health care. Engage clinicians in change and train and support clinical leaders. Learn from experience and scale up successful projects (The Commonwealth Fund, 2017).

Bundled Payment Model An early example of a bundled payment model that surfaced in 1988 was reimbursement for coronary artery bypass grafting (CABG) surgery, which incentivized coordinated care by aligning it with a fixed fee-for-service (Muhlestein, Burton, & Winfield, 2017). Bundled payments for a wide variety of procedures and diagnoses are initiated by CMMI as part of the ACA mandates to accelerate the inclusion of best practices into healthcare delivery (CMS, 2017b). Bundled payments are also known as “episode-of-care” payments and provide a single

amount of reimbursement that includes all fees such as hospitalization charges, physician charges, physical therapy, and respiratory therapy, and all providers of care receive a portion of the ­reimbursement (Baseman et al., 2016). CCMI has developed four models of b­ undled payment or episodes of care that each reduce duplicative services focus on quality healthcare differently (CMS, 2017b). See TABLE 13-4 for a brief description how the four different bundled payment care improvement (BPCI) models meet VBP challenges based upon the scope of service, organizational type, and payment type (Baseman et al., 2016).

Other Payment and Delivery Innovations There are several key care delivery initiatives and alternative payment models (APM) that are active, but don’t fit into an ACO, PCMH, or bundled payment category. The Congressional

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Chapter 13 Innovation for the Delivery System of the Future

TABLE 13-4  CMS Innovation Center BPCI Models BCPI Model

Description

Model #1 Retroactive Acute Care, Hospital Stay Only (concluded 2016)

Defined as the inpatient stay in the acute care hospital. Medicare paid the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare paid physicians separately for their services under the Medicare Physician Fee Schedule.

Model #2 Retrospective Acute and Post-Acute Care

This payment model continues to make fee-for-service (FFS) payments to providers and suppliers furnishing services. The total expenditures per episode are reconciled afterward against a bundled payment amount (the target price) determined by CMS. A payment is made by Medicare reflecting the aggregate performance compared to the target price.

Model #3 Retrospective PostAcute Care Only

Retrospective bundled payment occurs by reconciling actual expenditures against a target price for an episode of care.

Model #4 Prospective Acute Care, Hospital Stay Only

A prospective determined bundled payment to the hospital that encompasses all services furnished by the hospital, physicians, and other practitioners during the episode of care, which lasts the entire inpatient stay. Physicians and other practitioners submit “no-pay” claims to Medicare and are paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge are included in the bundled payment amount.

Sources: Data from Centers for Medicare & Medicaid Services. (2017b). Innovation models. Innovation Center. Retrieved from https://innovation.cms.gov/initiatives /index.html#views=models; Baseman, S., Boccoti, C., Moon, M., Griffin, S., & Dutta, T. (2016). Payment and delivery system reform in Medicare: A primer on medical homes, accountable care organizations, and bundled payments. Kaiser Family Foundation.

Budget Office (CBO) testified that the combined savings from all Innovation Center activities and initiatives, “would reduce federal spending by $34 billion through 2026” (CMS, 2016). The overarching goal is to transform care by developing and learning from evidence that demonstrates quality improvement reduces healthcare costs. One significant initiative to achieve this goal is the Health Care Payment Learning and Action Network (LAN) established by the CMS in 2015. The LAN is a collaborative of public, private, and nonprofit affiliates that collaborate to increase the adoption of ACOs, PCMHs, bundled payments, and other APMs to support the momentum of CMS quality improvement measures across the United States (CMS, 2016).

Another significant initiative is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which explores creative ways for CMS to reimburse physicians that participate in APMs (USDHHS, 2017). MACRA focuses on incentives for practitioners to deliver quality health care through HIT, greater care coordination, and population health (USDHHS, 2017).

▸▸

Conclusion

As the implementation of healthcare reform continues to evolve, new healthcare delivery models will continue to be evaluated by government and private entities to assure effective VBP (CMS, 2016).

References

This is an advantage for consumers of health care, care providers, and key stakeholders at all levels, and will have a lasting effect for the new millennium.

References American Academy of Pediatrics (AAP). (2013). National Center for Medical Home Implementation website. Retrieved from http://www.medicalhomeinfo.org/ Agency for Healthcare Research and Quality (AHRQ). (2013). Defining the PCMH. Patient-Centered Medical Home Resource Center (PCHM). Retrieved from http:// www.pcmh.ahrq.gov/portal/server.pt/community /pcmh__home/1483/pcmh_defining_the_pcmh_v2 Agency for Healthcare Research and Quality (AHRQ). (2017). Care coordination. Retrieved from https://www.ahrq .gov/professionals/prevention-chronic-care/improve /coordination/index.html Arvantes, J. (2009). PCMH likely to form basis of federal health care reform. American Academy of Family Physicians (AAFP). Retrieved from http://www.aafp.org/news-now /pcmh/20090217pcmhfedreform.html Baseman, S., Boccoti, C., Moon, M., Griffin, S., & Dutta, T. (2016). Payment and delivery system reform in Medicare: A primer on medical homes, accountable care organizations, and bundled payments. Kaiser Family Foundation. Retrieved from https://www.kff.org/medicare/report /payment-and-delivery-system-reform-in-medicare/ Berenson, B. A., & Cafarella, N. (2012, February). The Center for Medicare & Medicaid Innovation: Activity on many fronts. Timely analysis of immediate health policy issues. Urban Institute. Retrieved from https://www.giaging .org/documents/73921.5643ctrformedicare.2012.feb .fullrpt.pdf Berenson, R., Devers, K., & Burton, R. (2011). Will the patient-centered medical home transform the delivery of health care? Robert Woods Johnson Foundation. Retrieved from http://www.rwjf.org/content/dam/farm /reports/reports/2011/rwjf70764 Bobbit, J. (2011). What family physicians need to know about ACOs. Family Practice Management, 18(5), 17–22. Centers for Medicare & Medicaid Services (CMS). (2013). Program news and announcements. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for -Service-Payment/sharedsavingsprogram/Downloads /MSSP-ACOs-List.pdf Centers for Medicare & Medicaid Services (CMS). (2014a). Accountable care organizations. Retrieved from http:// www.medicare.gov/manage-your-health/coordinating -your-care/accountable-care-organizations.html Centers for Medicare & Medicaid Services (CMS). (2014b). Where innovation is happening. Innovation Center (CMMI). Retrieved from http://innovation.cms.gov /initiatives/map/index.html

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Centers for Medicare & Medicaid Services (CMS). (2016, December). Center for Medicare and Medicare Innovations Report to Congress. Retrieved from https://innovation .cms.gov/Files/reports/rtc-2016.pdf Centers for Medicare & Medicaid Services (CMS). (2017a). Accountable care organizations: General information. Innovation Center. Retrieved from https://innovation .cms.gov/initiatives/ACO/ Centers for Medicare & Medicaid Services (CMS). (2017b). Innovation models. Innovation Center. Retrieved from https:// innovation.cms.gov/initiatives/index.html#views=models Davis, K., Schoen, C., & Stremikis, K. (2010). Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally. New York, NY: The Commonwealth Fund. No. 1400. Retrieved from http://www.commonwealthfund.org/publications /fund-reports/2014/jun/mirror-mirror Frakt, A., & Mayes, R. (2012). Beyond capitation: How new payment experiments seek to find the “sweet spot” in amount of risk providers and payer bear. Health Affairs, 31(9), 1951–1958. Gates, A., Rudowitz, R., & Guyer, J. (2014). An overview of delivery system reform incentive payment (DSRP) waivers. Kaiser Family Foundation Commission on Medicaid and the Uninsured. Retrieved from https://www.kff.org /medicaid/issue-brief/an-overview-of-delivery-system -reform-incentive-payment-waivers/ Gilfillan, R. J. (2013, March 20). Reforming the Delivery System: The Center for Medicare and Medicaid Innovation. Congressional Testimony Before the U.S. Senate Committee on Finance. Retrieved from https://www.finance.senate .gov/hearings/reforming-the-delivery-system-the-center -for-medicare-and-medicaid-innovation Healthcare Information and Management Systems Society, National Committee for Quality Assurance (HIMSS /NCQA). (2010). Patient-centered medical home fact sheet. Retrieved from http://www.ncqa.org/Portals/0 /Public%20Policy/HIMSS_NCQA_PCMH_Factsheet.pdf Hoffman, B. (2003). Health care reform and social movements in the United States. American Journal of Public Health, 93(1), 75–85. Kaiser Family Foundation. (2011). Snapshots: Health care spending in the United States & selected OECD countries. Retrieved from http://kff.org/health-costs/issue-brief /snapshots-health-care-spending-in-the-united-states -selected-oecd-countries/ Keehan, S., Cuckler, G., Sisko, A., Madison, A., Smith, S., Lizonitz, J., Poisal, J., & Wolfe, C. (2012). National health expenditure projections: Modest annual growth until coverage expands and economic growth accelerates. Health Affairs, 31(7), 1600–1612. Meyer, H. (2012). Many accountable care organizations are now up and running, if not off to the races. Health Affairs, 31(11), 2363–2367. Muhlestein, D., Burton, N., & Winfield, L. (2017, February 3). The changing payment landscape of current CMS

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payment models foreshadows future plans. Health Affairs Blog. Retrieved from http://healthaffairs.org /blog/2017/02/03/the-changing-payment-landscape-of -current-cms-payment-models-foreshadows-future-plans/ Rubenstein, G. (2013, January 10). New health rankings: Of 17 nations, U.S. is dead last. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2013/01 /new-health-rankings-of-17-nations-us-is-dead-last /267045/ Shortell, S., Gillies, R., & Wu, F. (2010). United States innovations in healthcare delivery. Public Health Reviews, 32(1), 190–212. Squires, D. (2012). Explaining high health care spending in the United States: An international comparison of supply, utilization, prices, and quality. The Commonwealth Fund. No. 1595. Vol. 10. Retrieved from http://www .commonwealthfund.org/publications/issue-briefs/2012 /may/high-health-care-spending The Commonwealth Fund. (2017). The Commonwealth Fund designing a high-performing health care system for patients with complex needs: Ten recommendations for policymakers. Retrieved from http://www.commonwealthfund.org /publications/fund-reports/2017/aug/ten-recommendations The World Bank. (2013). Health expenditure per capita (current US$). Retrieved from http://data.worldbank. org/indicator/SH.XPD.PCAP

United Health Foundation. (2013). America’s health rankings. Retrieved from http://www.americashealthrankings .org/About U.S. Department of Health and Human Services. (2013). Key features of the Affordable Care Act. Retrieved from http://www.hhs.gov/healthcare/facts/timeline/index.html U.S. Department of Health and Human Services. (2016). Report to Congress: Social risk factors and performance under Medicare’s value-based purchasing programs. Office of the Assistant Secretary for Planning and Evaluation (ASPE). Retrieved from https://aspe.hhs .gov/pdf-report/report-congress-social-risk-factors -and-performance-under-medicares-value-based -purchasing-programs U.S. Department of Health and Human Services. (2017, March). Physician-Focused Payment Model Technical Advisory Committee. Office of the Assistant Secretary for Planning and Evaluation (ASPE). Retrieved from https://aspe.hhs.gov/ptac-physician-focused-payment -model-technical-advisory-committee World Health Organization (WHO). (2000). The World Health Report 2000—Health systems: Improving performance. Retrieved from http://www.who.int/whr/2000/en/

SECTION 5

Health Care and Provider and Care Delivery CHAPTER 14 Hospitals: Consolidation and Compression CHAPTER 15 Enhanced Primary Care Roles for Nurses and Other Professionals CHAPTER 16 Physicians: It Is Increasingly about the Team CHAPTER 17 Health Information Technology and the Intersection of Health Policy CHAPTER 18 Political Power of Nurses: Harnessing Our Values and Voices

© Anthony Krikorian/Shutterstock

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CHAPTER 14

Hospitals: Consolidation and Compression Barbara Caress and Nancy Aries

OVERVIEW This chapter discusses the critical role of hospitals in the delivery of health care. Hospitals historically have been at the center of the healthcare system, reliably accounting for more than one-third of personal healthcare expenditures. For the most part, they have functioned independently given their history, the context of the communities where they were located, and the financing system that supported them. The role of hospitals in the medical care system is changing because of the evolving nature of healthcare delivery. Most hospitals are no longer single, independent operations. Rather, each is part of larger system, which usually includes physicians, surgi-centers, community-based urgent care, laboratory and radiology services, postacute providers, as well as other hospitals. While still dominant as the provider of tertiary care, hospitals are becoming integrated into a model of care that is population based with payments, in part, dependent of their willingness and capacity to manage comprehensive and integrated care as a way to improve the community’s health.

OBJECTIVES ■■

■■

■■ ■■

■■

Understand the transformation of hospitals from social welfare providers to independent acute care facilities to part of care systems. Identify how hospitals became the hub of the healthcare delivery system and competing pressures for change. Recognize how external pressures are changing the nature of hospital services. Delineate the strategies being used by hospitals to ensure their centrality to the provision of services as well as the quality of care. Assess the impact of the Affordable Care Act on the role of hospitals.

© Anthony Krikorian/Shutterstock

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292

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Chapter 14 Hospitals: Consolidation and Compression

Hospitals’ Role within the Delivery System

Twentieth-century hospitals provide an excellent example of the limits of using competitive markets to provide health services. Superficially, hospitals look like the competitive suppliers of salable services that economics textbooks hail as the necessary condition for market-driven efficiency. The term “market” means a situation in which the sellers and buyers of a product come together voluntarily to exchange money for goods at a price that is set by the competition among all the sellers to attract willing and able buyers of the service in question. According to the theory, the pressure of competition will drive sellers to provide the best possible care at the lowest possible price. Because U.S. hospitals were not part of a singular healthcare system, like the hospitals in Canada or other industrial nations, their circumstances suggested that they could operate as efficient textbook competitors in search of paying customers. The difficulty with this idealized market-based and regulation-free approach to hospital care is that hospitals acting in their own best interests do not necessarily serve the needs of the population where they are located. The dilemma is most obvious for hospitals serving financially vulnerable populations, i.e., populations that cannot afford to pay the full costs of the care they receive and do not have insurance or enough insurance to cover the difference. Such hospitals are unstable financially, as they must rely upon nonmarket sources of funding and are frequently not attractive partners for most hospital systems. Not surprisingly in an era of hospital consolidation, this has resulted in many hospital closures since the 1990s (Cutler, 2009). Hospital competition is rarely a rationalizing force. Recognizing the challenge of making essential services available to persons who cannot afford to pay, public policymakers have adopted other methods to push for a more effective and efficient system. The basic instruments

employed in recent years are payment incentives for consolidation and integration. With the passage of the Affordable Care Act (ACA), there is now an enhanced emphasis on improving the complementarity between providers who participate in integrated networks, which provide a continuum of care from wellness to outpatient and inpatient care, to nursing home care and hospice. It is believed that there is the potential for hospitals to become more fully integrated into optimized systems of care by reorienting the entire system away from one that rewards volume to one that creates incentives for improving the quality of care and controlling cost across specific populations. In this chapter, the development of the hospital sector will be explained, as will the current state of the healthcare industry. The following sections will explicate how the politics of healthcare reform are impacting hospitals and the industry’s response.

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Hospitals in a Historic Context

The origin of hospitals is more tied to the provision of social services than medical services. Before the Civil War, there were just a handful of hospitals, including Philadelphia General, Massachusetts General, and New York Hospital. These were often founded at the urging of doctors as workshops to study and train physicians. They were endowed by city elites. They were supported by the public because they were places that cared for persons who had no family to care for them (Starr, 1982). The number of hospitals increased dramatically after the Civil War, as cities grew in numbers and size (Rosner, 1982). Given the social stresses due to immigration, industrialization, and urbanization, hospitals were critical to urban stability. New hospitals were built to respond to the defined needs of specific communities. These hospitals were a principal tool whereby community elites organized assistance to the poor who were dislocated from their religious and ethnic groups.

Hospitals in a Historic Context

The names of the hospitals told of their affiliation: Mount Sinai, Lutheran, Swedish, St. Luke’s, French, Methodist, and St. Vincent’s. The goal was not just medical cure. The goal was to provide assistance in whatever form it was needed (Starr, 1982). The modern U.S. hospital industry was born between the 1860s and the 1920s as these hospitals underwent a transformation from social welfare institutions to institutions that provide acute medical care. Rather than serving the generic needs of the community, the mission of the hospital became one of curing the acute problems of the sick. The change in purpose was related to the rise of the biomedical sciences. For the first time, physicians could provide services that positively impacted the health of their patients. Patients who could benefit from medical intervention began to be treated in hospitals, whereas chronic or social problems, such as alcoholism or old age, that were not responsive to medical intervention were moved into the realm of ­social services. Another factor impacting the transition was that medical services could no longer be provided in a patient’s home. They required a centralized location where sterile conditions could be assured and where equipment such as X-ray machines and pathology laboratories could be located. The growing complexity of medical care called for more complex staffing functions and organizational structures. By 1920, for example, the transformation of the hospital was achieved in Philadelphia when three distinct institutions formed out of Philadelphia General Hospital: an acute care hospital, an asylum, and an almshouse (Rosenberg, 1982). Beyond the growth of the hospital, two other transformations occurred. First, the hospital changed from an institution operated as charity into one run as a business. Hospitals were becoming costlier ventures to operate because of changes resulting from scientific advances. Their former business model that relied on philanthropy was no longer tenable. Hospitals needed new sources of revenue. They began charging for services and opening their doors to private practitioners who had access to

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potentially paying middle-class patients. Once opened and dependent on private physicians to supply the patients, the second transformation occurred. Control passed from the boards of trustees, drawn from among elite members of the community, to physicians who controlled admissions (the most important source of revenue) and, ultimately, mission (Rosner, 1982). As the hospitals grew in number and size, the role and influence of physicians also grew. One organized agent of the physician community, the American College of Surgeons, even sought to standardize hospital services as a way to ensure quality. The College surveyed all hospitals to determine whether: (1) physicians were licensed, (2) the medical staff met monthly, (3) there were accurate patient records, and (4) there were diagnostic and therapeutic facilities under competent supervision (Stevens, 1989). By the late 1930s, the hospital had become the hub of the healthcare delivery system. It was the locus of both patient care and medical training. Centralizing care in increasingly complex institutions was the most important manifestation of the transformation of U.S. health care in the 20th century. Hospital care defined medical care as the treatment of injury and disease, not prevention and comfort, and physicians were its heart and soul (Rosenberg, 1982). Since that time, the hospitals have fought to maintain their hegemony in this tremendously complex system and its disease-based focus on the provision of care. Starting in the 1990s, public policymakers sought to move the center of the organization of healthcare delivery away from hospitals. In part, this was accomplished by promoting technological changes that meant care previously provided in a hospital could now be provided in nonhospital ambulatory care settings. Changing surgical practices, for example, enabled patients to be operated on and discharged the same day (Kalra, Fisher, & Axelrod, 2010). The implication was that surgical suites could be disconnected from hospitals that were structured to provide inpatient care. Second, both public and private health insurance shifted away from

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Chapter 14 Hospitals: Consolidation and Compression

fee-for-service retroactive payments. Rather than paying for everything and anything ordered by the physician and provided by the hospital, ­insurers negotiated payments for services deemed ­“medically necessary.” Some services were covered in full; others were not (Baicker, Chernew, & Robbins, 2013). Taken together, these changes made possible the idea of integrated care models embedded in the 1993 Clinton Health Security Act proposal. Increasingly, it was understood that even the most complex patient care could be provided in a variety of settings. What was important was to focus on the integration of services across settings so that patients did not become lost between providers and there was better management of healthcare costs. The hospitals’ response to President Clinton’s health plan proposal and the challenges posed by both changing medical care practice and payers seeking less costly ways to provide services was to look for ways to integrate many modalities under their roof. Many hospitals, for example, purchased physician practices to centralize the payment and control the delivery of services. The 1990s movement towards integrated models of care, however, floundered with the public reaction to tightly controlled managed care and the demise of healthcare reform. The idea of service integration to which most policy analysts subscribed was not formally on the public agenda again until consideration of the Affordable Care Act in 2009 to 2010. The ACA made the necessity to change imminent. Medicare payments to hospitals incorporate value as well as the bundling of care, including inpatient, outpatient, clinician, and posthospital care. There is little room left for independent providers. All the financial incentives point towards consolidated, integrated, and managed models of care.

▸▸

Baseline Information

In 1920, the second Hospital Census identified 5,700 institutions, practically the same number as today (Starr, 1982.) The number of

hospitals peaked at approximately 7,200 in the early 1970s, and by 2015 there were 5,564 hospitals (American Hospital Association [AHA], 2017). Of these, 4,862 are community hospitals. A community hospital is broadly defined as a nonfederal, short-term, general, and other hospital whose services are available to the public (AHA, 2016) and where the average length of stay (LOS) is less than 30 days. This definition excludes hospital units in institutions that are not available to the public, such as prisons. Discussions about hospitals typically refer to community hospitals. There are 702 noncommunity hospitals. Noncommunity hospitals include federal (Veterans Adminstration [VA], U.S. Public Health Service, and Marine hospitals) and longterm institutions (AHA, 2016). Their defining characteristic is a LOS that is greater than 30 days. Long-term general hospitals refer to psychiatric hospitals, tuberculosis and other ­respiratory diseases hospitals, institutions for the intellectually disabled and alcohol and chemical dependency, and long-term stay units in short-term institutions. The number of community hospitals is declining. Most recent closures were rural hospitals and “safety net” urban hospitals that are financially at risk because they serve patient populations with limited ability to pay. Despite a growing and aging population, an increase in surgical operations, and growth in the number of births, admissions numbers since 2000 have been flat. However, the decreased average LOS means the number of beds is also declining. TABLES 14-1 and 14-3 provide more detailed information about community hospitals. As can be seen in Table 14-1, the number of hospital beds fell by more than 200,000 between 1980 and 2014. During the same 25-year period, the number of outpatient encounters, however, has increased over 300%. When looking at surgical operations, for example, there is a steady increase in the number of outpatient surgeries and a decrease in the number of inpatient surgeries. The average number of beds in Table 14-1 shows that the typical community hospital is quite small—averaging between 150 and 200

295

Baseline Information

TABLE 14-1  Community Hospitals, Beds, Admissions, Average Length of Stay, and Occupancy Rate—Selected Years 1980–2014 Category

1980

1990

2000

2010

2014

Hospitals

5,830

5,384

4,915

4,985

4,926

Beds

988,287

926,436

823,560

804,943

786,874

Beds/hospital

169

172

168

161

160

Admissions (in millions)

36.1

31.2

33.2

35.2

33.1

Admissions (per 1,000)

159.5

125.3

117.6

113.7

103.7

Average length of stay (in days)

7.6

7.2

5.8

5.4

5.5

Occupancy rate (percent)

75.2

66.8

63.9

64.5

61*

Inpatient surgeries (in millions)

15.7

10.8

9.7

10.0

9.0

Outpatient surgeries (in millions)

3.1

11.1

16.4

17.4

17.4

Emergency department (ED) visits (in millions)

N/A

86.7

103.1

127.2

136.3

ED visits (per 1,000)

N/A

349

366

412

428

Outpatient visits (in millions)

202.3

300.5

521.4

651.4

693.1

Outpatient visits (per 1,000)

892.9

1,208.0

1,852.8

2,107.8

2,173.7

All data except occupancy rate from American Hospital Association. (2016). TrendWatch Chartbooks 2000-2003, 2016. Retrieved from http://www.aha.org /research/reports/tw/chartbook/index.shtml; data for occupancy rates from Centers for Disease Control and Prevention, National Center for Health Statistics. (2016). Health United States, 2015: With special feature on racial and ethnic health disparities. Hyattsville, MD: U.S. Government Printing Office. Table 89. Hospitals, beds, and occupancy rates, by type of ownership and size of hospital: United States, selected years 1975–2013. *MEDPAC, (March 2016). Report to Congress: Medicare payment policy. p. 62.

beds. They are not large institutions equipped with facilities to provide the complexity of services required for many of the surgeries indicated in the table. The typical hospital size stands in sharp contrast to a city like New York, NY, where practically every hospital has more than 200 beds (New York State Department of Health, 2009). The larger hospitals tend to be academic medical centers or affiliated hospitals

that train physicians and care for people with complex medical and social problems. These hospitals find themselves in competition for patients with the smaller community hospitals. One dominates regarding numbers and the other regarding prestige. Hospitals had been a prime driver of increasing healthcare costs since the passage of Medicare. Hospitals costs comprise the largest

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Chapter 14 Hospitals: Consolidation and Compression

single portion of spending in the healthcare sector. More is spent on hospitals than is spent on Social Security or defense (Kocher & Emmanuel, 2012). In 2014, hospital spending was $972

billion dollars or 38% of personal healthcare spending. As TABLE 14-2 indicates, the relative percentage of health spending on hospitals rose dramatically between 1960 and 1980,

TABLE 14-2  Personal Health Expenditures and Hospital Expenditures by Source of Funds—Selected Years 1960–2014 Expenditure by Source of Funds

1960

1970

1980

1990

2000

2009

2014

Per capita

$125

$300

$942

$2,425

$4,121

$6,905

$8,054

Personal health expenditures (in billions)

$23.3

$63.1

217.0

$615.3

$1,162.0

$2,115.9

$2,563.6

Out of pocket

55.7

39.6

26.8

22.4

17.1

13.9

12.9

Private insurance

21.3

22.3

28.4

33.3

34.9

34.7

33.9

Medicare

N/A

11.5

16.7

17.4

18.6

22.2

22.7

Medicaid & CHIP (2000)

N/A

8.0

11.4

11.3

16.3

16.9

17.8

All other

23.0

18.6

16.7

15.6

13.0

12.3

12.7

Hospital expenditures (in billions)

$9.0

$27.2

$100.5

$250.4

$415.5

$778.1

$971.8

Out of pocket

20.6

9.0

5.4

4.5

3.2

3.3

3.2

Private insurance

35.6

32.5

36.6

38.5

33.9

36.6

37.3

Medicare

19.7

26.1

26.9

29.7

27.6

25.8

Medicaid & CHIP (2000)

9.7

9.2

10.6

17.3

17.6

17.6

29.1

22.8

19.4

15.9

15.0

16.2

Percent distribution

Percent distribution

All other

43.8

Data from Centers for Disease Control and Prevention, National Center for Health Statistics. (2016). Health United States, 2015: With special feature on racial and ethnic health disparities. Hyattsville, MD: U.S. Government Printing Office. Table 95, Personal health care expenditures, by source of funds and type of expenditure: United States, selected years 1960–2014.

297

Baseline Information

representing almost 50% of personal healthcare spending in 1980. Cost-control efforts on the part of the government and private health insurance companies have managed to bring these costs down, and hospital spending is just slightly lower as a percentage of all healthcare spending than it was in 1960. As the average annual growth in healthcare spending has slowed, so has the growth in hospital spending. Since 2009, the rate of increase in hospital spending has been steadily declining. The source of payment has also changed considerably over the last 60 years. The government is the largest single payer of hospital costs. This is a direct result of the passage of Medicare and Medicaid in 1965 and the ACA in 2010. There was no accounting of the federal and state spending as a percent of hospital expenditures in 1960. By 2014, it accounted for over 40% of hospital expenditures. As government

funding increased, private insurance payments remained relatively constant, but there was a marked decline in out-of-pocket payments. Between 1960 and 2014, direct out-of-pocket payments decreased from 21% to just over 3% of hospital expenditures, but are ticking up as costs are shifted from insurance to patients. There are three types of community hospitals based on ownership: (1) nonprofit hospitals include both community-based hospitals and academic health centers, (2) public hospitals are state and locally owned hospitals, and (3) privately owned or for-profit hospitals (Starr, 1982). Ownership creates different financial and legal constraints on the institutions that impact both the population served and the underlying financing of the institution. Two major shifts can be seen in the distribution of hospitals and hospital beds by ownership type in TABLE 14-3. The first is the steady decline of nonprofit

TABLE 14-3  Community Hospitals and Beds by Type of Ownership, Selected Years Type of Ownership

1975

1980

1990

2000

2010

2013

Nonprofit

5,875

5,830

5,384

4,915

4,985

4,974

For-profit

775

730

749

749

1,013

1,060

State and local government

1,761

1,778

1,444

1,263

1,068

1,010

Nonprofit

658,195

693,459

656,755

582,988

555,768

543,929

For-profit

73,495

87,033

101,377

109,883

124,652

134,643

State and local government

210,154

208,895

169,228

130,689

124,523

117,031

Hospitals

Beds

Data from Centers for Disease Control and Prevention, National Center for Health Statistics. (2016). Health United States, 2015: With special feature on racial and ethnic health disparities. Hyattsville, MD: U.S. Government Printing Office. Table 89. Hospitals, beds, and occupancy rates, by type of ownership and size of hospital: United States, selected years 1975–2013.

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Chapter 14 Hospitals: Consolidation and Compression

community hospitals. Hospitals that have been lost to the sector typically served a low-income population that was either uninsured or did not have adequate insurance coverage. These hospitals had fewer beds and decreased operating margins (Daugherty & Escobedo, 2013). As a result, they were the most financially vulnerable. Alternatively, there has been growth in the for-profit sector that can be attributed, in part, to the purchase of failing nonprofit hospitals (Ault, Childs, Wainright, Young, & Williams, 2011). The growth of the for-profit sector marks an intensification of financial imperatives driving change in the hospital sector. Likely, the loss of community hospitals will mean that low income patients have even fewer options available to them for hospital care (Bazzoli, Lee, Hsieh, & Mobley, 2012).

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Challenges Facing the Community Hospitals

The pressures that hospitals have experienced since the 1980s are related, in part, to the rapidly changing knowledge about how to manage and treat disease and, in part, to increased efforts to control healthcare costs. The imperative to control cost came from the fact that health care consumed an ever-larger share of domestic spending. Consequently, hospitals find themselves contending with excess capacity despite the closure of many hospitals. The increasing competitive market for hospital services makes a hospital’s survival dependent on its ability to control enough of the paying market to generate adequate revenues to cover costs.

Excess Capacity Hospitals have been forced to deal with surplus inpatient capacity because of declining admissions and decreased LOS. There are 3 million fewer admissions today than there were in 1982, even though the population has increased by

more than 92 million persons. In addition to the declining rate of admissions, between 1980 and 2014, the average LOS in the United States decreased 28% from 7.5 to 5.5 days. As a result, the occupancy rate of U.S. hospitals is about 61% (Medicare Payment Advisory Commission [MEDPAC], 2016). There is wide variation in the number of beds and the number of inpatient days per 100,000 persons across the country (see FIGURE 14-1). Ironically, excess capacity is not highly correlated to number of inpatient beds. In areas where there are fewer beds and fewer inpatient days, there is excess hospital capacity; however, in areas where there are more beds and inpatient days per 100,000, there may be even less excess capacity. While the count of inpatient beds has declined by 20%, the number of beds per 1,000 population has decreased by one-third. The declines in admissions and LOS are the result of many factors. First, there has been an improvement in the nation’s health. The incidence of breast cancer in women under age 65 years, for example, is declining. The same is true for coronary disease, cardiovascular disease, and pneumonia. Second, there are the growing alternatives to hospitalization. The management of diseases and conditions that required hospitalization has changed dramatically. Scientific advances have minimized the invasive nature of many procedures and changed our understanding of how best to care for patients (Kalra et al., 2010). It is now the case that myriad surgeries and diagnostic and other procedures can be done in ambulatory settings. Ambulatory surgery centers, diagnostic imaging, and radiological centers are being opened throughout the country (Mitchell, 2007). Thirdly, reductions in admissions and LOS have occurred because of changing payment methodologies. The first studies of health maintenance organizations (HMOs) found that hospital admissions for HMO patients fell by as much as 40% (Luft, 1981). LOS declined with the implementation of hospital payment based on

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Challenges Facing the Community Hospitals Hospital beds per 1,000 population by ownership type: state/local government, 2015 WA MT

ME

ND

VT

MN

OR ID

WI

SD WY

CA

NV

MI

UT

AZ

PA

IA

NE

IL

CO

KS OK

NM

IN

MO

NH MA RI CT

NY

OH WV

VA

KY

NC

TN

NJ DE MD DC

SC

AR MS

AL

GA

TX LA FL 0.0-0.1 0.2-0.4 0.5-0.8

AK

0.9-2.2 HI

NA

FIGURE 14-1  Hospital Beds per 1,000 Population, 2015 Reproduced from Kaiser Family Foundation. (2015). Hospital beds per 1,000 population by ownership type. Retrieved from http://kff.org/other/state-indicator/beds/#

diagnosis-related groups (DRGs) in 19831 rather than per day (per diem) payments. With a fixed price for each type of patients, DRGs created incentives to discharge patients more quickly. The growth of managed care further impacted hospitals as physician risk-sharing contracts meant physicians receive more income if their patients used fewer and less-expensive services—the challenge was to better manage patients’ care by treating patients in less-costly settings and eliminating or reducing inpatient stays (Draper,

Hurley, Lesser, & Strunk, 2002). The issue of hospital capacity has been further complicated by implementation of the ACA since increased insurance coverage leads to increased demand for services. However, the data to date indicate the management of patient flows as opposed to an increase in admissions and occupancy rates. Last, it is important to note the contribution of long-standing variation in medical practice patterns that accounts for the regional variations described (Mechanic, 2011).

1 Diagnosis-related group is a system of payment for hospital inpatient services based on predetermined rates per discharge for approximately 500 groupings. It was developed for Medicare and has been in use since 1983. A Medicare recipient is assigned to a payment group depending on principal diagnosis. Other criteria include the patient’s age, sex, secondary diagnoses, procedures performed, discharge status, complications, and comorbidity.

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Chapter 14 Hospitals: Consolidation and Compression

Increasingly Competitive Financial Environment Hospital financing has gone through three distinct phases and is entering a fourth. Initially, hospitals were financed by philanthropy. Hospital matrons would sit with wealthy trustees to negotiate a budget that they would fund through annual donations (Rosner, 1982). These donations paid the hospital’s small administration staff and operating expenses. Patients were cared for by each other and by student nurses who worked for free in return for their education and certification. By the early decades of the 20th century, hospitals needed more income than a few benefactors could regularly supply. They became increasingly dependent upon patient payments for service. The 1920s boom in hospital construction ended abruptly as the country fell into the depths of the Great Depression. With the stock market crash of 1929 and ensuing financial cal­ amity, hospitals’ revenues fell dramatically. One response was the organization of Blue Cross to guarantee patient payment for hospital services. At its origin, Blue Cross offered Dallas teachers 21 days of care for $6 a year. Blue Cross began as a wholly owned subsidiary of the hospital’s trade group, the American Hospital Association. It remained so until the early 1970s when the Congress forced the American Hospital Association to divest (Law, 1986). Blue Cross and other retrospective payers arrived on the scene and covered the costs associated with a specific segment of the hospital’s patients. Blue Cross funded hospitals retrospectively. Put simply, there was an annual reckoning. At the end of the year, Blue Cross would pay its share of hospital costs. If 50% of the patients were Blue Cross subscribers, Blue Cross would pay half of the hospitals’ annual expenses. Medicare was established in 1965 with a similar reimbursement scheme. This inherently inflationary payment mechanism was replaced in the 1980s with prospective payment. In this third phase of hospital financing, led by the introduction of Medicare’s Prospective Payment System in 1983, hospitals were paid a fixed amount based on the type of

illness and type of patient—known as DRGs. The theory underlying this reimbursement system was that hospitals would increase efficiency to cover costs. There is some evidence that this happened (Lee, Berenson, Mayes, & Gauthier, 2003). On the other hand, critics charged that hospitals were discharging patients “sicker and quicker” to achieve the same ends (Newcomer, Wood, & Sankar, 1985). Private insurers adopted similar reimbursement schemes. By the early 1990s, virtually all hospital reimbursement systems contained some element of the prospective payment, case-based system. With each payment iteration, reimbursement became more specific and more focused. With the growth of managed care and the power of private insurers to direct where patients receive care, hospitals have had to provide steep discounts in exchange for guaranteed patient share. Medicare and Medicaid, the public payers, accounted for 54% of all hospital care in 2014 (National Center for Health Statistics, 2016) but reimburse hospitals less than full cost (AHA, 2016). Medicare paid only 92 cents for each dollar spent caring for a Medicare patient, and Medicaid paid only 89 cents for every dollar spent by the hospital. The combined funding shortfall for hospital care was almost $37 billion. The size of hospitals’ discount rates to private insurers is dependent on the market. Where hospitals are part of systems, they can dictate prices to insurers. Where there is an insurance concentration, they can negotiate lower prices (Frakt, 2010). The other area where financial stress can be seen is in access to capital (Robinson, 2002). Hospitals were encouraged to debt finance, as all interest and depreciation expenses were treated as allowable costs and could be built into their hospital payments from public and private insurance companies. Without adequate capital, hospitals cannot replace or modernize outdated facilities, respond to changing demand such as the growth of outpatient surgery, or add new technology and equipment, but getting capital is sometimes difficult. For-profit hospitals have greater access to capital, as they can sell stocks and bonds in the public markets. Nonprofit

Hospital Strategies in a Competitive Market

and public hospitals finance most capital needs through tax-exempt revenue bonds. Multihospital systems with substantial assets and cash flow have an easier time gaining access to capital markets than freestanding hospitals. Those in the worse position are in inner-city and rural hospitals. Competition for scarce resources reinforces the situation whereby the strongest and best-financed hospitals get stronger, and the weak, less-financed hospitals get weaker.

Vulnerable Hospitals Serve Vulnerable Populations The financial shortfalls are not evenly spread across all hospitals. Hospitals with highest proportion of paying patients are the most viable economically. Hospitals that disproportionately serve the working poor, the unemployed, those with inadequate insurance, undocumented ­immigrants, and Medicaid patients are most vulnerable due to low reimbursement rates (Tompkins, Altman, & Eilat, 2006). These might be public or nonprofit hospitals. The situation of public hospitals is further complicated by their provision of unprofitable services that are highly labor intensive (Horwitz, 2005). These are inpatient and outpatient services that combine medical and social services that many nonprofit hospitals find too costly to offer. In the 10 largest cities, public hospitals account for 11% of acute care hospitals but provide 20% of emergency visits and 27% of outpatient visits. These hospitals represent 32% of Level I trauma providers and 58% of the beds for burn patients (National Association of Public Hospitals and Health Systems, 2009). Their debt is picked up by local government, but the tax base is not adequate in lower-income communities to assure their survival. Local tax revenues have risen less quickly than hospital costs. Hospitals in rural areas were largely built as a result of the Hill-Burton legislation (Dowell, 1987). To distribute funds equitably across the 50 states, money went into the construction of hospitals in communities of less than 10,000

301

persons. There are currently 2,000 rural hospitals, which is 40% of all nonfederal hospitals. Rural hospitals are even more financially vulnerable than many of the inner-city community hospitals because they tend to be smaller, have less than 50 beds, and cannot offer highly complex care. As a result, there is a reduced demand for rural hospital beds because many medical procedures that might have been done in such a facility can now be done on an outpatient basis. They have occupancy rates of less than 40%. Also, rural hospitals received a lower DRG rate than do urban hospitals, and they have increased debt from bills that are uncollectable due to serving very-low-income patients (Chul-Young & Moon, 2005). Recognizing the need for hospitals in rural communities, Medicare has created a category of rural hospital called Critical Access Hospitals (CAH). CAHs have an average LOS of 96 hours, no more than 25 beds, and are reimbursed based on cost plus 1%, as opposed to fixed reimbursement rates (Centers for Medicare & Medicaid Services [CMS], 2013).

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Hospital Strategies in a Competitive Market

With hospital survival dependent on their generating adequate revenues to cover costs, hospitals have found themselves investing in two types of strategies to assure their financial viability. Both aim to control the market for health services. The first is the creation of formalized hospital networks so that hospitals strengthen their competitive position vis-à-vis health insurers. The second is to hire physicians so that hospitals do not find themselves in competition with the doctors who increasingly can provide a wide range of services in ambulatory settings.

Networks and Systems Hospitals have sought to secure their situation by seeking control over the market for health services through consolidations and mergers

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Chapter 14 Hospitals: Consolidation and Compression

(Kocher & Emanuel, 2012). This is not a new strategy, and it has proved relatively successful. Health plans prefer more inclusive networks as they best meet the preferences of physicians and patients. Control over local and regional markets has also proven financially beneficial to hospitals as they have been better able to dictate prices. Health plans (insurance companies) find they have little or no negotiating power if hospitals control the supply of services. As a result, prices for hospital care are reported to be 13% to 25% higher where there is consolidation in hospital markets (Kendall, 2012). Starting in 1999, the American Hospital Association began reporting statistics on the number of hospitals that were identified as part of hospital systems that were defined as “a corporate body that may own and manage health provider facilities or health-related subsidiaries as well as non-health-related facilities including freestanding and/or subsidiary corporations” (2016). The number of mergers per year has been increasing since 2000. It leveled off in 2006 to 2007 but then began to rise again following passage of the ACA. Over the last

15 years, there have been 1,163 hospital merger deals—some involving many hospitals, some only one or two institutions. In total, 3,000 hospitals have been involved in mergers or acquisitions since the turn of the century. In 2014, 65% of all community hospitals identified themselves as being part of a system (AHA, 2016). Deloitte, a major accounting and consulting firm, predicts the complete disappearance of independent hospitals by 2024 (Skillrud, Gerhardt, & Shukla, 2014) (FIGURE 14-2).

Hospital/Physician Integration Not only have hospitals sought to control the market for hospital services, but they have also sought to control patient admissions through their relationships to the physicians who d ­ irect patient care. Affiliations with primary care physicians ensure referrals into the hospitals’ specialty practices whose services were highly lucrative, such as cardiothoracic surgery. Many younger physicians and physicians in primary care, who faced reimbursement rates that have been r­ elatively constant and who want more balanced lifestyles,

350 300 250 200 150 100 50 0 1988 1989 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Number of deals

Number of hospitals

FIGURE 14-2  Announced Hospital Mergers and Acquisitions, 1998–2015 Reproduced with permission from Irving Levin Associates, Inc..

The ACA and The Rationalization of Hospital Care

have opted for such arrangements. It becomes a way to have greater leverage when negotiating rates with insurers and more steady hours (O’Malley, Bond, & Berenson, 2011). The first round of hospitals purchasing physician practices began in the 1990s. H ­ ospitals lost money on these arrangements as compensation was salary based, not productivity based (Kocher & Sahni, 2011). Poorly developed ­contracts guaranteed physicians almost 100% of their previous year’s salary. This arrangement invariably led to losses as physicians continued to provide lucrative services in settings not affiliated with the hospitals (O’Malley et al., 2011). Once again, hospitals are looking to employ physicians. In part, this is driven by fear that physicians will become competitors by aggregating into larger integrated groups that direct referrals and utilization to their advantage. Strategically, hospitals with robust employment strategies believe they will be positioned to compete under a variety of reimbursement scenarios because hospital-employed primary care physicians direct patients to their hospitals and the specialists affiliated with them (Kocher & Emanuel, 2012). As the payment system moves toward risk-based (“value-based”) reimbursement, large outpatient networks will allow a system to shift patients away from higher-cost hospital-based care and capture revenue that otherwise would have been lost. By January 2015, 38% of physicians were employed directly by hospitals (Physicians Advocacy Institute, 2016).

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The ACA and The Rationalization of Hospital Care

Not since the implementation of DRG-based reimbursement systems has federal action demanded so many changes in the hospital sector. Built into the Affordable Care Act (ACA) legislation are provisions that address both the organizational fragmentation of the healthcare system

303

and the financial incentives that have led to rapidly increasing costs. The provisions related to the organization of accountable care organizations (ACOs) create a mechanism whereby providers who previously operated independently within a community develop mechanisms that assure patients of receiving comprehensive and continuous care. Also, the ACA uses the reimbursement system to support the alignment of these providers. While the ACOs and pay-for-performance (P4P) constructs are still in their infancy, they incorporate legislative incentives to improve quality and control costs. Under threat of reduced Medicare (and in some cases Medicaid) reimbursement, whether organized in ACOs or not, hospitals have been required to adopt electronic medical records systems, reform their inpatient safety procedures, and manage all levels of care from preadmission to postdischarge services.

Accountable Care Organizations and the Alignment of Services The concept of integrated care is not new. The model of an organization taking responsibility for the provision of comprehensive and continuous care has origins with health maintenance organizations first organized in the 1930s. These organizations bore the risk for ensuring that patients received all-inclusive services. With the growth of managed care in the late 1980s, there was pressure for hospitals to integrate services both vertically and horizontally. The rational for integration was twofold. By creating a continuum of care, the quality of care would be improved, and by reorganizing payment using global capitation and risk contracting, it would be more efficient. The 1980s assumptions that drove the growth of managed care were not borne out. Under the influence of fixed capitation payments, providers often sought to maximize their revenues by denying or delaying care. The projected economies of scale did not follow the development of these first integrated systems nor did synergies occur (Burns & Pauly, 2001). Instead,

304

Chapter 14 Hospitals: Consolidation and Compression

integration became a financial strategy to protect hospital position. The term accountable care organization was first used in 2006 as a new way to explain efforts to make care providers responsible for both the quality of care and the costs of care. This would be achieved through payments linked to quality improvement. Demonstration programs funded by the Centers for Medicare & Medicaid Services (CMS) led to the inclusion of language about ACOs in the Affordable Care Act. The ACA created the Medicare Shared Savings Program (MSSP), which encourages voluntary groups of physicians, hospitals, and other healthcare providers to become identified as ACOs. According to the legislation, over a 3-year period, the ACOs become responsible for the overall quality, cost, and care of a defined group of at least 5,000 Medicare beneficiaries. By including the MSSP in the ACA, it becomes a permanent option under Medicare. There is a clear understanding that care coordination is not easily achieved and that creating ACOs can be costly. The success of ACOs relies very heavily on shared information systems that enable providers in different practice settings to work from the same database so they have access to information about prior medical care and can avoid unnecessary duplication of services. The implementation of electronic health records is expensive and raises complex problems related to data compatibility and data sharing (Friedman, Parrish, & Ross, 2013). The difficulties and costs were recognized by the Health Information ­Technology for Economic and Clinical Health Act (HITECH Act), a part of the American Recovery and Reinvestment Act of 2009, which offered hospitals and other providers financial assistance and incentives to support rapid adoption of electronic health record technology during the period 2011 to 2014. Any hospital that failed to adopt meaningful use of electronic medical records by 2015 would become subject to significant financial penalties—an increasingly large reduction in their year-to-year market-basket

price increases. The carrot and stick approach is working. In 2008, only 9.4% of hospitals had adopted basic electronic health record technology. As of 2015, nearly all hospitals had been certified as having met the technological capability, functionality, and security requirements required by the U.S. Secretary of Health and Human Services. This extraordinary growth was accomplished in less than a decade (Henry, Pylypchuk, Searcy, & Patel, 2016). ACO take-up has also been very rapid. As can be seen on FIGURE 14-3, at the end of January 2016, there were 838 active ACOs in the U.S. Just 5 years earlier there were 64. Results are mixed as to whether ACOs reduce overall healthcare costs. About half of Medicare ACOs (205 ACOs) reported $1.6 billion in costs below benchmarks in 2015. At the same time, 189 Medicare ACOs had expenditures $1.1 billion over their benchmarks. Net-net, according to health policy researcher Ashish Jha, the savings of approximately $0.5 billion in Medicare’s $646 billion program “is decidedly mixed news for the ACO program” (Jha, 2016). Findings related to the impact of ACOs is still being studied although early reports also suggest mixed results depending on the patients served (Kocot & White, 2016).

Payment Reform to Improve Quality While payment reform has had a decidedly uneven impact on cost, its effect on quality is much more well established. The use of payment incentives and penalties is a way to influence how medicine is practiced. The overall intent is to design reimbursement so that there are incentives for practitioners to coordinate care and control costs. Starting in 1983 with the implementation of DRGs, hospitals changed the way they cared for patients and monitored length of stay with a concomitant reduction in cost (White, 2013). In 2011, Medicare extended the concept to bundled physician services and postoperative care

The ACA and The Rationalization of Hospital Care

305

900

Number of public & private ACOs

800 700 600 500 400 300 200 100 0 Q1 2011

Q1 2012

Q1 2013

Q1 2014

Q1 2015

Q1 2016

FIGURE 14-3  ACOs Over Time Reproduced from Muhlestein, D., & McClelland, M. (2016). Accountable Care Organizations In 2016: Private and public-sector growth and dispersion. Retrieved from https://www.healthaffairs.org/do/10.1377 /hblog20160421.054564/full/

into the prospective payment system. By bundling payments, physician interests were aligned with the hospitals as well as with postoperative care providers. All benefited from care coordination. As was demonstrated with the introduction of DRG payment schemes, the evidence shows if one significant payer like Medicare changes the way payment is structured, hospitals in turn reform the way they provide care regardless of payer. For example, Medicare introduced reimbursement penalties for patient safety incidents such as central-line infections, sepsis, and other hospital-acquired conditions (HACs) in 2010. While 738 hospitals were penalized in 2015, there had been a decline of 21% in all HACs between 2010 and 2015, not just those in which elderly patients were harmed—a cumulative reduction of 3.1 million cases (Agency for Healthcare Research and Quality [AHRQ], 2015). Pay for performance (P4P) is another strategy to control costs by better aligning hospitals and doctors to improve quality. The pay-for-performance model adjusts the fee-forservice payment system by making higher payments for higher quality care. CMS initiated its first pay-for-performance program in 2003.

Under the aegis of the ACA, some new or enhanced P4P programs were specifically designed to improve hospital quality of care. ■■

■■

Hospital Value-Based Purchasing program. 1% of Medicare-based payments are withheld from 3,500 eligible hospitals and redistributed based on whether a hospital meets 20 specific quality standards. Hospitals that score well are given bonus payments. Hospital Readmission Reduction Program. A penalty of up to 3% of all Medicare payments is applied when a hospital readmits patients with heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), elective hip or knee replacement, and coronary artery bypass graft (CABG) within 30 days of discharge.

While there remains disagreement of the extent to which improvements in hospital quality are due to payment interventions or result from changes in medical practice that might have occurred, there is no question that U.S. hospital care is safer today than it was before the 2010 passage of the ACA. Medicare hospital readmission rates began falling in 2012 and

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Chapter 14 Hospitals: Consolidation and Compression

have continued to decline since. For example, heart failure readmissions fell from 24.7% (July 2008 to June 2011) to 22% (July 2011 to June 2014). Likewise, readmissions for heart attack declined from 19.7% to 17% and readmissions for pneumonia fell from 18.5% to 16.9% (Boccuti & Casillas, 2017). There are many fewer instances of patients harmed by their hospital stays. Most dramatically, AHRQ estimates 124,348 averted deaths between 2011 and 2015 as a result in the decline of HACs.

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Healthcare Policy, Health Reform, and the Role of Hospitals

Although much altered since the turn of the 21st century, hospitals remain at the center of the U.S. healthcare delivery system. The 5,000 general care hospitals still account for more than one-third of healthcare spending. As centers of patient care, teaching, and research they continue to influence everything that happens on the US health system. In 1982 Paul Starr, author of The Social Transformation of American Medicine, surveyed the state of health care in the early years of the Reagan Administration. He predicted a coming corporatization: The failure to rationalize medical services under public control means that sooner or later they would be rationalized under private control (Starr, 2017, p. 449). His prediction rings truer today than it did 35 years ago. Hospital corporatization has taken three main forms: for-profit hospital/physician systems; nonprofit fully integrated healthcare systems; and hybrid nonprofit/for-profit networks of hospitals, practices, technology, and insurance entities operated by nonprofit hospital-organized holding companies.

The largest for-profit chain is Nashville-based Hospital Corporation of America (HCA). In 2017 it owned 172 hospitals, 119 free-standing surgical centers, 71 urgi-care centers, and 830 physician clinics plus several complementary businesses. The largest noncare business is Parallon, an outsourcing firm that offers various healthcare management functions, including revenue cycle, workforce management, and supply chain operations. Reporting 27 million patient encounters in 2016, it employed 240,000 people including 80,000 RNs and 37,000 MDs. HCA had $37 billion in operating income (HCA, 2016). “We are committed to providing the communities we serve with high quality, cost-effective health care,” according to its 2016 SEC filing, “while growing our business, increasing our profitability and creating long-term value for our stockholders” (HCA, 2016). Whether both goals can be accomplished in the same settings remains an open question. Kaiser Permanente is the quintessential fully-integrated, closed, nonprofit healthcare system. Kaiser, headquartered in Oakland, California, is both insurer and provider. First organized in 1945 to provide medical care to thousands of shipyard workers on the docks of Richmond, California, Kaiser Permanente has grown to 12 million subscribers cared for by 190,000 healthcare workers, including 54,000 RNs and 21,000 MDs. Kaiser is an HMO with a closed network. It provides care to no one other than its plan enrollees, and those enrollees are not covered for any out-of-network care. Its $64.4 billion (2016) operating revenue supported 38 hospitals and 673 medical offices, which include clinicians, labs, and radiological suites in 9 states and Washington, DC. A prototype for the HMOs that were created in the 1980s and 1990s, Kaiser’s patients are more likely to receive preventive care and far less likely to be admitted for inpatient services. Kaiser uses much of its excess operating income to invest in healthcare technology development. In fact, more patient–doctor interactions happened via telehealth (59 million) in 2015 than in person (50 million) (Kaiser Permanente, 2015).

References

To complete its vertical and horizontal integration, Kaiser operates nearly a full complement of health professions training programs. Kaiser runs its school of allied health sciences, has a close affiliation with an RN/BSN-granting program at nearby Samuel Merritt University, and has received approvals to open the Kaiser Permanente School of Medicine in 2019. Can a network that controls all its inputs produce better care at lower cost? New York’s Northwell Health System is an example of a nonprofit, hospital-led hybrid network. It is the fourteenth largest network in the U.S. Spanning 22 hospitals, 550 outpatient facilities, and 16 postacute facilities, Northwell opened a medical school in 2011—the Hofstra Northwell School of Medicine, and in 2015, Hofstra Northwell added a graduate school of nursing and physician assistant studies. It is now the biggest private employer in New York state with 62,000 employees, including 15,000 nurses and 3,900 directly employed physicians. Its operating budget in 2017 was $11 billion. In addition to a very substantial service network, Northwell has made significant investments in for-profit health-related entitles—HealthReveal (remote monitoring and analytics), Avizia (telehealth), Peerbridge Health (wireless cardiac monitoring), and Conversa (digital patient–doctor “discussion platforms”) (Northwell Health System, 2017). It has also created a commercial insurance company to sell Northwell network–based products on and off the ACA marketplace. Not a closed or fully integrated network like Kaiser Permanente, most of its patients have non-Northwell commercial or public insurance. In which direction is Northwell likely to go: to look more like the for-profit sector with its focus on finances or like a fully integrated healthcare conglomerate able but not certain to produce better care at a lower price? One prediction we can make with certainty: There will be no standalone, independent hospitals in the United States. Whatever the resolution of the debate over the expansion of health insurance, consolidation and corporatization in the health sector, often lead by the

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large academic medical centers, will be the dominant trend for the foreseeable future. Hospitals will be integrated into complex systems of care. What we cannot predict is the effect this accelerating process will have on patients or healthcare workers.

Discussion Questions 1. 2. 3. 4.

Why have hospitals experienced declining lengths of stay and admissions over time? How do you explain the decline of free-standing, independent hospitals? How have hospitals sought to ensure their position within the communities they serve? How have initiatives codified in the Affordable Care Act changed the way hospitals function?

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Boccuti, C., & Casilllas, G. (2017, March). Aiming for fewer hospital u-turns: The Medicare hospital reduction program. Issue Brief. Kaiser Family Foundation. Retrieved from http://www.kff.org/medicare/issue-brief/aiming-for-fewer -hospital-u-turns-the-medicare-hospital-readmission -reduction-program/ Burns, L., & Pauly, M. (2001). Integrated delivery networks: A detour on the road to integrated health care? Health Affairs, 20(6), 128–143. Centers for Medicare & Medicaid Services (CMS). (2013). Critical access hospital: Rural health fact sheet series. Retrieved from https://www.cms.gov/Outreach-and -Education/Medicare-Learning-Network-MLN/MLN Products/downloads/CritAccessHospfctsht.pdf Chul-Young, R., & Moon, M. J. (2005). Nearby, but not wanted? The bypassing of rural hospitals and policy implications for rural health care systems. Policy Studies Journal, 33(3), 377–394. Retrieved from http://search .proquest.com/docview/210555132?accountid=8500 Cutler, D. (2009). The next wave of corporate medicine —How we all might benefit. New England Journal of Medicine, 361, 549–551. Retrieved from http://dx.doi .org/10.1056/NEJMp0904259 Daugherty, D.A., & Escobedo, E. (2013). An empirical study of the determinants of safety-net hospital failures. Global Conference on Business & Finance Proceedings, 8(2), 79–88. Hilo, HI: Institute for Business and Finance Research. Retrieved from http://search.proquest.com .remote.baruch.cuny.edu/docview/1434203593/fulltext /14113C06F704328E039/1?accountid=8500 Dowell. M. (1987). Hill-Burton: The unfulfilled promise. The Journal of Health Politics, Policy and Law, 12(1), 153–176. Draper, D. A., Hurley, R. E., Lesser, C. S., & Strunk, B. C. (2002). The changing face of managed care. Health Affairs, 21(1), 11–23. Frakt, A. (2010). Expert voices: The future of health care costs: Hospital-insurer balance of power. Washington, DC: National Institute for Health Care Management (NIHCM) Foundation. Retrieved from http://www .nihcm.org/pdf/EV_Frakt_FINAL.pdf Friedman, D. J., Parrish, R. G., & Ross, D. A. (2013). Electronic health records and US public health: Current realities and future promise. American Journal of Public Health, 103(9), 1560–1567. Retrieved from http://search.proquest .com/docview/1440078906?accountid=8500 Henry, J. Pylypchuk, Y., Searcy, T., & Patel, V. (2016, May). Adoption of electronic health record systems among U.S. non-federal acute care hospitals: 2008–2015. Data Brief 35. The Office of the National Coordinator (ONC) for Health Information Technology. Retrieved from https:// dashboard.healthit.gov/evaluations/data-briefs/non -federal-acute-care-hospital-ehr-adoption-2008-2015.php Horwitz, J. R. (2005). Making profits and providing care: Comparing nonprofit, for-profit, and government hospitals. Health Affairs, 24(3), 790–801.

Hospital Corporation of America (HCA). (2016). HCA Annual Report Pursuant to Section 13 or 15(d) of the Securities Exchange Act for the fiscal year ended December 31, 2016. 2016 Annual Report to Shareholders. Jha, A. (2016, August 30). ACO winners and losers: A quick take. An Ounce of Evidence—Health Policy: The Blog of Ashish Jha. Retrieved from https://blogs.sph.harvard .edu/ashish-jha/2016/08/30/aco-winners-and-losers-a -quick-take/ Kaiser Family Foundation. (2015). Hospital beds per 1,000 population, 2011. Retrieved from http://kff.org/other /state-indicator/beds/# Kaiser Permanente. (2015). Annual Report, 2015. Retrieved from https://share.kaiserpermanente.org/static/kp _annualreport_2015/#quality Kalra, A.D., Fisher, R.S., & Axelrod, P. (2010, April 29). Decreased length of stay and cumulative hospitalized days despite increased patient admissions and readmissions in an area of urban poverty. Journal of General Internal Medicine, 25(9), 930–935. doi: 10.1007/s11606-010 -1370-5 PMCID: PMC2917661 Kendall, B. (2012, March 18). Regulators seek to cool hospital-deal fever. The Wall Street Journal Online. Retrieved from http://online.wsj.com/article/SB100 01424052702303863404577286071837740832.html Kocher B., & Emanuel, E. J. (2012). Overcoming the pricing power of hospitals. Journal of the American Medical Association. 308(12), 1213–1214. doi:10.1001/2012 .jama.11910 Kocher, R., & Sahni, N. R. (2011). Hospitals’ race to employ physicians—the logic behind a money-losing proposition. New England Journal of Medicine, 364(19), 1790–1793. Kocot, S. L., & White, R. (2016, September 21). Medicare ACOs: Incremental progress, but performance varies. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog /2016/09/21/medicare-acos-incremental-progress-but -performance-varies/ Law, S. (1986). Blue Cross: What went wrong? In P. Conrad & R. Kern (Eds.), The sociology of health and illness (2nd ed.). New York, NY: St. Martin’s Press. Lee, J. S., Berenson, R. A., Mayes, R., & Gauthier, A. K. (2003, July-December). Medicare payment policy: Does cost shifting matter? Health Affairs, Web Exclusives W3-480-8. Luft, H. S. (1981). Health maintenance organizations: Dimensions of performance. New York, NY: John Wiley and Sons. Mechanic, D., (2011). The ‘brilliant, persistent’ pursuit of health care as a complex social system. Health Affairs, 30(2), 362–363. Medicare Payment Advisory Commission (MEDPAC). (2016, March) Report to Congress: Medicare payment policy. Retrieved from http://www.medpac.gov/docs /default-source/reports/march-2016-report-to-the -congress-medicare-payment-policy.pdf?sfvrsn=0

References Mitchell, J. M. (2007). Utilization changes associated with physician ownership of ambulatory surgery centers (ASCs). Paper presented at International Health Economics Association 6th World Congress: Explorations in Health Economics. Copenhagen, Denmark; July 5, 2007. Retrieved from http://ssrn.com/abstract=992622 Muhlestein, D., & McClellan, M. (2016). ACOs in 2016. Health Affairs Blog. Retrieved from http://healthaffairs .org/blog/2016/04/21/accountable-care-organizations -in-2016-private-and-public-sector-growth-and -dispersion/ National Association of Public Hospitals and Health Systems (NAPH). (2009, June 13). America’s safety net hospitals and health systems, 2007: Results of the NAPH Annual Hospital Characteristics Survey. Retrieved from http:// www.naph.org/Main-Menu-Category/Our-Work/Safety -Net-Financing/Characteristics-Report/Characteristics -2007.aspx National Center for Health Statistics (NCHS). (2016). Health, United States, 2015: With special feature on racial and ethnic health disparities. Hyattsville, MD: NCHS. Newcomer, R., Wood, J., & Sankar, A. (1985). Medicare prospective payment: anticipated effect on hospitals, other community agencies, and families. Journal of Health Politics, Policy and Law, 10(2), 275–282. New York State Department of Health. (2009). Hospital profile. Retrieved from http://hospitals.nyhealth.gov/ Northwell Health System. (2017). About Norwell Health. Retrieved from https://www.northwell.edu /about-northwell-health O’Malley, A. S., Bond, A. M., & Berenson, R. A. (2011). Rising hospital employment of physicians: Better quality, higher costs? Issue Brief No. 136. Center for Health

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System Change. Retrieved from http://www.hschange .com/CONTENT/1230/ Physicians Advocacy Institute (PAI). (2016, September). Physician Practice Acquisition Study: National and regional employment changes. Retrieved from http:// www.physiciansadvocacyinstitute.org/Portals/0/assets /docs/PAI-Physician-Employment-Study.pdf Robinson, J. C. (2002). Bond-market skepticism and stock-market exuberance in the hospital industry. Health Affairs, 21(1), 104–117. Rosenberg, C. E. (1982). From almshouse to hospital: The shaping of Philadelphia General Hospital. Milbank Memorial Fund Quarterly, 60(1), 108–154. Rosner, D. (1982). A once charitable enterprise: Hospital and health care in Brooklyn and New York, 1885–1915. Princeton, NJ: Princeton University Press. Skillrud, I., Gerhardt, W., & Shukla, M. (2014). The great consolidation: The potential for rapid consolidation of health systems. Deloitte Center for Health Statistics. Retrieved from https://www2.deloitte.com/content /dam/Deloitte/us/Documents/life-sciences-health-care /us-lshc-great-consolidation-111214.pdf Starr, P. (1982, 2017). The social transformation of American medicine. New York, NY: Basic Books. Stevens, R. (1989). In sickness and in wealth: American hospitals in the twentieth century. New York, NY: Basic Books. Tompkins, C. P., Altman, S. H., & Eilat, E. (2006). The precarious pricing system for hospital services. Health Affairs, 25(1), 45–56. White, C. (2013). Contrary to cost-shift theory, lower Medicare hospital payment rates for inpatient care lead to lower private payment rates. Health Affairs, 32(5), 935–943.

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CASE STUDIES

CASE STUDY Rebranding of North Shore-LIJ Health System Barbara Caress

Purpose/Scope To examine one aspect of corporatization of hospitals—an investment in rebranding effort to promote high-tech, patient services to a wider regional marketplace.

Background “I can’t tell you the number of people over the years who said you’re just a Long Island system,” CEO Michael Dowling explained in 2002 (LaMantia, 2015). North Shore-LIJ Health System (NS-LIJ) was created in 1997 with the merger of Long Island Jewish Medical Center, an 827-bed, three-site hospital (general care, children’s, and psychiatric), and nearby North Shore Health System, a small,

Courtesy of Northwell Health.

two-hospital “system.” By 2015 it had grown to a $7.4 billion operation encompassing 21 hospitals, 400 clinics and physician practices, 2,000 employed doctors, and 11,000 RNs. It created a research center and made financial deals with several for-profit hospital or health-oriented businesses. NS-LIJ sponsored the area’s first medical school and a graduate program for nurses and physician assistants. And in 2014 establishment of its own insurance company was announced (NS-LIJ, 2015). Straddling the New York City–Nassau County border, it was the dominant local hospital system. Eighty-five percent of its patients came from the boroughs of Queens (31%) and nearby Staten Island (15%) or one of Long Island’s two counties—Nassau (22%) and Suffolk (17%). Despite its Manhattan, Brooklyn, and northern suburban presence only, 15% of patients came from outside the core service area. Although NSLIJ was the largest health system in the NYC area (by beds, income, and discharges), expansion appeared to be blocked by the growth of four nearby, very large hospital networks, which together had captured much of the rest of the regional market.

Case Study

The Rebranding Program

ad campaign (18 commercial spots) focused on new technologies from genomics, to robotics, to a hospital curtain that reduces the threat of infection. Each ended with the tag line, “Not just raising our standard of care, but the standard of care.” Stacey Bonhomme, a hospital intake clerk, commented that the name change was “a really big deal. It’s going to take a while to get used to, but it’s catchy” (Ramey, 2015).

Case Study Questions 1. Why do you think the system wanted to expand? Did it have to expand to be successful? 2. What were some important reasons for North Shore-LIJ to change its name? 3. What was the message the TV ads were trying to convey? Was this consistent with the meaning attributed to its new name? What other types of care (services) might a healthcare system want to promote? 4. How might the values implicit in the branding campaign affect the way Northwell employees see their jobs? 5. Do you think rebranding changes the character of an institution? Or is more likely the other way around—the character of an institution shapes the name change?

References Bermis, L. (2016, January 8). 8 questions with brand expert behind Northwell Health. Becker’s Hospital Review. Retrieved from http://www.beckershospitalreview.com /hospital-management-administration/8-questions -with-the-brand-expert-behind-northwell-health.html LaMantia, J. (2015, November 2). An $8 billion health care giant outgrows its name—and loses its Long Island accent. Crains New York Business, 31(44), 0010. North Shore-LIJ Health System. (2015). What’s possible: The face of health care’s future. 2014 Annual Report. Retrieved from https://www.northwell.edu/sites/default/files /NSLIJAR2014.pdf Northwell Health. (2017). Making the impossible possible. 2017 Annual Report. Retrieved from http://onwardpublishing .com/Northwell-Health-Annual-Report-2017/ Ramey, C. (2015, December 29). Long Island Health Network rebrands. The Wall Street Journal Online. Retrieved from https://global-factiva-com.remote.baruch.cuny.edu /ha/default.aspx#./!?&_suid=15325379964420374730 92003868214

CASE STUDIES

Bigness was not enough. “Who wants to be the Walmart of health care?” asked Ramon Soto, NS-LIJ’s newly hired senior vice president and chief marketing/communications officer (LaMantia, 2015). Unspoken was the limitations inherent in the inititals of its name—LIJ, which stood for Long Island Jewish, a sectarian local institution. NSLIJ wanted to get beyond both attributes. It was difficult to reach a broader market, including the rapidly growing Chinese community, when the translation of the initials was Hospital for Jews by the Sea. In addition to hiring the experienced Mr. Soto, the health system engaged Monigle, a major branding company whose clients included Chase Bank, Enterprise Rent-A-Care, AT&T, plus several large hospital systems in the midwest and south. Monigle conducted an array of surveys and focus groups with stakeholders (including current patients and staff ), and market research about the regional target communities of Connecticut, New Jersey, and New York City’s northern suburbs. According to Justin Wartell, Monigle’s managing director, they were able to isolate key findings. “What was intriguing about the New York region in general is it was the only market that we’ve yet encountered where the idea of innovation— latest medical treatments, latest technologies, cutting-edge medical breakthroughs—where those ideas or attributes matter” (Bermis, 2016). In September 2015, North ShoreLIJ announced that beginning January 1, 2016, the system would be known as “Northwell Health.” Facilities would retain their names with Northwell Health added as a tag line. According to CEO Dowling, the compound name was intended to convey a journey (North) and focus on preventive care (well). “A neutral name that has a meaning can be very helpful as we continue to build the organization” (LaMantia, 2015). The system’s leadership expected to increase their advertising budget six-fold from $2 million to more than $12 million (Ramey, 2015). A 30-second Super Bowl ad directed at the regional market, plus two 30-second pregame ads, ate up a substantial piece of that budget. Consistent with the findings described by its branding agency, Northwell’s TV

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CHAPTER 15

Enhanced Primary Care Roles for Nurses and Other Professionals Betty Rambur

OVERVIEW There is a quiet revolution occurring in health care. Behind the swirling, politicized rhetoric on health reform and diverging perceptions about the role of government in health care, substantive and unprecedented changes are creating major shifts in the organization and delivery of services. Fueled by a growing recognition of the impact of social determinants of health and the inherent limitations of the predominant medical model of care, and its related waste, cost, and quality challenges, payment reform is shaping new forms of delivery. A revitalized primary care foundation is essential to the success of these models. This need can be addressed only through revitalized and reconceptualized roles for all health professionals, arguably with the greatest responsibility falling to their largest group, the registered nurses (RNs). Indeed, George Thibault of the Macy Foundation notes: “We simply can’t meet the primary care needs of the nation unless registered nurses are part of the solution, and we must prepare them appropriately and then use them for this role” (2016, p. 6). Most contemporary health professionals, however, have been educated and practice in acute care– centric settings, specialty practices, or singular endeavors such as standalone dental or mental health services. Thus it can be difficult to fully comprehend the societal need for a shift from a specialtydominant system to one grounded in a broad, firm, primary care base. This transition creates career opportunities, but also, for those unwilling to evolve professionally, potential career threats. Far more important, however, the transition to a strong primary care foundation represents rectification of a costly, flawed, and in some cases fatal U.S. healthcare system. Thus, the transition to a system grounded in primary care is nothing less than a massive reconstitution of service delivery that, optimally, will (continues) © Anthony Krikorian/Shutterstock

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OVERVIEW

(continued)

address foundational defects in the U.S. healthcare system. The flaws in this foundation resulted from early 20th-century educational initiatives that were appropriate for that era, when infectious disease and trauma were leading causes of morbidity and mortality. Early reimbursement models were tied to this orientation. Thus reinforced and fed, a particular type of care emerged as “standard.” It targeted acute and episodic medical interventions, invasive procedures, and pharmaceutical solutions, and it flourished. Yet today health care itself is the third leading cause of death in the U.S. (Makary & Daniel, 2016) and chronic conditions are the prime malady (Centers for Disease Control and Prevention [CDC], 2017). Contemporary challenges include expanding populations with geriatric declines, disabilities, and cognitive impairments; technological innovations that support virtual care; and an epidemic of mental health issues and substance abuse, the later unfortunately fueled by the opioid-prescribing habits of healthcare providers (Barnett, Olenski, & Jena, 2017). And, despite costs roughly double those of 10 other wealthy nations, the United States ranks dead last in outcomes among them (Schneider, Sarnak, Squires, Shah, & Doty, 2017). Healthcare professionals, despite good intentions, are—with the intent of helping—doing harm and costing both taxpayers and families a great deal of money. However, this seemingly grim situation has a silver lining: With awareness of the deep flaws and missteps comes an opportunity to create a healthcare environment that truly heals. Given the magnitude of the problem, informed action toward change should be construed as an ethical imperative, particularly in light of the fundamental moral obligation of any health professional: “do no harm.”

OBJECTIVES ■■

■■ ■■

Describe the economic and ethical forces propelling the need for a stronger primary care foundation for the U.S. health care system. Propose redesigned models of patient care that enhance access to primary care. Describe the relationship between payment reform and enhanced primary care.

HOW TO BEGIN An ancient parable offers an exacting vision of why it is so important to understand the bigger picture and context of the work nurses and other professionals are called to do as the nation’s foundation is transformed from an uncoordinated, specialty-centric system to one of primary care: Three laborers are laying brick in exactly the same manner. The first, when asked what she is doing, responds flatly, as it seems obvious to her, “Laying bricks.” The second is asked a similar question and responds, proudly, “Building a wall.” The third, joyfully doing exactly the same task responds, beaming, “Me? I’m building a cathedral!” Similarly, to fully participate as a change agent and leader, it is essential to understand the healthcare ecosystem; how it came to be what it is; how it needs to change, and why; and what personal and professional steps must be undertaken. To be fully relevant to a changing healthcare landscape, nurses and other professionals must be prepared to contribute in fresh ways. This includes new roles, but also those roles and functions that nurses and others are well prepared to execute, but which have not been financially rewarded under the predominant fee-for-service system, and thereby atrophied. In other words, relevance means not only “new” roles, but also “renewed” roles that

Overtreatment, Overuse, Waste, and Healthcare Harm

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better serve societal health needs. To be fully satisfied when faced with the frustration and ambiguity that necessarily accompanies change, it is helpful for professionals to recognize the profound social significance and importance of the shift to which they are contributing. They should appreciate how their immediate, tangible actions in their local setting are indeed redirecting delivery away from its current mishmash of fragmentation, error, and expense, and toward a genuinely healing healthcare system, analogous to the bricklayer’s cathedral. What follows, therefore, is an overview of the forces that created the U.S. health system, the drivers of the essential corrective shift to primary care, the social and ethical relevance of this shift, and an explication of vital new and renewed roles for nurses and others.

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Why Primary Care? The Case for Change

International comparisons illustrate fundamental flaws in the U.S. system of care. The U.S. system is weighted with specialists; high-performing nations have a greater emphasis on primary care with proportionally fewer specialists. The U.S. system focuses on medical care; the systems that perform best focus more on determinants of health and social support. They also achieve better outcomes at lower cost. The U.S. system is characterized by waste, and a paradox of overutilization by some and underutilization by others (Bodenheimer & Grumbach, 2016). Both overtreatment and undertreatment are fueled by a fee-for-service payment mechanism that rewards high volumes of care for those who are insured, even when that care is not effective. In the fee-for-service model, each item, procedure, and intervention is charged and reimbursed; the more intensive and extensive the care, the greater the compensation. All services, even if unnecessary, ineffective, or actually harmful, manifest as revenue for the organization or provider. As a result, overtreatment, overutilization, and waste are rampant. New models of care in which nurses coordinate services with others, services aimed directly at health and well-being outcomes, are an exciting, socially important, and ethical approach toward optimizing health and containing costs. Strategies will be discussed in detail later in this chapter. First, a primer on why this shift is essential.

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Overtreatment, Overuse, Waste, and Healthcare Harm

Roughly one-third of heathcare is considered to be unnecessary; estimates range from roughly 20% to almost 50% (Berwick & Hackbarth, 2012). Overtreatment is not benign. As noted, health care is the third leading cause of U.S. deaths (Makary & Daniel, 2016), alarming in and of itself, but even more so when the harmful treatment was not needed in the first place. Unnecessary treatments turn healthy people into victims of the healthcare system. Unnecessary treatments prolong suffering at our most vulnerable times of existence, including at the end of life. Unnecessary treatments raise ethical issues not only because they extract an emotional toll from individuals and families (and in some cases providers), but also because they are related to the ethical principle of justice as fairness originally promulgated by John Rawls (1999, p. 200). Saloner and Daniels (2011) clarify the ethical importance of efforts to address healthcare costs; exorbitant healthcare costs are inconsistent with “the social obligation to protect fair equality of opportunity” (p. 816). These authors further note that the disruption to fairness exists at both the individual/family level and at the level of the nation. As an example of the former, consider $8,000 in yearly healthcare expenses for three families, one who earns $30,000/year, one who earns $90,000/year, and

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one who earns $250,000/year. These costs erode opportunity in very unequal ways: They devastate the lowest earners, they deeply strain the middle, and they are little more than an annoyance for the highest earner, with minimal impact on otherwise disposable income or lifestyle. At the national level, high costs relative to other countries erode American’s equality of opportunity on the global stage. Unnecessary and wasteful care, while providing revenue for healthcare providers, funnels financial resources away from other social goods and valued options. There is a subtle tragedy in the irony of shifting money away from other social benefits to health care. Social determinants of health—such as education and where you live and work—are the best predictors of health status. Yet, overspending on health care paradoxically erodes the nation’s capacity to invest in job creation and education, the very antecedents to the social determinants that best create health. Moreover, the cost of care is also woven into U.S. goods and products as part of the fringe benefit packages of employers who offer health insurance. This, in turn, makes these products more expensive and thus less competitive in the global arena and more expensive at home. And this, in turn, results in more jobs transitioning out of the United States and more imported products consumed here. This broad cost impact is complemented by another largely invisible divergence of resources close at hand: Americans’ home ownership. Healthcare expenses directly impact current and potential homeowners’ monthly carrying costs, that is, the amount of money needed to pay their mortgages, loan interest, insurance, and taxes. Currently, workers pay first, into Medicare, via a payroll tax and general fund taxes, so they thereby support funding of others who are Medicare eligible; next, through state and federal taxes they fund others—those who are on Medicaid; and finally, they fund their own healthcare insurance, either directly out of pocket, or through an individual product on the health insurance exchange (roughly 8% of the population), or as a reduction in real wages by way of their employer-based insurance. They

are also providing resources to fund the health care of teachers and other school workers. This is because the cost of health care for teachers is funded largely by property taxes. Compensation packages for teachers and school staff typically include relatively generous health benefits, and teachers are often represented by unions that advocate for higher salaries and benefits for teachers and school staff, including rich health benefit packages with relatively low employee contributions to premiums and low out-ofpocket expenses. And so there is inherent tension between family desire (or need) for low or reduced property taxes and teachers and their unions who negotiate longstanding rich health benefit packages. Thus, although a convoluted path, overtreatment brings about higher property taxes. In summary, the tentacles of healthcare costs grasp the U.S. economic system in both visible and largely cryptic ways. Although many of these economic effects are not easily discernable, it is widely recognized that healthcare costs contribute to stagnant real wage growth in the United States. In other words, Americans are earning more income, yet feeling a greater financial pinch: the effect of flat or declining real wage growth. What has all this to do with new primary care roles? It illustrates the urgent need for change, and the broad impacts of the unsustainable status quo. Clearly, the nation cannot afford such an expensive, unevenly effective health system, particularly as Baby Boomers march toward Medicare eligibility. Moreover, Medicaid—funded through state and federal taxes—pays for roughly 51% of long-term care services and supports, with other public sources covering an additional 21% (Reaves & Musumeci, 2015). The needs of the aging U.S. population will create unprecedented demands and financial strains on these publically funded segments, which together may involve roughly two-thirds of the population in some states. The high cost of these tax-supported systems erodes the nation’s capacity to invest in other social goals, such as defraying the cost of education, even as student debt approaches crisis levels (Friedman, 2017). In summary, the

Support for Value-Based Care as a Bipartisan Approach

emphasis on cost control within entitlement programs such as Medicare and Medicaid offers further rationale why the creation of more effective, affordable primary care–centric approaches has become critical.

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Support for Value-Based Care as a Bipartisan Approach

Fee-for-service reimbursement is now largely recognized as a significant driver of the expensive, fragmented, error-ridden U.S. healthcare system, and a shift from the fee-for-service model to value-based care is well underway. The term “value-based care” has become somewhat of a buzzword. After all, who doesn’t support “value"? Yet, true value-based care is a dramatic departure from the high-volume, low-accountability reimbursement scheme represented by feefor-service programs. Value-based care actually means both outcome-attentive care and cost-attentive care. Although a plethora of types exist, we can discern two broad categories that reflect these forms of attention. The first is care in which providers accept accountability for results and are financially rewarded for positive measurable outcomes. This includes models in which providers accept “upside-only risk,” which means they receive additional compensation if quality metrics are met and cost of care for a specific population is less than that projected relative to fee-for-service or comparable baseline references. The second is care where providers accept accountability both for outcomes and for cost. In these models, providers are rewarded financially when they achieve measurable positive outcomes, but docked for care that does not meet defined metrics or is more costly than that projected relative to fee-for-service estimates or some other standard. This is termed “downside risk” or full risk bearing. Examples of the former include patient-centered medical homes and “upside-only” accountable care

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organizations (ACOs), while the latter includes bundled payments, risk-bearing ACOs, and all-inclusive total cost-of-care models, sometimes termed a global budget. These approaches are referenced, directed, and in some cases driven by measurement. Such capabilities are comparatively new in health care. They are propelled by—among other things—the Health Information Technology for Economic and Clinical Health Act of 2009, more commonly known as the HITECH Act. It aimed to modernize health information systems, meaningful use initiatives and criteria, and the now ubiquitous employment of electronic health records (EHRs). Reimbursement from payers increasingly requires that outcomes be measured. Primary care nurses can play vital roles that enhance the financial viability and clinical outcome effectiveness of practices, provided they understand the changing world of reimbursement that is now tied to cost and quality. For example, the Medicare Access and CHIP Reauthorization Act (MACRA) and its associated Merit-based Incentive Payment System (MIPS) allow two paths to reimbursement for providers who see Medicare patients. Providers must either participate in a qualified advanced alternative payment model (AAPM) or be subject to MIPS. The AAPM criteria are defined to include downside risk and the measurement and reporting of outcomes. The AAPM providers receive a 5% bonus payment. If a provider is not in an AAPM, reimbursement is subject to MIPS and based on a composite score in four weighted categories. These are: resource use (cost), quality, clinical practice improvement activities, and meaningful use of EHR technology inclusive of reporting measures of interoperability and information exchange. Over time, weights are expected to shift to place a greater emphasis on cost of care. Under MIPS, reimbursements will increase from +/– 4% in 2018 to +/– 9% by 2022. It is important to note that the aggregate sum among all participants must be budget neutral, which means that roughly half the participants will receive cuts. Although this policy change

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is directed only toward Medicare at this time, Medicaid and commercial insurance typically follow Medicare’s approaches. Why is this relevant to primary care? For these models to be successful, primary care must play the central role. In summary, payment reform is an essential driver of the primary care movement. As expensive, intensive treatments diminish rather than generate revenue, there is new room for the broad, socially based, and minimally invasive primary care interactions and interventions nurses can so ably offer. To understand the measurement and reporting within these payment systems, and to redesign care toward measurable outcomes as well, are vital primary care roles.

The Role of Measurement As illustrated in the example of MACRA and MIPS, the level and influence of measurement are unprecedented and have enormous impact on the viability of the organization. Data-referenced care fueled by payment reform is a stunning reversal of the long-term status quo. As Kumar and Nash note: “Most physicians practice in a virtually data-free environment, devoid of feedback on the correctness of their practice. They know very little about the quality and outcomes of their diagnosis and treatment decisions. And without data indicating that they should change what they’re doing, physicians continue what they’ve been doing all along” (2011, para 17). Physician decision making, together with patient preferences and demands, drive healthcare delivery and its costs. Despite good intentions, the systemic result of the interaction of these factors is the overtreatment, high cost, and poor quality previously noted. Arguably, the introduction of outcome metric–referenced payment in healthcare is as radical as the emergence of oxygen in Earth’s atmosphere once was. Though it was initially a toxin, new forms of life quickly adapted to this new element, while others diminished or became extinct. The parallel to health care—both for organizations and professions—should be evident. New primary care roles require a level of data savvy

that many professionals may not fully appreciate; yet measurement of outcomes and cost is central as the nation pivots from fee-for-service to value-based care. So, too, is the need to keep individuals well, to manage chronicity, and—when care is needed—to treat individuals in the most efficient, effective manner. This cannot be done without a robust system of primary care. Professionals, innovators, and entrepreneurs who understand emerging economic and social incentives can offer reimagined and redesigned solutions. It is a dramatic departure from “business as usual” and the physician and hospital-centric landscape of the health care of yesteryear.

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How Payment Reform Shapes Needs and Opportunities in Primary Care

Value-based payments, particularly those that are risk bearing, dramatically change the incentives in healthcare from those in “the often antiquated fee-for-service model” (Phelps, 2017). In fee-for-service health care, physicians—and in most cases nurse practitioners and physician assistants—are drivers of revenue production. Nurses are considered a labor cost in the hospital and ambulatory care setting. In addition, in fee-for-service reimbursement, accountability horizons are also remarkably narrow. Understanding these differing incentives is essential to a successful shift from specialty-centric to primary care. Contrast the differences between these two scenarios.

Scenario 1A: Traditional Fee-For-Service, Independent Primary Care Provider Oscar is a patient in the primary care office of Dr. Larson. He has occasional checkups and is overweight. On his last visit, at age 36, he is

How Payment Reform Shapes Needs and Opportunities in Primary Care

diagnosed with type 2 diabetes. Dr. Larson prescribes appropriate medications for Oscar and refers him to an endocrinologist and a diabetes educator. Oscar nevertheless ends up in the emergency department (ED) with diabetic ketoacidosis. He is capably managed in the ED and referred back to his physician, Dr. Larson. However, Oscar frequently visits the ED on a regular basis with varying medical crises. Note the interactions that generate revenue for the healthcare system: 1. 2. 3. 4. 5. 6.

Visits to the primary care provider, Dr. Larson The diabetes educator The endocrinologist—a specialist compensated at a higher rate ED visits Associated lab tests Medications

Observe that although each segment of the system is acting appropriately within its defined role, the system still fails to help Oscar. The delivery model is characterized by accountability horizons that are both very narrow and very short: narrow because they involve one provider at a time, and short because there is only one visit at a time. As long as Oscar is reasonably insured, he—and the millions like him— generate revenue for the health system and poor health outcomes for the nation.

Scenario 1B: Care in a Risk-Bearing Advanced Alternative Payment Model Instead, imagine that Oscar receives his care through a risk-bearing delivery entity. The provider group accepts overall accountability for the outcomes and cost of care over time. This demands a better understanding of the antecedents of Oscar’s illness, his lifestyle and habits, and any potentially modifiable risk factors. The registered nurse, Rosa, is the team member assigned to take the lead and develop a plan with Oscar. (Note: She does this with Oscar, not for Oscar).

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While developing a relationship with Oscar, Rosa discovers that he lives alone and frequently purchases his dinner at the gas station on the way home from his work as a stonemason. He has no idea how to cook, and has even less interest. Using motivational interviewing techniques, Rosa uncovers a focal point of enthusiasm in Oscar. His beloved younger sister is planning to wed next summer. He is a groomsman, and would very much like to be thinner for the wedding pictures. Rosa suggests a peer coach. Oscar notes that he doesn’t want to work with “one of those buff, gym-rat guys. Those guys are so smug. They make me feel bad.” Rosa concludes that Oscar needs someone with whom he can relate, and suggests Peter. Peter is of similar age, has struggled with his own weight, and is now at a healthy, albeit somewhat generous weight. Rosa accompanies Oscar to make a “warm handoff ” to Peter (See TABLE 15-1 for terms used within the risk-bearing care delivery process). Over time, Peter and Oscar plan a number of supportive activities designed to help Oscar make long-lasting lifestyle changes. Peter, for example, organizes a grocery shopping trip with a community health team peer, and follows with a home visit to demonstrate healthy, easy food preparation. Oscar loses a modest amount of weight and continues to interact with the health team, initially on a weekly basis, then monthly, using a combination of face-to-face, phone, text, and group visit activities and interventions. Oscar eventually has a reasonable weight and healthier lifestyle and he returns to the office on a yearly basis, or if something new arises. Over time, unfortunately, Oscar’s weight creeps up again; at age 47 he is diagnosed with type 2 diabetes during his yearly visit with the nurse practitioner (NP). The NP prescribes appropriate medication and reconnects him with a health coach and a diabetes educator, with plans for ongoing follow-up. In doing weekly panel reviews of ED visits, however, Rosa notes that shortly after initial diagnosis and initiation of treatment, Oscar visited the ED presenting with diabetic ketoacidosis. She calls Oscar and he reveals that he is not taking the medication.

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TABLE 15-1  Terms Used in Advanced Primary Care Term

Definition

Warm handoff

“A warm handoff is a transfer of care between two members of the health care team, where the handoff occurs in front of the patient and family. This transparent handoff of care allows patients and families to hear what is being said and engages patients and families in communication, giving them the opportunity to clarify or correct information or ask questions about their care (Agency for Health Research and Quality, n.d.). Evidence suggests that this approach facilitates the initiation of behavior change services such as, for example, enrollment in a smoking cessation program (Richter et al., 2012) or behavioral health services.

Job embeddedness

Job embeddedness theory posits that people stay in work positions when they are embedded. Aspects include: (1) perceived links to other people, teams, and groups; (2) a sense of fit between themselves, their job, their organization, and community; and (3) a belief they would experience loss or sacrifice if they left their job (Mitchell, Holtom, Lee, Sablynski, & Erez, 2001).

He declines a visit to the primary care office, and offers no reason. He does, however, agree that Peter or Rosa can make a home visit. Rosa mentions that Peter is no longer with the practice, but she would like to visit and see how Oscar is doing. Oscar agrees. During the home visit, Oscar admits that he has returned to his gas station grocery shopping. Rosa uncovers three additional health-impeding factors. First, his beloved sister has moved across the country. Oscar states, “I didn’t realize how much I depended on her. I really miss her.” In addition, Oscar is afraid to take the medication prescribed for his diabetes. A close childhood friend died of insulin shock when he was 11 and the death continues to haunt him. Also, he is not enthusiastic about lifestyle changes. “Last time I was really motivated... I wanted to be buff for the wedding. I don’t have so much to look forward to now.” Finally, his sister’s move, coupled with the diagnosis of diabetes, has spiraled him into “feeling blue.” He shares that he can’t stop thinking about death and feels very anxious; this nearly immobilizes him. Rosa concludes that Oscar is at high risk and that the magnitude and nature of his problems are beyond her

scope of practice and expertise. She talks with Oscar about a visit with the physician and perhaps with a psych-mental health NP, as well as a social worker. He declines. Rosa asks about the ED visit, and Oscar remarks that he feels comfortable going there, but did not enjoy feeling so out of control. Rosa suggests that they take steps to prevent such feelings, and Oscar agrees to a second visit from her. In preparation, Rosa brings Oscar’s story to the health team’s weekly case review meeting. In developing a plan, the team considers the significant facts. First, Oscar has a longstanding relationship of trust with Rosa. She needs to remain a key point of contact and care coordinator, until or unless a trust rappport with another team member eclipses their relationship. Next, Rosa needs substantial additional support beyond her scope for Oscar’s health needs, particularly the recent mental health issues and the poorly managed chronic condition. Finally, there are complex, interacting factors at play in the manifestation of Oscar’s diabetes. Given his unwillingness to visit the office, or to have visits from anyone other than Rosa at his home, the team decides to offer a telehealth

How Payment Reform Shapes Needs and Opportunities in Primary Care

home visit, with the primary care physician and psych-mental health nurse practitioner onsite at the primary care office while Rosa joins Oscar in his home. Oscar agrees. During this visit, Oscar reveals a bit more about his unwillingness to visit the clinic. He admits that he can no longer drive his pickup truck, following an accident in which he drove into a tree. He sheepishly adds that he didn’t call the police or try to claim insurance because he had "a drink or two before driving.” Using techniques of screening and brief intervention in primary care settings (Fleming, 2004/2005), and approaches described in Screening, Brief Intervention and Referral to Treatment (SBIRT) (Substance Abuse and Mental Health Services Administration, n.d), a more complex pattern emerges. Oscar experiences loneliness and perhaps depression; substance dependency, if not abuse; and limited current capacity to meet some basic needs, such as transportation. Oscar agrees that he needs help, and even requests it, and he

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may be willing to see whomever Rosa recommends. The physician, psych-mental health NP, Rosa, and Oscar develop a joint plan, based on realistic options and Oscar’s interests, starting with an Uber/Lyft or taxi to the health team paid for by the provider group. Several contrasting points are evident in these two scenarios. In the second, the accountability horizon is not episodic, it is temporal; it stretches across time. And, although the emergence of diabetes was not prevented in this scenario, it manifested over a decade later than in the first scenario. In other words, health promotion may not prevent the development of chronic conditions, but it can delay its onset and reduce related morbidity and even early mortality. Next, development of trust and relationship are critical and organizations are well advised to cultivate role commitment and organizational embeddedness (refer back to Table 15-1) among their employees (see TABLE 15-2 for additional key orientations and skills of primary care nurses).

TABLE 15-2  Essential Orientations and Skills of Primary Care Nurses Orientation/Skill

Definition

Upstream thinking and action

The ability to consider all antecedents to an acute or chronic condition and act to modify conditions toward health. Considerations include economic, social, educational, and spatial factors in the home, community, region, or nation, as well as personal factors such as lifestyle habits, choices, and family dynamics. Actions may be at the level of social policy change, the community level (for example, working with town council and school districts to support creation of safe bike/walking paths to school as a childhood obesity prevention strategy), or directly with the family or individual. Upstream action directed at individuals and families require skills, first of assessment of readiness for lifestyle/behavioral changes, and next, motivational interviewing skills.

Readiness for behavioral change

Prochaska and DiClemente’s (1983) classic transtheoretical model for stages of change toward health behavior is a well-established, useful guide that recognizes that behavioral change is difficult and does not represent a single discrete event. Instead, they posit five interacting, dynamic states: precontempletation, contemplation, preparation, action, and maintenance. ­Empirical studies have found that an individual often recycles these ­behaviors before they cease, for example, addictive behavior (Prochaska, DiClemente, & Norcross, 1992). (continues)

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TABLE 15-2  Essential Orientations and Skills of Primary Care Nurses Orientation/Skill

(continued)

Definition The primary care RN needs different tactics at the different stages. In precontemplation, the individual may (or may not) wish to change the behavior, but does not yet have serious intent to do so. Although the individual recognizes the behavior, it is not seen as a problem. This period is associated with self-deception and other behaviors to minimize the problem. In the contemplation stage, the patient recognizes the problem and is considering change, while recognizing the amount of “effort, energy, and loss it will take” (Prochaska, DiClemente, & Norcross, 1992, p. 1103). In the preparation state, intention to change begins to be combined with preparation for action or small changes in the problematic behavior. In the action stage there is visible effort and alternation of behavior. Although action includes visible effort, it is not synonymous with change; instead, “significant and overt efforts to change are the hallmarks of action” (Prochaska, DiClemente, & Norcross, 1992, p. 1004). Finally, maintenance, the prevention of relapses and continuing improvement. Maintenance implies a steady state. This, however, is not the case. Instead, it is a continuance of the change process, and it also needs ongoing support. Clearly, recommending smoking cessation classes for someone in the precontemplation stage, for example, is not a successful strategy. Motivational interviewing can help determine what is important to an individual, as a sound platform toward change.

Motivational interviewing

Motivational interviewing respects that a patient’s timeline and interests may not coincide with providers’ views and values. It is a counseling style, an approach that identifies things that are important to a person, such as the example of the wedding of Oscar’s sister. Successful approaches are not limited to face-to-face contact, but also include home telehealth (Battaglia et al., 2016) and telephone calls. The Cochrane review of 28 studies on the use of motivational interviewing for smoking cessation found motivational interviewing conducted by nurses and counselors to be more effective when the sessions were brief (less than 20 minutes) rather than longer, and a ­single session to be marginally more effective than multiple contacts. There was no ­difference in face-to-face versus telephone approaches, and both were more ­successful than brief advice or routine care (Lindson-Hawley, Thompson, & Begh, 2015). A second review of 14 studies found motivational interviewing to positively influence changes in eating among people with type 2 diabetes (Ekong & Kavookjian, 2015). Motivational interviewing is a foundational nursing skill. The primary care RN can also support the development of motivational interviewing skills among health coaches.

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Orientation/Skill

Definition

Leading, following, and coordinating teams

Multifactorial approaches to health care require a broad range of skills and aptitudes that no single discipline can fully master. This is particularly apt in the era of specializations. Consider, for example, a pediatric surgeon who specializes in repair of blunt abdominal trauma. This highly refined skill set is lifesaving for the few children who need this sort of care. The surgeon, as skilled as she or he is in this one particular area, is likely to be poorly prepared to deal with the same child’s development of juvenile myoclonic epilepsy. The neurologist who is prepared for the medical management of epilepsy may be poorly prepared for dealing with the child’s shame and embarrassment after a seizure in the school cafeteria. Fortunately, there are generalists who are licensed to practice across the array of settings where individuals live, work, and play who are knowledgeable in the full spectrum of health and illness. These are the ­baccalaureate-prepared registered nurses. Social workers offer complementary skills, with great understanding of family systems and, in general, less preparation with disease management and medications. Family practice physicians, nurse practitioners, and physician assistants are prepared as generalists, but with a pronounced socialization in the medical model of treatment of disease. Thus, the RN—often in concert with a social worker—is in an ideal situation to coordinate care, lead teams when necessary, and provide supportive followership as appropriate. All members of the team should be prepared to both lead and follow. Team members must first understand their own strengths, potential contributions, and weaknesses, and seek peers to complement their talents and bridge their gaps.

Panel management, directed at both individual and the panel population

Although the terms care management or case management are often used, it may be more useful to conceptualize the needed skill set as panel management directed at both the individual and the panel population. Various practices may organize the overall panel in varying manners. A large practice many have a primary care nurse who monitors all superutilizers of health care in their practice, or may disaggregate these by chief medical complaint (for example, congestive heart failure, diabetes, etc.) and thus provide a consistent level of support for individuals with the condition. It is important to note that the expertise needed is not merely with the disease state. Rather, it is experience in support of those individuals, with their own self-management as an optimal goal. Nurses in such roles will work with those who support information technology to use clinical and claims data for predictive analytics and, optimally, prescriptive analytics. Use of clinical data can predict, with 70% accuracy, which patients will have a health event long before they reach the level of decline that enables detection in the clinical setting. The addition of claims data increases that predictive capacity to 90% (Culver, 2015).

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Arguably, if Peter—the health coach with whom Oscar had previously bonded—were still in the practice, Oscar might have been more willing or forthcoming about his circumstances. Fortunately, he had a good relationship with another longstanding team member, Rosa. Finally, the team is a unit that provides care, not an individual provider, and no one member of the team has greater power or authority than any other. Each scenario requires an appropriate combination of professionals. Note, in these examples, the traditional “medical intervention” of a prescription for medication and “diabetes education” are not sufficient to address Oscar’s challenges.

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What Skills Do Nurses Need in These Advanced Primary Care Settings?

Our previous example illustrates individual care that was spurred through Rosa’s review of ED visits among her panel of patients, or her patient population. Primary care is indeed directed toward population health; it is thus very important that the nurse and other providers understand the concept of population health and how it differs from public health. Kindig and Stoddard’s (2003) broadly cited definition of population health is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (p. 381, emphasis added). By contrast, public health is defined by the American Public Health Association (APHA; n.d.) this way: “Public health promotes and protects the health of people and the communities where they live, learn, work and play. While a doctor treats people who are sick, those of us working in public health try to prevent people from getting sick or injured in the first place. We also promote wellness by encouraging healthy behaviors” (para 1, 2). Public health oversight is also a vital role of government.

Clearly, although noting some overlap, the emphasis on outcomes is an essential attribute that defines population health. This includes not only health outcomes, but also cost effectiveness and overall value. Thus the nurse must understand exactly what metrics are used to measure their practice and how they relate to compensation. It also requires a broad and systematic understanding of the interactions that create these outcomes, since outcomes reflect determinants beyond traditional medical care and even public health. Essential determinants include both the social environment—aspects such as employment status, social support, income, education, and culture—and the physical environment, whose aspects consist of both the natural and the built landscape, and include water, air quality, and urban design. Both factors interact with a third: personal elements such as genetics and behavior. Obviously these interactions are complex and may multiply and cascade. Nurses and other professionals need to be able to discern and act on “upstream” factors to halt any cascade that fuels morbidity and mortality. As illustrated in Oscar’s case, this is much more complicated than simple, reductionalistic medical care that is focused on biomedical models of disease. It is also much more realistic and aligned with the real, whole lives that people lead. It is also ever so much more interesting! Upstream thinking is a foundational primary health skill. Manchanda and Hochman (2014) define upstreamists as “health professionals who are equipped to transform their health care system and the social and environmental conditions that make people sick” (p. 1553, emphasis added). They further note that they must have a passion for social justice, but, importantly, must put that passion to action in the routine practice of care to include assessment of social determinants. Assessment is indeed a necessary first step, but it must be followed by action. This is a new order, and a tall one, for health professionals—including physicians—who have traditionally been educated in silos and practice in them. Because no single discipline has the prerequisite skills and knowledge in this vast and

What Skills Do Nurses Need in These Advanced Primary Care Settings?

profound landscape, it takes a team. Yet the team is a strategy toward an end—individual and population health—not an end in and of itself. Hierarchical models in which the physician is the “captain of the ship” are destined to fail. They create tremendous burnout for the physician who is attempting to manage the kaleidoscope of interacting aspects that need to be addressed in these comprehensive models of care. Physician-centric care has been empirically identified as a barrier to development of advanced models of primary care such as patient-centered medical homes (Nutting, Crabtree, & McDaniel, 2012). These authors also cite unimaginative use of nurse practitioners and physician assistants as yet another barrier. Although not specifically noted, an even stronger case can be writ large for the unimaginative use of nurses. For nurses, this critical social action lays the foundation for truly differentiated practice. Associate degree nurses may continue to be prepared for acute and episodic care, but baccalaureate nurses must complement these skills with those needed in advanced primary care models: upstream thinking and action, measurement referenced strategies, health promotion, management of chronicity, motivational interviewing, and identifying markers of readiness for behavior change; leading, following, and coordinating teams; and panel management to direct both individual and aggregated strategies (see Table 15-2 for working definitions, then review Oscar’s second scenario to see how many of these elements you can identify).

Upstream Thinking and Action Karen Hein, MD, former Executive Director of the Institute of Medicine, states: “Whatever clinical problem you’re focusing on, it’s only one or two steps away from one of the ‘social determinants’ of health that account for nearly 90% of premature mortality” (personal communication, August 5, 2017). She notes, for example, the commonly used marker of blood sugar control familiar to all clinicians and many patients: HbA1c. Yet, hitting the mark on HbA1c

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is influenced by transportation access, medications, health beliefs, exercise, nutrition, education, income, and physical environment. They all relate, and actually contribute, to this seemingly “medical-only” blood test. Upstream thinking must be accompanied by new approaches to health promotion, prevention of illness, and management of chronic conditions, and to using panel management for data referenced care.

Scenario 2: Panel Review as a Vital Skill In reviewing her panel of patients, Rosa notes that 11-year-old Marco has had three ED visits in the past 2 weeks, and a pattern of increasing visits over the past 6 months or so. A detailed review of Marco’s record reveals that these are very serious health events, with extreme respiratory distress. Rosa immediately calls Marco’s mother and learns from her that he has repeatedly been seen in the emergency department suffering from uncontrolled asthma. In further discussion, it seems clear to Rosa that he is adhering to his medication regimen. Rosa probes possible school-related stress, bullying, or other factors that may be contributing to the escalation of Marco’s symptoms. Marco’s mother shares that she thinks school is going well. Marco has friends and is a steady student. “Actually,” his mother notes with astonishment, “Marco’s asthma may be worse at home!” Rosa askes about any recent changes. Rosa’s experience with the family suggests that they function very well, so new family stressors do not seem to be a triggering factor. The parents have also followed instructions about limiting allergens in the home, with one exception. Although the beloved family dog, Rufus, remains in the house, he no longer sleeps with Marco. Rosa offers a visit while Marco is at home. Marco’s mother eagerly agrees. Visiting the home, Rosa immediately identifies a serious environmental trigger. The house smells musty and there is evidence of massive water stains and mold. The parents reveal that

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they purposely bought the house as a “fixer upper” about 8 months ago, and they are indeed addressing these problems, but can do so only as financial resources permit. Marco’s mother notes: “I actually never thought that Marco has been worse since we moved into this house . . . we were so happy to finally be out of that terrible apartment.” Rosa recognizes a teachable moment and, fortuitously, had previously developed materials directed at the most common conditions in her patient panel: congestive heart failure, arthritis, diabetes, and asthma. She downloads the material on mold, dust, and mite-induced allergies and asthma and texts it to Marco and his mother. “Wow,” Marco reacts, “those dust mites are really gross. I guess I will clean my room, Mom!” After reviewing the material and discussing questions, they agree that new strategies to reduce mold, mites, dust, and mildew needed to be implemented until the building problems can be fully addressed. These include more frequent washing of bedsheets and hypoallergenic bedding, improved household airflow using exhaust fans, redirecting rainwater flow away from the house, and removal of the most obvious sources of dampness. Notably, the leaks are the worst in Marco’s room, and the family is committed to addressing them first, yet recognize it will be some time before they have the resources to address all the household mold. Marco is adamant about staying in his bedroom at night, even though he understands this may be triggering asthma attacks, but commits to doing his homework in the well-ventilated kitchen. In the interim, in addition to the previously adopted strategies, Rosa suggests that Marco’s asthma could potentially be improved with air conditioning to minimize particulate-induced episodes and a dehumidifier during humid months. Marco’s mother states: “We can swing the new bedding and a few fans, but we really can’t afford an air conditioner and a dehumidifier right now.” Fortunately, the provider organization funds such items when the family truly hasn’t the means to afford them. This is in the best interest of the

organization as well as Marco’s, because the provider organization is responsible for all cost of care and the investment is nominal when compared to even a single ED visit. Following implementation of these steps, Marco’s condition is ameliorated, and there are only two flair-ups over the next 6 months. The family prioritizes renovation of Marco’s bedroom, and once this is complete he has no further episodes. Note that the salutary intervention in Marco’s care was not medication or hospitalization, but environmental modification. To assess and redirect the environment toward health are ideal roles for primary care nurses. Moreover, they are firmly in keeping with nursing’s long legacy of “environment” as one of its core concepts. Modern professional nursing is rooted in care that is data driven toward environmental modification. Florence Nightingale, the mother of modern professional nursing, worked with injured soldiers during the Crimean War. There she used statistics as an early means of measurement-referenced care, and recognized the role of the unsanitary hospital environment as a principal contributor to mortality. Improvements in hygiene, light, ventilation, and related factors resulted in a dramatic reduction in posttrauma deaths of wounded soldiers. The value of Nightingale’s approach is apparent in Marco’s case. As she wrote of the environment, there are “internal and external elements of nature that can be altered to foster human health. Proper use of fresh air, light, warmth, cleanliness, quiet, proper food, all at least expense of vital powers of the patient” (1860, p. 3). Nightingale’s canons include elements evident in Marco’s care: ventilation and warmth; light, cleanliness of rooms and walls; and health of houses, beds, and bedding. Clearly, environmental modification as primary care nursing skill is not a “new” nursing skill, but a renewed one. Similarly, “housing as health care” (Doran, Misa, & Shah, 2013, p. 2374) is critical and may seem like a fresh approach. Yet, such broad upstream thinking is inherent in the true heart of nursing and in early nurses’ initiatives such as the Henry Street

What Skills Do Nurses Need in These Advanced Primary Care Settings?

Settlement. These efforts have renewed value in our era and are an essential element of contemporary primary care. Finally, Marco’s scenario demonstrates one other element of upstream thinking: the value of preparing materials in advance to be used when a family is ripe to hear them. The stages of behavioral change theory (Prochaska, ­DiClemente, & Norcross, 1992) are a helpful reminder that individuals become ready for behavioral change in their own time frame, not that of a clinic or office visit. Materials provided in the office at the time of a visit may not even make it out of the family car, much less into implementation, and this may be one of the reasons that counseling and education is so low on the health impact pyramid (see FIGURE 15-1). Multimedia materials, including

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videos and podcasts prepared in advance and delivered at the ripe moment, when individuals and families are taking action rather than merely contemplating change, can enhance effectiveness. Organization, preparation, and delivery of such materials, geared appropriately for each specific generation, and reflective of the broad array of human orientations, are essential. Every person and family—regardless of race, gender, sexual orientation, ethnicity, or religion—should be able to recognize themselves in the materials prepared. The message is more likely to resonate if and when the individual can identify with the messenger. Thus, an array of packaging of the same content, yet tailored to the recipient, is essential. Artful and imaginative preparation of these materials is an important primary care role. Next, not all

Increasing population impact

Increasing individual effort needed Counseling and education

Clinical interventions

Long-lasting protective interventions

Changing the context to make individuals' default decisions healthy

Socioeconomic factors

FIGURE 15-1  The Health Impact Pyramid Reproduced from Frieden, T. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4), 590-595.DOI:10.2105/AJPH.2009.185652.

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necessary primary care interventions occur outside the more traditionally defined practice setting, as we see in the case of Heather.

Scenario 3: The Case of Heather, the Walk-In Patient Today, Rosa is focused on health management of individuals visiting the primary care office. In this role, she also performs triage of both phone calls and walk-ins. Heather, a “walk in,” has never been seen before in the office. She is a pleasant, attractive, fashionably dressed, and impeccably coifed 19-year-old who presents with an enlarged salivary gland that she states has been present for a month. Heather is very concerned that the mass is affecting her appearance and would like it removed or somehow otherwise addressed. “I’m really here for a referral to a surgeon. I want this gone!” Other than a low body mass index, the remainder of Heather’s exam is normal. Rosa is uneasy about the presentation, however, and rather than scheduling a later appointment with a primary care provider in her setting or referring Heather to an otolaryngologist, she pulls the medical doctor (MD) and nurse practitioner (NP) aside. “Something is off here,” says Rosa. “I know it can likely wait, but my gut tells me something is up and if she leaves she won’t come back.” The MD, a 69-year-old male, and the NP, a 37-year-old female, both have great respect for Rosa’s judgement. “How far behind are you?” asks the MD of the NP. He remarks, “We should do this. Are you OK with it? Go for it, and if you need me let me know. I can see her, but you are better with young people than I am. I can help you catch up at the end of the day if needed.” The NP agrees to see Heather without delay. This trust and division of labor is illustrative of a highly functioning team. As this example portrays, the NP and MD have somewhat differentiated their practices by interests and developed corollary expertise. The MD sees more of the elderly diabetics and congestive health failure patients and has a special interest in hospice and palliative care. The NP has a special interest

in adolescent and women’s health. After hearing Rosa’s description of Heather, she remarks that she suspects salivary gland enlargement secondary to anorexia and/or bulimia may be the etiology of the enlargement. During the history and exam, the NP works to establish a connection with Heather. In their conversation, Heather admits a relentless need to exercise and be ever thinner. “I’m so fat right now I can barely stand myself,” she states, demonstrating a distorted body image, given that her concern is counter to a clear and objective underweight condition. The NP suggests that the nutritionist may be able to help, and also that there is another clinician in the office who works with people concerned about their weight. “Anything to lose weight,” says Heather. A warm handoff is made to the nutritionist and the psychiatric-mental health nurse practitioner in turn, both of whose expertise includes eating disorders. During this interval, the NP discusses the case with the physician, who recalls that salivary gland enlargement can persist even after a return to normal weight. Together they do a quick literature review, and find that individuals with eating disorders are very attentive to their appearance and thus may consult about facial swelling without sharing their eating patterns or other social and emotional stressors; further, a focus on only the salivary gland enlargement may lead to unnecessary procedures and delay in appropriate treatment (Walsch, Croft, & Katz, 1981). Heather’s primary concern is her appearance and the team knows they must start from this concern, because it is what is important to Heather. They explain to Heather that the salivary gland that concerns her is likely a symptom of disturbed eating habits, and this motivates her to begin to address her nutritional behavior. It is a long road to recovery and the salivary gland, for now, is being observed with watchful waiting. This scenario once again demonstrates the teamwork and upstream thinking so essential for today’s primary care team. It also demonstrates that Rosa does not need to know everything. Indeed, no one does and no one can. Rosa’s key skill in this scenario is her ability to

Nursing Education

trust her sense of unease. Something didn’t feel right. In traditional fee-for-service models focused on the 15-minute visit with its associated charge, referral to a surgeon would have moved things along. The patient would have received what she thought she wanted. The surgeon might also have performed surgery, a comparatively expensive approach that, in this example, fails to address the root cause of Heather’s health challenges. In models where providers are accountable for the cost and outcomes of care over time, it is essential to first identify, and then address these root causes. Even if Heather eventually does have surgical removal of the gland, the more important underlying causes will have been recognized and, we hope, addressed over time. Without such efforts, Heather will continue to present with an array of health-related problems. These may stretch over time, for example, in osteoporosis induced by low body weight in her sixth or seventh decade of life. The accountability horizon in these new models of care is indeed broad, for it encompasses many disciplines and approaches, and long, since it covers years or even decades. What an exciting time to be a health professional!

Health Promotion Revitalized These examples illustrate the new, more robust approach to health promotion. Nurses have typically been involved with health promotion activities (e.g., smoking cessation, blood pressure screening, and referrals), but they have not been uniformly involved in tailored approaches, using claims and clinical data, that address specific determinants within particular individuals or populations. General information on health-promoting strategies is not sufficient, and perhaps not even fully useful, as identified in the CDC health impact pyramid mentioned earlier. Friedman (2010) notes that among five broad strategies listed in Figure 15-1, counseling and education, followed by clinical interventions, have the least health impact. It is noteworthy that the traditional healthcare system has focused on the two strategies with

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the least impact. So, too, professional education has concentrated on the two upper strata of the pyramid, the least impactful pair. Revamping education so that its impact comes to the foreground as an element of the pyramid’s base is an important endeavor.

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Nursing Education

Why Have There Been So Few Nurses in Primary Care? Much of health care as it is known today is the result of historical flukes and unintended consequences, both positive and untoward, which, taken as a whole, have created a disproportionally intensivist, specialized, acute care–centric system. Yet, as noted, the evidence is very clear that nations with more primary care and less specialist involvement have better health outcomes at lower cost. Further, nations that spend more on social supports and less on medical care have better outcomes at lower cost. How did the United States get it all wrong? At the beginning of the 20th century, health care looked dramatically different than today. Physicians were largely prepared through apprenticeship with others; there was little standardization in their education. They were poorly compensated, and relied on bartering and how much families could afford to pay them. By and large, they were not a highly compensated or respected segment of society. Similarly, hospitals—far from the medical industrial complexes of today—were not the venue of choice for care. Instead, home was the healing haven, while hospitals were reserved for those not wanted at home or without a home in which to heal: those with infectious diseases, the unmanageably “insane,” and the homeless (Sultz &Young, 2011).

Abraham Flexner and the Flexner Report Abraham Flexner, an influential educational reformer, who among other notable efforts

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brought Albert Einstein to Princeton University, was commissioned by the Carnegie Foundation to study medical education and make recommendations to improve the quality of physician training. Initiated by the American Medical Association’s voiced concern about the varying routes to becoming a physician and the divergence of standards and quality that resulted, this educational reform was also likely to have been rooted in organized medicine’s desire for greater social authority (Group & Roberts, 2001; Starr, 1982). Flexner was deeply influenced by the hyper-rational approach of the Germans and the scientific biomedical model he saw at Johns Hopkins (Duffy, 2011). The recommendations he promulgated became the criteria for medical schools. The result was closure of 80% of the schools, which offered what we now call “complementary and alternative” training (Stahnisch & Verhoef, 2012)—likely because they were “alternative” to the “standard” model envisioned by Flexner. It also resulted in the closure of most schools that prepared people of color (Harley, 2006) and women. There was a virtual absence of women in the physician workforce until the 1970s (Barkin, Fuentes-Afflick, Brosco, & Tuchman, 2010). Medical education became more expensive and more white, with a socioeconomic schism that favored admission to those from more affluent families (Prislin, Saultz, & Geyman, 2010), a challenge that is still reflected in the ongoing U.S. struggle to create a professional health workforce that mirrors the population it serves. These authors also note that the Flexner report spurred physician specialization rather than the primary care base exemplified in other high-performing nations and, according to Duffy (2011), encouraged a scientific orientation not counterbalanced with an equal drive toward excellence in caring. Medicine also carved an expansive scope of practice (Group & Roberts, 2001). Nurses, if educated at all, were trained in hospitals with entry-level services similar to those of a maid. To this day, nursing care remains bundled into hospital charges in the same manner maid services are bundled into those of a hotel. Early

schools of nursing were owned and operated by hospitals, with nursing students providing an unpaid labor force. Practice experiences reflected the various units of a hospital: medical, surgical, obstetrics, and pediatrics. Over time, in baccalaureate programs, a single community health course would come to augment these acute care–centric student learning experiences. Some such courses were focused on public health, while others concentrated on nursing care of individuals and families outside the hospital, even though hospitals are actually part of a community. Still others were an amalgamation of both of these orientations. In summary, nursing programs adopted the medical model promulgated by the Flexner report; for many years the licensing exam of the National Council of State Boards of Nursing, the exam designed to test for competency as a strategy to protect the public, actually named licensing exam sections after these hospital units. Thus, it is unremarkable that nursing education has been focused on acute care. Contemporary faculty have a tremendous opportunity to shape the overall conceptual orientation of novices by what they do and do not include in a course, and they can shape foreground and background considerations by what titles they give to courses. Consider, for example, the different representations invoked by a course called “Med-Surg Nursing” versus one called “Managing Chronicity Across Care Settings." Arguably, no area of nursing education is more in need of reform than “Foundations of Nursing.” Former “foundations” of nursing such as bed-making and other custodial care tasks, for example, generally are not performed by RNs, nor should they be, except perhaps in the care of the critically ill. Initial role socialization can instead teach student RNs these skills within the realistic context of their oversight of nursing assistants and others, those who actually do make beds. True foundational skills include care management across transitions, motivational interviewing that reflects readiness to change, and understanding and using data to drive care. Use of data includes the critique of evidence for application in

Dental Care

practice, an essential baccalaureate skill (American Association of College of Nursing, 2008) currently taught in contemporary programs. This orientation should be enhanced with skill acquisition in the use of individual and panel costs and outcome data for strategic interventions. As illustrated in Oscar’s scenarios earlier in the chapter, these data-inspired interventions can address the immediate situation, and they should also treat modifiable upstream antecedents that are illustrated in all three scenarios. Finally, payment shapes delivery, and payment reflects policy and policy changes. Thus, understanding the organization, financing, and policy of health care is a critical foundational skill, not a leadership skill, and should be introduced early in the curriculum and reinforced throughout the program. The magnitude of such a shift is profoundly at variance with the education of most faculty and the experience of many. It may therefore be important for programs in nursing to totally redirect their curricular design away from reductionalistic, Flexner-shaped terms and orientations such as “medical-surgical nursing” or “care of the individual with mental health issues” in order to prevent reflexive recreation of their own educational experiences.

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Mental Health

As two of the scenarios illustrated, mental health issues are an integral part of the manifestation of disease and illness. So, too, must primary health care include mental health services as an integral part of their practice. Nurses with interest and expertise in this domain can complement the background of other professionals who are part of the setting. More complicated scenarios, particular those that necessitate pharmacotherapies, may require the expertise of a psychiatric nurse practitioner or psychiatrist. Social workers can provide beneficial support and interventions at the level of the family or individual, and clinical psychologists offer yet another complementary skill set. It has been documented that

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the warm handoff that directly links an individual to a provider or service, as illustrated in both Heather’s and Oscar’s scenarios, can facilitate the initiation of behavior change services such as, for example, enrollment in a smoking cessation program (Richter et al., 2012). There are also well-established screening tools that are appropriate for the primary care setting, for example, the Patient Health Questionnaire (PHQ)-2 and PHQ-9 for depression screening, Generalized Anxiety Disorder (GAD)-7 for anxiety, and the Alcohol Use Disorders Identification Test (AUDIT-C) for alcohol abuse (Drake & Valenstein, 2015). Primary care providers should review and be prepared to use these tools and have clearly identified pathways that assure segue to follow-up that patients are not prepared to access by themselves.

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Dental Care

The mouth contributes to the overall health of the body. As providers take accountability for the outcomes and cost of care it becomes increasingly vital that oral care be integrated into the overall primary care approach. Although this is evident in some Federally Qualified Health Centers, most primary care offices have largely left dental care to solo dentist practices. Dentists have not been subject to the same cost and outcome accountability as physicians and others, and they currently have less incentive to participate in emerging delivery models. Gaps in oral care manifest far removed from the dentist, for example, in hospital emergency rooms, or—for the poor and uninsured—in uncompensated care for dental surgeries. Changes in state regulations to allow dental hygienists to provide their full scope of care to patients—while referring to a dentist when necessary—would provide a valuable contribution to primary care and our nation’s health. The scope of practice of dental hygienists varies by state, and expanded scopes have been associated with positive and significant population health improvements; the more autonomous

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Chapter 15 Enhanced Primary Care Roles for Nurses and Other Professionals

they are, the better the oral health of the populace (Langelier, Continelli, Moore, Baker, & Surdu, 2016). These population-level metrics are of vital significance for advanced primary care models that assume accountability for the health of a given population, and they are even more important if they are taking responsibility for outcomes and overall cost of care over time. Moreover, more than 50 countries and four U.S. states allow a “midlevel” practitioner with more preparation than dental hygienists, while less than dentists, to offer preventative and restorative treatment. Although these have primarily been in the public health sector (Koppleman, Vitzthum, & Simon, 2016), the model offers an exciting way for advanced primary care to i­ncorporate badly needed dental services in their portfolio. The evidence supports their safety and effectiveness. Koppelman et al. (2016) conclude that they “may thrive in a climate where providers must deliver on access and outcomes” (p. 2205) by offering perfect alignment with the goals and orientation of advanced primary care. Yet, as Mertz (2016) powerfully notes: “It remains unclear whether twenty-first-century dental science, information technology, interprofessional practice, and population health needs can be mounted onto the current nineteenth-century dental care delivery model. At stake is whether reform efforts will lead to a reduction in disparities and the widespread incidence of dental disease, or whether those efforts will maintain a system in which poor oral health serves as a primary marker of social inequality for the next generation of Americans” (p. 2168). Primary care leadership can close this gap.

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Conclusion

When atomic energy was first discovered, Einstein famously said: “Everything has changed but the way we think,” which reflected the power, potential, and danger of the atomic age. The responsibility that accompanies this power is an ethical obligation to protect the safety and well-being of society though new,

more comprehensive ways of thinking and acting. Similarly, we now have irrefutable evidence that our healthcare system is deficient, unevenly distributed, and often dangerous. The evidence clarifies healthcare’s financial drain on our nation and its families, and the impact of this drain on the very social determinants that best predict health status. Professions exist to service the public and must evolve to serve the public welfare. Redesign toward primary care is not merely a movement or a clever approach by which to capture new markets. Rather, it represents a fresh creation of the very fabrication of a healthcare delivery system that is safe, cost effective, and sustainable. Each of us has a role to play in laying the granite blocks of this citadel—the healthcare system we wish to inhabit throughout our lives, and bequeath to the next generations. The time to act is now.

Discussion Questions 1.

2.

Enhanced primary care requires highly effective teams. What roles would you play on the team? How do you describe your contributions to your teammates? How should your performance be measured? What supports do you need from other team members? Imagine that you have been hired by a health care system to help their six traditional, physician-centric clinics transition to a patient-centered advanced primary care delivery model. How would you approach this critical work assignment?

References Agency for Health Research and Quality. (n.d.). Warm hand off: Intervention. Retrieved from https://www .ahrq.gov/professionals/quality-patient-safety/patient -family-engagement/pfeprimarycare/interentions /warmhandoff.html American Association of College of Nursing. (2008). Essentials of Baccalaureate Education. Washington, DC: Author. American Public Health Association (APHA). (n.d.). What is public health? Retrieved from https://www.apha.org /what-is-public-health

References Barnett, M., Olenski, A., & Jena, A. (2017). Opioid-prescribing patterns of emergency physicians and risk of long-term use. New England Journal of Medicine, 376(7), 663–673. Barkin, S., Fuentes-Afflick, E., Brosco, J. & Tuchman, A. (2010). Unintended consequences of the Flexner Report: Women in pediatrics. Pediatrics, 126(6), 1055 – 1057. Battaglia, C., Paterson, J., Whitfiled, E., Min, S., Benson, S., Maddox, T., & Prochazka, A. (2016). Integrating motivational interviewing into a home telehealth program for veterans with posttraumatic stress disorder who smoke: A randomized control trial. Journal of Clinical Psychology, 1–13, doi: 10.1002/jclp.22252 Berwick, D., & Hackbarth, A. (2012). Health Policy Brief: Reducing waste in health care. Health Affairs. Retrieved from http://www.healthaffairs.org/healthpolicybriefs/ Bodenheimer, T., & Grumbach, T. (2016), Understanding health policy: A clinical approach. New York, NY: McGraw Hill Lange. Centers for Disease Control and Prevention (CDC). (2017). Chronic diseases: The leading causes of death and disability in the United States. Retrieved from https://www.cdc .gov/chronicdisease/overview/index.htm Culver, D. (2015, September 20). Presentation at Vermont Information Technologies Leaders Annual Meeting, Burlington, VT. Doran, K., Misa, E., & Shah, N. (2013). Housing as health care—New York’s boundary-crossing experiment. New England Journal of Medicine, 369, 2374–2377. Drake, E., & Valenstein, M. (2015). Behavioral health integration into ambulatory care. Retrieved from https:// www.stepsforward.org/Static/images/modules/25 /downloadable/Embedded_behavioral_health.pdf Duffy, T. (2011). The Flexner report—100 years later. Yale Journal of Biology and Medicine, 84, 269–276. Ekong, G., & Kavookjian, J. (2015). Motivational interviewing and outcomes in adults with type 2 diabetes: A systematic review. Patient Education and Counseling. doi: http:// dx.doi.org/10.1016/jpec2015.11.003 Fleming, M. (2004/2005). Screening and brief intervention in primary care settings. Alcohol Research and Health, 28(2), 57–62. Frieden, T. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4), 590–595. doi:10.2105/AJPH.2009.185652 Friedman, Z. (2017, February 21). Student loan debt in 2017: A $1.3 trillion crisis. Forbes. Retrieved from https:// www.forbes.com/sites/zackfriedman/2017/02/21/student -loan-debt-statistics-2017/#36cb74ff5dab Group, T., & Roberts, J. (2001). Nursing, physician control, and the medical monopoly: Historical perspectives on gendered inequality in roles, rights, and range of practice. Bloomington, IN: Indiana University Press. Harley, E. (2006). The forgotten history of defunct black medical schools in the 19th and 20th centuries and the impact of the Flexner Report. Journal of the National Medical Association, 98(9), 1425-1429. Hein, K. (2017, August 5). Personal communication.

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Himmelstein, D., & Woolhandler, S. (2016). The current and projected taxpayer shares of US health costs. American Journal of Public Health, 106, 449–452. doi:10.2105 /AJPH.2015.302997 Kindig, D., & Stoddard, G. (2003). What is population health? American Journal of Public Health, 93(3): 380–383. Koppelman, J., Vitzthum, K., & Simon, L. (2016). Expanding where dental therapists can practice could increase American’s access to cost-efficient care. Health Affairs, 35(12), 2200–2206. doi: 10. 1377/hlthaff.2016.0844 Kumar, S., & Nash, D. (2011, March 25). Health care myth buster: Is there a high degree of scientific certainty in modern medicine? Scientific American. Retrieved from https://www.scientificamerican.com/article /demand-better-health-care-book/ Langelier, M., Continelli, T., Moore, J., Baker, B., & Surdu, S. (2016) Expanded scopes of practice for dental hygienists associated with improved oral health outcomes for adults. Health Affairs, 35(21), 2207–2215. doi: 10.1377 /hlthaff.2016.0807 Lindson-Hawley, N., Thompson, T., & Begh, R. (2015). Motivational interviewing for smoking cessation. Cochrane Database of Systemic Reviews, 3, CD006936. doi: 10.1002/14651858.CD006936.pub3 Macy Foundation. (2016). Registered nurses: Partners in transforming primary care: Recommendations from the Macy Foundation Conference on Preparing Registered Nurses for Enhanced Roles in Primary Care. New York, NY: Josiah Macy Jr. Foundation. Makary, M., & Daniel, M. (2016, May 3). Medical error—the third leading cause of death in the US. British Medical Journal, 353. doi: http://dx.dio.org/10.1136/bmj.i2139 Manchanda, R., & Hochman M. (2014, November) Improvement happens: Impacting health at its roots: An interview with Rishi Manchanda. Journal of General Internal Medicine, 29(11), 1552–1556. doi: 10.1007/ s11606-014-2902-1 Mertz, E. (2016, December). The dental–medical divide. Health Affairs, 35(12), 2168–2175. doi:10.1377/hlthaff.2016.0886 Mitchell, T., Holtom, B., Lee, T., Sablynski, C., & Erez, M. (2001). Why people stay. Using job embeddedness to predict voluntary turnover. Academy of Management Journal, 444, 1102–1122. Nightingale, F. (1860). Notes on nursing: What it is and what it is not. Edinburgh, UK: Churchill Livingston; 1980. Nutting, P., Crabtree, B., & McDaniel, R. (2012, November) Small primary care practices face four hurdles−−including a physician-centric mind-set −−in becoming medical homes. Health Affairs, 31(11), 2417–2422. doi: 10.1377 /hlthaff.2011.0974 Phelps, A. (2017). MACRA: Quietly transforming health care. Modern Healthcare. Retrieved from http://www .modernhealthcare.com/article/20170522/SPONSORED /170529979 Prislin, M., Saultz, J., & Geyman, J. (2010, February). The generalist disciplines in American medicine one hundred years following the Flexner report: A case

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study of unintended consequences and some proposals for post-Flexnerian reform. Academic Medicine, 85(2), 228–235. Prochaska, J., & DiClemente, C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Counseling and Clinical Psychology, 51(3), 390–395. Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1104–1114. Rawls, J. (1999) A theory of justice. Cambridge, MA: Harvard University Press. Rawls, J. (2001). Justice as fairness: A reinstatement. Edited by E. I. Kelly. Cambridge, MA: Belknap Press. Reaves, E., & Musumeci, M. (2015). Medicaid and long-term services and supports: A primer. Henry J. Kaiser Family Foundation. Retrieved from http://www.kff.org/medicaid /report/medicaid-and-long-term-services-and-supports-a -primer/ Richter, K., Faseru, B. Mussulman, L., Ellerbeck, E., Shireman, T., & Hunt, J.... Cook, D. (2012). Using “warm handoffs” to link hospitalized smokers with tobacco treatment after discharge: Study protocol of a randomized control trial. Trials, 13, 127. doi.org/10.1186/1745-6215-13-127. Retrieved from http://www.trialsjournal.com/content /13/1/127 Schneider, E., Sarnak, D., Squires, D., Shah A., & Doty, M. (2017) Mirror, mirror 2017: International comparison reflects flaw and opportunities for better U.S. health

care. The Commonwealth Fund. Retrieved from http:// www.commonwealthfund.org/publications/fund -reports/2017/jul/mirror-mirror-international-comparisons -2017 Saloner, B., & Daniels, N. (2011). The ethics of the affordability of health insurance. Journal of Health Politics, Policy and Law, 36(5), 815-827. Stahnisch, F., & Verhoef, M. (2012). The Flexner Report of 1910 and its impact on complementary and alternative medicine and psychiatry in North American in the 20th century. Evidence-Based Complementary and Alternative Medicine, 2012, 647896. doi:10.1155/2112/647896. Starr, P. (1982). The social transformation of American medicine: The rise of a sovereign profession and the making of a vast industry. New York, NY: Basic Books. Substance Abuse and Mental Health Services Administration (SAMHSA) (n.d). SBIRT: Screening, brief intervention, and referral to treatment opportunities for implementation and points for consideration. Retrieved from https://www .samhsa.gov/system/files/screening-brief-interventionreferral-treatment-implementation.pdf Sultz, H., & Young, K. (2011). Hospitals: Origin, organization, and performance. In Health care USA: Understanding its organization and delivery (7th ed.) Sudbury, MA: Jones & Bartlett Learning. Walsch, B., Croft, C., & Katz, J. (1981). Anorexia nervosa and salivary gland enlargement. International Journal of Psychiatry Medicine, 11(3), 255–261.

Case Study

CASE STUDY

Nancy Rudner, Graduate Faculty, George Washington University

Purpose/Scope Identify issues and strategies for nurse practitioners’ (NPs’) full practice authority.

Background Nurse practitioners (NPs) must meet the national certification and educational requirements established by the profession. Yet the regulation of health professions is a state function. The rationale for state regulation is the state role in ensuring safety for its residents, based on the premise that consumers cannot assess healthcare provider quality. This has created a wide variation in state regulations of advanced practice nurses. In some states, NPs practice to the full extent of their education, as a professional with full practice authority (FPA). In other states, NPs are required to have a supervising physician and/or work under a physician for a prescribed number of months. In some states, NPs are limited in what they can prescribe, and cannot order physical therapy or sign certain documents requiring a provider authorization. Physician resistance to expanding NP practice authority is rooted in physician dominance in health care. Physicians were the first health profession to codify healthcare practitioner requirements. In 1760, New York City barred unlicensed physicians from practicing. By the early 1900s, every state had a medical practice act, broadly defining the practice of medicine to encompass all aspects of the human body and mind (Safriet, 1994, 2002; Starr, 1982). Other healing professions, including nursing, had to carve out space to practice around the broad scope of medicine. In the mid-1900s, nursing licensure laws developed, defining the profession with limited functions. The primary independent nursing functions were observation, task completion, and

record keeping. Other functions were delegated from the physician. Blood pressure assessment was not considered a nursing function, but instead, was a medical task delegated by the physician.

Variability and Evolution of State Regulations of NPs Since the development and expansion of the NP role, each state has updated their nurse practice acts to recognize the advanced practice nurse role. However, NP scope of practice and autonomy varies widely among the states. This variability was found to persist in several studies (Kuo, Loresto, Round, & Goodwin, 2013; Rudner, O’Grady, Hodnicki, & Hanson, 2007). NP regulations tend to be more consumer friendly when the Board of Nursing has sole authority for NP regulatory oversight, not shared with another profession (Rudner, O’Grady, Hodniki, & Hansen, 2010). FIGURE 15-2 and TABLE 15-3 show NP regulations also are more consumer friendly in states that have more equalitarian views of women, as reflected in the state’s approval of women’s equality in the Equal Rights Amendment (Rudner, 2016). The National Council of State Boards of Nursing (NCSBN) now maintain maps and data showing NP regulatory status in each state (NCSBN, 2017), looking at two core components of NP practice: authority to practice independent of another profession and the authority to prescribe medications (FIGURE 15-3). As states have considered revisions to NP regulations, physician groups have often raised strong concerns about safety and quality, seeing NPs only as members of a physician-led care team (American Academy of Family Physicians, 2013, 2014; American Academy of Pediatrics, 2016). Over 50 years of evidence support the safety and quality of NPs (Horrocks, Anderson, & Salisbury, 2002; Laurant et al., 2005; Newhouse et al., 2011; Office of Program Policy Analysis and Government Accountability, 2010; Office of Technology Assessment, 1981, 1986; Oliver, Pennington, Revelle, & Rantz, 2014; Perloff, DesRoches, & Buerhaus, 2016; Stanik-Hutt et al., 2013; Swan, Ferguson, Chang, Larson, & Smaldone, 2015). The National Council of State Boards of Nursing (NCSBN) developed a consensus document among nursing stakeholders, reflecting

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Mending the Patchwork of NP Regulations

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Chapter 15 Enhanced Primary Care Roles for Nurses and Other Professionals Percentage of states with full practice authority for nurse practitioners, 1998, 2012, 2014, by state ERA vote 60%

53% 47%

50%

40%

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40%

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10% 0%

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FIGURE 15-2  Percentage of states with full practice authority for nurse practitioners by state ERA vote (1998, 2012, 2014) Online journal of issues in nursing by American Nurses Association Reproduced with permission of American Nurses Association in the format Book via Copyright Clearance Center.

TABLE 15-3  Percentage of States with Full NP Practice, with Prescribing, in ERA-Supporting and ERA-Opposing States (1998, 2012, 2015) Nurse Practitioners (NPs)*

Nurse Midwives (CNMs)**

Nurse Anestheticists (CRNAs)*

Clinical Nurse Specialists (CNSs)

All states (n 5 50)

20 (40%)

20 (40%)

19 (38%)

17 (34%)

ERA supporting (n 5 30)

16 (53%)

17 (57%)

15 (50%)

13 (43%)

ERA opposing (n 5 20)

4 (20%)

3 (15%)

4 (20%)

4 (20%)

States

*p , 0.05; **p , 0.01 Online journal of issues in nursing by American Nurses Association Reproduced with permission of American Nurses Association in the format Book via Copyright Clearance Center.

agreement on core principles of NP regulations (NCSBN, 2008). Based on this consensus, NCSBN prepared a model act for NP regulation, toward harmonizing regulations of NPs among the states (NCSBN, 2012) and a toolkit for modernizing state regulations (NCSBN, n.d.).

Expanding NP roles was among the key recommendations in the 2010 The Future of Nursing: Leading Change, Advancing Health report and recommendations by the highly esteemed Institute of Medicine (IOM, 2010). That report recommended the removal of scope of practice barriers and called

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FIGURE 15-3  NCSBN consensus model map Reproduced from NCSBN. (2017). Implementation status map. Retrieved from https://www.ncsbn.org/5397.htm

for full deployment of nurses, nurses working at the “top of their license” in order to meet the needs of patients and the needs of the healthcare system. AARP, representing seniors, supported the IOM recommendations for the future of nursing, including full practice authority of NPs through its Center to Champion Nursing in America campaign (AARP, 2016). Additionally, the National Governors Association published a report calling for broader practice authority for NPs (National Governors Association, 2012).

Florida Florida’s regulations of NPs have consistently lagged behind most of the states. Until 2016, Florida was one of the only states where NPs could not prescribed controlled medications, such as cough medication with codeine as well as some seizure and pain medications. Several NP groups advocated for modernizing the regulations, but

their disjointed efforts were not successful against the well-organized and well-funded resistance from state physician groups. The groups formed an NP coalition to focus their strategies and advocate with a united voice. The NPs worked to change the regulations so that NPs could prescribe all medications a patient may need, sign death certificates, and order involuntary confinement for mental illness. In 2010, the state legislature’s Office of Program Policy Analysis and Government Accountability (OPPAGA) produced a study showing cost savings to be gained by expanding the scope of practice for NPs, physician assistants, and dental hygienists (OPPAGA, 2010). Florida Tax Watch also supported lifting the restrictions on NPs as an avenue to improve the efficiency of tax dollars. Two strong champions in the state legislature helped move NP-favorable bills forward. Former emergency medicine physician and state

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Representative Cary Pigman served on the Health Quality Subcommittee. He spoke intensely and frequently on the absurdity of the limitations on NP practice. State Senator Denise Grimsley, RN, sponsored legislation to modernize the NP regulations. Organized medicine claimed NPs were not safe to perform these acts, and that they lacked the education that physicians have. The nurses achieved some victories in the 2015 and 2016 sessions. The legislature approved changes to allow NPs to prescribe most schedule 3 to 5 medications and a 7-day supply of schedule 2 medications (such as codeine for pain). Psychiatric NPs were given authority to order involuntary confinement for mental illness. The authority for NPs to sign death certificates did not pass. The NP Coalition is now focusing on full practice authority (FPA), removing the requirements for physician supervision.

Summary In spite of over 50 years of evidence showing the safety and quality of NPs, NP regulations vary across the states. Florida nurses’ attempts to modernize its NP regulations for specific acts, such as prescribing controlled substances and signing death certificates, were supported by several non-nursing groups. They achieved partial success, gaining the ability to prescribe some controlled substances as needed. This study examines background, contributing factors, and strategies to achieve harmonization among state regulations so that NPs can practice to the full extent of their education and abilities.

Case Study Questions 1. Examine the map of state regulations (NCSBN, 2017). What are some reasons for the variability? In what ways does gender play a role? What role does evidence play? What other factors influence NP regulations? What patterns do you see? Why do you think Massachusetts and Illinois score lower than their neighboring states? Why do the Western states score higher? 2. What are the benefits and disadvantages of pursuing legal authority for specific functions, such as ordering physical therapy, prescribing controlled substances, or signing death certificates? Should prescriptive authority for controlled substances have

been the focus on NPs efforts? What other aspects of NP regulations might they have focused on? Would it be more effective for advocates to focus on removing physician supervision? What is the impact on the art of advance practice nursing when an NP is supervised by a physician? 3. Look at the literature regarding NP scope of practice and regulations. What studies are needed? The ranking of NP regulations by Rudner, O’Grady, Hodnicki, and Hansen (2007) looked at how regulations affected consumer access. Why look at the consumer perspective? What role does evidence play in determining policy? 4. The “silver tsunami” of aging Baby Boomers, increases in chronic disease, and new models of healthcare delivery are all factors calling for new approaches to care. What can NPs contribute to a new model of care to reflect the unique, valuable contribution of nursing? Propose a model of care to address an issue. What enabling legislation would be needed to make this viable? Consider a range of aspects, including access, staffing, financing, reimbursement, and quality. 5. Look at the NP regulations in your state and the NP policy activities of your state nurses association and other nursing groups. What are the pros and cons of the current regulations? What needs to be changed? What approaches do you think would be most effective? The Florida case shows alliances with multiple nonnursing organizations. What agencies and organizations might be allies in your state to improve nursing practice?

References AARP. (2016). Campaign for action. Retrieved from https:// campaignforaction.org/ American Academy of Family Physicians (AAFP). (2013). Guidelines on the supervision of certified nurse midwives, nurse practitioners, and physician assistants. Retrieved from http:// www.aafp.org/about/policies/all/guidelinesnurses.html American Academy of Family Physicians (AAFP). (2014). Nurse practitioners. Retrieved from http://www.aafp .org/about/policies/all/nursepractitioners.html American Academy of Pediatrics (AAP) (2016, February). AAP publications reaffirmed or retired. Pediatrics, 137(2). Retrieved from http://pediatrics.aappublications.org /content/137/2/e20154272

Case Study

Office of Technology Assessment. (1981).  The costs and effectiveness of nurse practitioners. Washington, DC: U.S. Government Printing Office. Office of Technology Assessment. (1986).  Nurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis. Washington, DC: U.S. Government Printing Office. Oliver, G., Pennington, L., Revelle, S., & Rantz, M. (2014). Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nursing Outlook, 62(6), 440–444. Perloff, J., DesRoches, C., & Buerhaus, P. (2016). Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians. Health Services Research. 51(4), 1407–1423. doi:10.1111/1475-6773.12425 Rudner, N. R. (2016, May). Full practice authority for advanced practice registered nurses is a gender issue. Online Journal of Issues in Nursing, 21(2). Retrieved from http:// nursingworld.org/MainMenuCategories/ANAMarketplace /ANAPeriodicals/OJIN/TableofContents/Vol-21-2016 /No2-May-2016/Articles-Previous-Topics/Full-Practice -Authority-for-APRN.html Rudner, N., O’Grady, E., Hodnicki, D., & Hanson, C. (2007). Ranking state NP regulation: Practice environment and consumer health care choice. American Journal of Nurse Practitioners, 11(4), 8–24. Rudner, N., O’Grady, E., Hodnicki, D., & Hanson, C. (2010). Are regulations more consumer-friendly when boards of nursing are the sole regulators of nurse practitioners? Journal of Professional Nursing, 26(1), 29–34. doi: 10.1016/j. profnurs.2009.09.001 Safriet, B. (1994). Impediments to progress in health care workforce policy: License and practice laws. Inquiry, 31(3), 310–317. Safriet, B. (2002). Closing the gap between can and may in health care providers’ scopes of practice: A primer for policy makers. Yale Journal on Regulation, 19(2), 301–334. Stanik-Hutt, J., Newhouse, R., White, K., Johantgen, M., Bass, E., & Zangaro, G.. . . Weiner, J. (2013). The quality and effectiveness of care provided by nurse practitioners. Journal for Nurse Practitioners, 9(8), 492–500. Retrieved from http://www .npjournal.org/article/S1555-4155(13)00410-8/fulltext Starr, P. (1982). The social transformation of American medicine. New York, NY: Basic Books. Swan, M., Ferguson, S., Chang, A., Larson, E., & Smaldone, A. (2015). Quality of primary care by advanced practice nurses: A systematic review. International Journal for Quality in Health Care, 27(5), 396–404. doi:10.1093 /intqhc/mzv054

CASE STUDIES

Federal Trade Commission. (2014). Policy perspectives: Competition and the regulation of advanced practice nurses. Retrieved from www.ftc.gov/policy/reports /policy-reports/commission-and-staff-reports Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324, 819–823. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from http://www.nap.edu/catalog/12956 /the-future-of-nursingleading-change-advancing-health Kuo, Y., Loresto, F., Round, L., & Goodwin, J. (2013). States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Affairs, 32(7), 1236–1243. doi:10.1377/hlthaff.2013.0072 Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2005). Substitution of doctors by nurses in primary care. Cochrane Database System Review, CD001271. National Council of State Boards of Nursing (NCSBN). (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from https://www.ncsbn.org/Consensus_Model_for_APRN _Regulation_July_2008.pdf National Council of State Boards of Nursing (NCSBN). (2012). 2012 Model Act. Retrieved from https://www.ncsbn .org/2012_APRN_Model_and_Rules.pdf National Council of State Boards of Nursing (NCSBN). (2017). Implementation status map: Consensus model implementation status. Retrieved from https://www .ncsbn.org/5397.htm National Council of State Boards of Nursing (NCSBN). (n.d.). APRN consensus model toolkit. Retrieved from https:// www.ncsbn.org/739.htm National Governors Association (NGA). (2012). The role of nurse practitioners in meeting increasing demand for primary care. Washington, DC: Author. Retrieved from www.nga .org/cms/home/nga-center-for-best-practices/center -publications/page-healthpublications/col2-content /main-content-list/the-role-of-nurse-practitioners.html Newhouse, R., Stanik-Hutt, J., White, K., Johantgen, M., Bass, E., & Zangaro, G.. . .Weiner, J. (2011, September-October). Advanced practice nurse outcomes 1990–2008: A systematic review. Nursing Economics, 29(5), 230–250; quiz 251. Office of Program Policy Analysis and Government Accountability (OPPAGA). (2010). Expanding scope of practice for advanced registered nurse practitioners, physician assistants, optometrists, and dental hygienists. Retrieved from https://www.floridanurse.org/ARNPCorner /ARNPDocs/OPPAGAScopeofPracticeMemo.pdf

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CHAPTER 16

Physicians: It Is Increasingly about the Team Nancy Aries and Barbara Caress

OVERVIEW The role of physicians and how they practice is at a crossroads. Health care is achieving greater collaboration between providers and the organizations where they work. This dynamic has resulted from two underlying changes. First, the dominance of the biomedical model, which focused on the treatment of acute conditions, is giving way to a comprehensive and continuous model of care embedded in the context of patients’ lives—the social determinants of health. Second is the use of financial and outcomes data to validate improved quality and lower costs. The increasing role of collaborative, team-based care impacts the autonomy of physicians and possibly the doctor–patient relationship. While physicians are still dictating how to treat patients, their role must be understood within the context of a comprehensive system of care that they no longer fully control. This chapter will describe how physician practice is changing as the healthcare system changes. We conclude with a consideration of how health policy impacts the doctor–patient relationship.

OBJECTIVES ■■

■■

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Describe both the centrality and limits of physicians in defining how the health system functions. Distinguish how changes in physician practice impact healthcare access, healthcare costs, and healthcare quality. Identify how the Affordable Care Act (ACA) and other changes to the organization and financing of care have already influenced physician practice.

© Anthony Krikorian/Shutterstock

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Chapter 16 Physicians: It Is Increasingly About The Team

Medical Professionalism

The pace of change in the delivery of health care is quickening. Increasingly we hear stories about physicians whose treatment of complex, chronic conditions based on standard practice might be out of step with evidence-based, current treatment protocols. Patient behavior and interaction are recognized as playing a key role in the effectiveness of any treatment. Not only are patients and their families important, but so is the team of clinicians including nurses, nutritionists, physical therapists, and social workers who support patients across time. Several years ago, stories like Lia Lee’s seemed frustratingly normative (Fadiman, 1997). Lia was a young Hmong woman diagnosed with epilepsy before her first birthday. Lia’s family had recently immigrated to the United States. They barely spoke English and were unfamiliar with Western medical practice. Lia’s condition was tenuous. Her medication regimen was complex and constantly changing, given the difficulty doctors had controlling the disease. Her parents’ failure to adhere to the regimen led one physician to report her family to Child Protective Services. As a result, Lia was placed in foster care. Although the foster family was loving and followed the prescribed medical regimen, the placement was exceptionally stressful for Lia. She was returned home following her parents’ agreement to comply with the doctors’ orders, but her condition deteriorated. Lia continued having seizures until one seizure, a grand mal, did not stop. Lia was taken to the hospital, where doctors found her in septic shock. They were able to stop the seizures and cure the sepsis, but Lia was brain dead. For the next 26 years, she lived at home, comatose (Fox, 2012). Although Lia’s story can be told as a story of medical noncompliance, that is too simple an explanation for her brain death. Lia’s parents, recently arrived Hmong refugees, spoke practically no English. The first times they took Lia to the emergency department there were no

interpreters who spoke Hmong; thus, her condition was misdiagnosed. A correct diagnosis was not made until Lia arrived at the emergency room during an epileptic seizure. With limited means of communication, there was no way to bridge what the doctors understood to be a disease best managed with anticonvulsant medications and her parents’ belief that Lia’s soul needed to be brought back to her body. Each acted in good faith. Each cared for Lia’s well-being. Lia’s medications were changed 23 times over 4 years in an attempt to stabilize her condition. The Lees engaged a shaman to treat her soul, which they thought was being hurt by her medications. The divide between the two practices resulted in what her doctors considered her death on the night of her grand mal seizure. In retrospect, everyone involved agreed that adherence to what was perceived as the best possible treatment regimen for epilepsy most likely resulted in a worse outcome than would have happened if the doctors and Lia’s parents jointly devised a plan that would accommodate the two differing cultural ideas about her disease and her care. Today, there is a growing movement to embed the principles of collaborative, team-based care in the practice of medicine. What started as lone voices and singular stories being told about physicians who worked closely with other health professionals in the delivery of complex care is becoming increasingly embedded in the institutions that oversee the organization and delivery of services. The Commonwealth Fund’s website has a section titled “Case Studies” that focuses on individual strategies for the better provision of patient-centered care, often for high-need and high-cost patients (The Commonwealth Fund, n.d.). Starting in 2009, the associations representing six heathcare disciplines (medicine, osteopathic medicine, dentistry, nursing, pharmacy, and public health) joined forces to identify a common core of competencies and learning experiences that would lead to improved team-based care (Interprofessional Education Collaborative, 2011). In 2015, the Institute of Medicine’s report, Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient

Physician Supply: Who Are the Doctors?

Outcomes (2015) further advanced the significance of the issue for policymakers. In this chapter, we examine the role of physicians in a system that is capable of providing high-quality care but often fails to meet the patient’s needs. To do so, the chapter is organized in three parts. We begin by explaining who makes up the physician labor force, where physicians practice, and whether the physician supply is adequate to meet patient demand. In the second part, we consider how physician practices are organized and financed, and the ways health policy reform is pushing physicians to practice in more coordinated and collaborative ways. The last section addresses the problem of medical errors to demonstrate how the healthcare delivery systems can undermine the best intents of those who practice medicine. We conclude by considering the impacts of a collaborative, team-based approach on the doctor–patient relationship.

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Physician Supply: Who Are the Doctors?

There are just over 1 million physicians in the United States (National Center for Health Statistics [NCHS], 2016). Is this enough to meet healthcare needs in the United States? This question has long been debated. The first part of the answer relies on the demand for services. There has been a steady increase in demand for physician care going back to the post–World War II era. This can be attributed to four primary factors. First is population growth. There are now more than 318 million Americans, and the elderly, an ever-greater percentage of the population, utilizes health services most intensely (NCHS, 2016). Second is the increasing percentage of the population with chronic conditions ranging from asthma, to diabetes, to heart disease that requires the ongoing involvement of healthcare providers (NCHS, 2016). Third is technological innovation that, in the long run, tends to increase the demand for services (Callahan, 2008). Last is increased affordability of

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health insurance that has increased access to and utilization of health services. Health insurance became widely available with the provision of employer-based insurance post World War II. The enactment of Medicaid and Medicare in 1965 expanded access to the elderly and poor. Implementation of the Affordable Care Act (ACA) in 2014 extended health insurance to an additional 25.6 million persons who enrolled in the ACA Marketplace or as part of the Medicaid expansion (Kaiser Family Foundation, 2017). As the demand for medical care has increased, there has been a steady increase in the both the supply of physicians and the ­physician-to-population ratio. As TABLE 16-1 indicates, the number of active physicians increased from 219,900 in 1950 to 860,939 in 2015. More important, the ratio of active physicians to population increased in that time period from 14.9 to 37.3 per 10,000. As the demand for medical care increased, medical schools increased class size and 40 new medical schools were built between 1960 and 1980. The result was that the number of graduates more than doubled from 7,000 to 16,000 by 1980 (Ludmerer, 1999). Between 2002 and 2016 there was another upswing in the founding of new medical schools. The current number stands at 146, and additional schools are in the planning phase (American Association of Medical Colleges [AAMC], 2016b). Between the continued increase in class size of established medical schools and the addition of new schools, the number of admitted medical students continues to rise, which has increased the overall number of physicians and physicianto-population ratios (Young et al., 2015). The supply of physicians is not solely dependent on educated American physicians. As of 2014, 23% of licensed physicians were international medical graduates (IMGs) (Young et al., 2015). Just over 10% of the IMGs are U.S. c­ itizens who studied abroad. The rest are foreign nationals who predominantly come from India, the Philippines, Mexico, and Korea. They complete their postgraduate training as interns and residents in the United States because there are more residency slots than there are American-trained physicians

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Chapter 16 Physicians: It Is Increasingly About The Team

TABLE 16-1  Number of Active Physicians and Medical Schools, 1950–2015 Year

Number of Active Physicians (MD and DO)

Active Physicians/10,000 Population

Number of Medical Schools (MD)

1950

219,900

14.9

79

1960

247,257

14.8

86

1970

310,845

16.0

103

1980

414,916

20.2

125

1990

547,310

22.0

125

2000

692,368

25.8

124

2010

794,862

27.2

135

2015

860,939

37.3

146

MD = medical doctor; DO = doctor of osteopathic medicine. Sources: Data from Statista. (n.d.). Statistics & facts on U.S. physicians/doctors. Retrieved from https://www.statista.com/topics/1244/physicians/ National Center for Health Statistics (NCHS). (2016). Health, United States, 2015: With special feature on racial and ethnic health disparities; Tables 83, 84, and 88. Retrieved from https://www.cdc.gov/nchs/data/hus/hus15.pdf American Association of Medical Colleges (AAMC). (2016b). Results of the 2015 Medical School Enrollment Survey.

to fill them. The impact of the increased number of medical school graduates on the availability of residency slots for IMGs is not known. If the number of residencies remains constant, there would be less need to rely on educated foreign physicians. One result might be greater competition for residencies and doctors considering a broader range of practice options. However, new funding for postgraduate training through provisions in the ACA and other federal and state agencies could widen the gap with the result being the admission of more IMGs and a smaller deficit in underserved areas (Mullan, Salsberg, & Weider, 2015).

Physician Characteristics: Race, Ethnicity, and Gender The profession of medicine has become more diverse than it was in 1960 when 97% of doctors

were white, and 93% were men. While the medical profession better represents the diversity of the society it serves, it masks the continued underrepresentation of blacks and Hispanics. Despite efforts to recruit underrepresented minorities to medical schools, the percentage of underrepresented minority physicians remains largely unchanged (American Association of Medical Colleges, 2014). An examination of medical school enrollments provides a window into the changes that can be expected in the workforce as a whole. One impact of the Civil Rights Movement was pressure on medical schools to integrate their classes and thus increase overall black enrollment. In 1970, there were only 697 black first-year medical students, 6% of the total (TABLE 16-2). Most of these students attended Howard University College of Medicine and Meharry Medical College, the two largest, historically black medical schools. In 1995 to 1996, black enrollment hit

8,069

11,348

17,186

16,876

17,058

16,699

19,082

19,947

Academic Year

1960–1961

1970-1971

1980-1981

1990-1991

1995-1996

2000-2001

2010-2011

2011-2012

1,182

1,174

1,243

1,519

1,263

1,128

5.9

6.1

7.4

8.9

7.5

6.6

6.1



– 697

Percentage

Number

Black First-Year Enrollment

1,707

1,612

1022

1209

933

818

100



Number

8.5

8.4

6.1

7.0

5.5

4.8

0.9



Percentage

Hispanic First-Year Enrollment

4,442

4,315

3,265

3,046

2,527

22.2

22.6

19.6

17.9

15.0

3.3



– 572



Percentage



Number

Asian First-Year Enrollment

9,037

8,756

7,472

6,941

6,550

4,757

1,228



Number

47.0

46.9

45.0

42.7

38.8

28.7

11.0



Percentage

Female First-Year Enrollment

Source: Data from Association of American Medical Colleges (AAMC). (2014). Diversity in the physician workforce: Facts & figures 2014; Tables 4, 5, 9. Retrieved from https://www.aamc.org/data/workforce/reports/439214 /workforcediversity.html

Medical School First-Year Enrollment Total

TABLE 16-2  Minority and Women’s First-Year Medical School Enrollment: 1960–2012

Physician Supply: Who Are the Doctors? 345

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Chapter 16 Physicians: It Is Increasingly About The Team

its peak at 9% when there were 1,525 first-year black medical students. Since that year, both the number and percentage of first-year black enrollees has dropped. In 2011 to 2012, the last year reported by the American Association of Medical Colleges, only 1,182 blacks were enrolled in a class of 19,947 students, making up 6% of the class. More distressing is the situation of black males. The number of first-year black male matriculates reached a high in 1978 at 542. In 2014 to 2015 there were only 515 (Thompson, 2015). The situation for Hispanics is slightly better, as the number of first-year enrollees continues to rise although the percentage has remained fairly flat given increasing large first-year classes. In 2011 to 2012 there were 1,707 Hispanics in the firstyear class, representing 8.5% of the total. Asians have seen the greatest gains in medical school enrollment. In 2011 to 2012 Asians comprised 22% of the first-year class. The large increase in Asian enrollment has resulted a decline in the percentage of white medical school students, who now comprise only 63% of the medical school class, but their overall number has grown. Women have fared much better than underrepresented minorities regarding medical school enrollment. Women are close to parity in medical school enrollments. They make up almost 50% of the entering classes. Gender parity in medical school enrollment brings us closer to gender parity in medical practice. In 1970, there were just over 25,000 active women physicians. By 2010, women comprised almost 30% of the physician labor force (Young et al., 2015). Black women have already reached and exceeded parity. Fifty-five percent of active black physicians in 2013 were women (American Association of Medical Colleges, 2014). The diversity of the physician work force is important for reasons ranging from larger social concerns for social equity to specific concerns about the delivery of care. Minority physicians increase access to health services because black and Hispanic physicians are more likely to practice in underserved minority communities and rural area communities (American Association of Medical Colleges, 2014). Minority physicians

have also been found to provide more culturally appropriate care (Ansell & McDonald, 2015). In addition, they advance medical research by exploring issues that are not always seen by the white majority. Women’s participation in the physician labor force is equally important because women are more likely than men to engage in primary care practice (Kane, 2015) where there are the most severe physician shortages (IHS Markit, 2017).

Physician Practice Characteristics: Medical Specialization and Geographic Location There is an unequal distribution of physicians by medical specialty and geographic location that results in limited patient access to services. Good primary care is critical to good health, but there is continued shortage of primary care physicians (American Academy of Family Physicians [AAFP], 2014). Although more physicians are being trained, the proportion that choose primary care has not increased (Goodfellow et al., 2016). The shortage of primary care physicians is expected to become even greater as the population ages and more individuals possibly have access to health insurance. Already in short supply, it is projected that there will be a 17% increase in the demand, with only an 11% increase in the supply for primary care physicians between 2013 and 2025 (NCHS, 2016). There is also an unequal distribution of physicians across geographic areas. The Bureau of Health Professions estimated that 20% of the population lives in areas that are designated as medically underserved based on the availability of primary care physicians (Rosenbaum, Jones, Shin & Ku, 2009). In 2010, there were 84 primary care physicians per 100,000 in urban areas but only 68 per 100,000 persons in rural areas (Petterson, Phillips, Bazemore, & Koinis, 2013). Despite the higher ratio of primary care physicians in urban areas, low-income communities

Physician Supply: Who Are the Doctors?

can be medically underserved. East Harlem, a New York City neighborhood in northern Manhattan, is designated as medically underserved despite one academic medical center being located at the community’s edge and two others within 2 miles (Health Resources and Services Administration [HRSA], 2017). Rural and low-income, inner-city communities find it hard to attract primary care physicians for several reasons (Council on Graduate Medical Education [COGME], 2017). The most common is the highly specialized nature of medical training. Residencies in primary care go unfilled while there is an excess demand for hospital-based residencies in subspecialties. Physicians find fewer opportunities to practice the type of medicine for which they were trained in these communities. Physicians’ decisions are also influenced by high student loan debt, substantial differentials in the salaries of primary and specialty care doctors, and lifestyle choices (COGME, 2017). There have been long-standing efforts to increase the number of physicians going into primary care specialties and underserved areas. In the 1960s, a new specialty in family practice medicine was developed that provided advanced residency training. The number of family practice residents has returned to the levels reached in 1998, while the percentage of internal medicine residents who intend to become primary care practitioners has dropped precipitously (AAFP, n.d.; Committee on the Governance and Financing of Graduate Medical Education, Board on Health Care Services, & Institute of Medicine, 2014). The National Health Service Corps, begun as part of the 1960s War on Poverty, provided loan forgiveness to doctors who practiced in rural and later urban medically underserved areas. The program was successful but was largely disassembled during the Reagan administration (Sardell, 1988). As more tightly managed care took hold in the 1990s, federal and state policies helped promote a rapid increase in the number of primary care physicians over the decade (Bodenheimer & Pham, 2010). More recently, several features of

347

the ACA support primary care physicians and those working in underserved communities (Klink, 2015). These include increased funding for the National Health Service Corps, decreased fees on medical school loan repayment, and increased funding for graduate medical education (GME) in community-based ambulatory care settings (COGME, 2017).

Physician Income Physicians have the highest median income of all occupational groups in the United States ­(Bureau of Labor Statistics [BLS], 2017). This does not seem intuitively obvious when one thinks about corporate executives whose salaries soared into the tens of millions of dollars, but in 1999, physicians and dentists were the only occupational groups to have median incomes above $100,000 (Weinberg, 2004). Physicians are also among the occupation groups with the greatest range in earnings. In 2017 physician-reported average income was $294,000, but the average income for specialists was 46% greater than for primary care physicians ($316,000 vs. $217,000) (Grisham, 2017). The average income for men was 35% greater than for women. Among specialists, men earned $345,000 versus women who earned $251,000. For primary care physicians, the gap was only 16%. The top earning specialties were orthopedics, plastic surgery, and cardiology, whose average incomes ranged from $410,000 to $489,000. The lowest earning specialties were family medicine ($209,000) and pediatrics ($202,000). There are also income disparities by race and ethnicity. White physicians earned on average $303,000; Asian physicians earned $283,000, Hispanic physicians earned $271,000, and black physicians earned $262,000. Little known is that physicians in the United States were the second most highly paid medical practitioners in the world as of 2010, following behind the Netherlands. On average, U.S. physicians earn three times what their counterparts working in countries belonging to the Organisation for Economic Co-operation and Development earn (Conover, 2013).

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Chapter 16 Physicians: It Is Increasingly About The Team

The Adequacy of the Physician Supply The question remains: Will the physician supply be adequate? There is a wide divergence regarding the extent of the problem based on the assumptions built into the predictive models about the ways healthcare delivery will be organized (Salsberg, 2015). The greater the reliance on physicians as primary care providers, the higher the ratio of physicians to population needed. Inversely, the greater the role of alternative practitioners, the lower the ratio needed to provide primary care in medically underserved areas (Bodenheimer & Bauer, 2016). The Association of American Medical Colleges (AAMC) reports that the shortfall in 2025 will range from 34,600 to 82,600 physicians depending on the organizational model used to make projections (IHS Markit, 2017). The report notes that this is substantially lower than the AAMC’s projection made 1 year earlier that put the shortfall between 61,700 to 94,700 physicians. The larger problem, however, is that medical training does not align as well as it should with the needs of those seeking care. Medical practice is heavily grounded in the biomedical sciences. This is a necessary component of medical education, but not a sufficient one for a healthcare system where population health is a starting point for practitioners to engage with the needs of individual patients in a more holistic way (Grover, Orlowski, & Erikson, 2016). Knowing this does not change the fact that most medical training occurs inside the hospital where patients are being treated for complex conditions. Training is limited in clinical settings where most care is delivered. This creates the disjunction between GME and the need to educate physicians to prepare to practice in community-based settings where most Americans obtain care (Institute of Medicine, 2014). The challenge is to bring the physician supply in equilibrium with demand for services consistent with a population-based approach to care. This calls for change in the organization and financing of GME (American Academy of Family

Physicians, 2014; COGME, 2017; Committee on the Governance and Financing of Graduate Medical Education, Board on Health Care Services, & Institute of Medicine, 2014; ­Jackson et al., 2014; U.S. Government Accounting Office [GAO], 2016).

▸▸

How Are Physicians Practices Organized and Reimbursed?

Where physicians practice, the organizations of these practices, and the ways physicians are compensated, are rapidly changing. The basic issue is to how best to provide integrated and continuous cases, such as received by patients whose narratives The Commonwealth Fund publicizes. It is argued that improved health outcomes and lower costs will result from longterm, stable, and trusting relationships between patients and their healthcare team (Reid et al., 2010). These teams can guide patients through the complex healthcare system and enable them to become active participants in their health and well-being (Nickitas, 2009). The fragmentation of the healthcare delivery system, however, undermines the level of coordination that would enable patients to receive care that extends beyond their acute medical needs (Wynia, Kohorn, & Mitchell, 2012).

Physician Practice Arrangements The trend is for physicians to work in group practices and as part of integrated care systems (Muhlestein & Smith, 2016). Historically, physicians worked alone or in partnership with another physician and oversaw all aspects of their patients’ care (Starr, 1982). Access and utilization of related services such as physical therapy or home care was dependent on the physicians’ knowledge of the alternative. Group practice was discouraged by the medical profession. The American Medical Association (AMA) feared

How Are Physicians Practices Organized and Reimbursed?

that such practices would undermine physician autonomy by imposing hierarchical control over physicians (Starr, 1982). Resistance began to lessen in the 1990s with the growth of managed care, and the trend accelerated as the ACA sought ways to create greater integration of care delivery (Kash & Tan, 2016). Consolidation of practices and integration into health systems offers organizational advantages if physicians want to participate in population-based arrangements (Muhlestein & Smith, 2016). There are also cost efficiencies that come from consolidation—for example, access to costly electronic medical records systems. Large practices are also able to negotiate higher fees and afford physicians a more regularized lifestyle. There has been a steady decline of physicians working in practices with fewer than five physicians. In 1983, almost 70% of physicians worked in such practices; by 2014, the percentage had dropped to 41%. The decline can primarily be attributed to the decreasing percentage of physicians working in solo practice from 44% to 19%. Small to moderate-sized groups have replaced solo practice as the most common practice setting, with 32% of physicians in practices of 5–24 patients. The largest percentage increase was in practices of 25 or more physicians, which grew from 5% to 20%. A 2015 analysis of Medicare Provider Enrollment forms indicates the same percentage of physicians in practices under 25, but a much larger percentage (35%) of physicians practicing in groups of 100 or more physicians (Muhlestein & Smith, 2016). The change in practice size is correlated to physicians’ age. Among the youngest cohort of doctors (younger than 40 years old), only 5% were in solo practice in 2011, in contrast to 32% of physicians older than 60. The percentages were reversed for physicians in group practices with more than 50 doctors: 48% were younger than 40, and 26% were 60 or older (Welch, Cuellar, Stearns, & Bindman, 2013). An equally significant trend is the changing ownership of physician practices. Physicians owned just over 50% of practices and were

349

employed in 43% as of 2014. The tendency is for younger physicians and women to be employed rather than own a practice. Hospitals had some ownership stake in 31% of physician practices (Kane, 2015). Hospital ownership is financially beneficial to both the hospital and the doctors in the current environment. With admissions and length of stay declining, hospitals want to secure access to patients and limit competition with physicians who can provide increasingly complex services in ambulatory settings. Hospital ownership of physician practices eliminates the potentially competitive relation between the two. A corollary benefit is the ability of hospitals to negotiate better payment rates for physicians (Casalino, 2017). Another significant change is the number of physicians who are directly employed by hospitals. The rate of increase in the number of hospital-employed physicians has accelerated. Between 2012 and 2015, the number of ­hospital-employed physicians grew by 46,000. In the last 6-month period of the study ­(between July 2014 and January 2015) 20,000 additional physicians became hospital employees. By the later date, 38% of all physicians were employed by hospitals. (Physicians Advocacy Institute [PAI], 2016). Included in the hospital-employed group is a large and growing number of hospitalists— who function as “primary care” practitioners coordinating the services of specialists and other healthcare providers and services to hospitalized patients. First employed in 1995, there are now an estimated 50,000 physicians trained in primary care working as hospitalists in the U.S. (Wachter & Goldman, 2016). Thirty percent of general internists under age 45 are reported by the American Association of Medical Colleges (AAMC) to be working as hospitalists (AAMC, 2016a). This type of practice type is also being shown to have positive benefits regarding costs but not necessarily patient outcomes (Auerbach et al., 2010). There are two other groups of physicians to be considered. First, is the small number of physicians engaged in public health activities.

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These physicians are typically employed in federal and state public health programs and are responsible for assuring the health of populations. Probably the best known public health physician is C. Everett Koop, Surgeon General of the United States during the Reagan administration, whose efforts led to the requirement of health warning labels on cigarettes (U.S. National Library of Medicine, 2009). Second, is the small number of physicians who work in clinics on a part- or full-time basis that provide services to persons who cannot readily access the private practices of physicians described above. These clinics may be operated as part of an academic medical center, public health department, or community group. Many community health centers incorporate not only medical care but also social services and provide the model of for integrated care.

The Relation between Physicians Practices and Care Coordination The relationship starts with the premise that care coordination is essential to quality outcomes. The ability to achieve better coordination between the diverse providers who can impact patient outcomes is related to the organization of the delivery system. The principles that underlie team-based care are shared goals between patients and providers, trust and respect between providers with differing expertise that enables them to carry out their respective roles on the team, and an organizational structure that facilitates coordination and case management (Wynia, Kohorn, & Mitchell, 2012). Advocacy for greater care coordination began in the 1980s and 1990s. Implementation of the ACA increased the rate of change in all areas of the health delivery system (Martin et al., 2016). Two organizational models drive the current movement to coordinate care. The first is accountable care organizations (ACOs), which were first described in the ACA as a Medicare demonstration program. ACOs are a model of care that uses financial incentives to promote

better care coordination based on savings and losses (Barnes, Unruh, Chukmaitov, & van Ginneken, 2014). Since passage of the ACA, a number of commercial insurance companies has adopted the model. Kocot and White (2016) found that ACO performance varies. The number of ACOs receiving shared savings has grown and appears to be partially related to the length of participation in the program. At the same time, less than one-third of the ACOs have reduced costs to the point that they share in the savings. As for quality indicators, the Office of the Inspector General (2017) reported that the ACOs improved their performance on 82% of individual quality measures with notable improvement in the areas of depression screening and assessment of fall risks. The other approach has been the development of patient-centered medical homes (PCMHs). In this case, care management and coordination is the driver for change. While care coordination has been central to the practice of health maintenance organizations (HMOs) and community health centers, it has played a more prominent role in addressing the needs of chronic care patients since the early 2000s (Fields, Leshen, & Patel, 2010). No singular definition of PCMHs exists. Guidance, however, is offered by both the National Committee for Quality Assurance and the Academy of Pediatrics Center for Medical Home Improvement. Both indicate some essential criteria with many attributes describing how these can be achieved. In reality, most medical practices that are identified as medical homes do not achieve the full range of expected continuous and coordinated care attributes. Bigger practices meet more of the criteria than middle or smaller practices, but even many middle and smaller practices are using the essential care coordination processes (Rittenhouse et al., 2011). The medical home is an appealing model. It explains the failure of Lia’s care and the success of those patients whose case studies are discussed on The Commonwealth Fund’s website (The Commonwealth Fund, n.d.). Essentially, the organization of medical homes requires a change in the culture of medical care practice (Martin et al.,

How Are Physicians Practices Organized and Reimbursed?

2016). Team-based care coordination ensures that existing siloes in the healthcare delivery system are broken down. This stands in contrast to the current assumption that patients will receive appropriate care if each silo is functioning properly. The level of organizational change required to break down barriers between previously independent sectors of the health system, such as medical care, public health, and social services, may ultimately involve a rebalancing of priorities and funding—if the goal is ultimately to improve not only the patient’s experience and the health of the population, but to decrease costs. The change process is typically a slow one, especially when it involves fundamental transformation of current approaches to care. However, in this case, the pace is faster than expected. Funding from the ACA has supported evidence-based research on health outcomes to determine best practices (Vaida, 2016). The results have been positive but mixed, demonstrating the complexity of the issues, as well as the challenge in undertaking such sweeping changes to the organization and delivery of health care. For example, a randomized pilot study designed to examine communication between patients and providers found that carefully designed interventions led to greater patient involvement in decision making (Tai-Seale et al., 2016). At the same time, a study of the comanagement of neurosurgical patients using hospitalists did not find an improvement in quality measures such as mortality rates, but did find a reduction in costs (Auerbach et al., 2010). An examination of rehospitalization rates for Medicare patients found declining rates for all hospitals, but the reduction of rehospitalization rates for ACO hospitals was greater than for non-ACO hospitals (Winblad, Mor, McHugh, & Rahman, 2017). Despite the push towards large practice, a study of care practices found that the smallest physician practices had the lowest rate of hospital readmissions, and it was lower than the readmission rate of hospital-owned practices (Casalino et al., 2014). Research examining the experience of minorities and low-income populations is less

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positive. There are several aspects. First, physicians practicing in areas with high percentages of blacks and persons living in poverty were less likely to join ACOs (Yasaitis, ­Pajerowski, Polsky, & Werner, 2016). Second, participation did not reduce the health status gap ­between low and higher income participants. A study of ­Alternative Quality Contracts in Massachusetts (a two-sided ACO) found that quality measures improved for all groups but the gap in health ­disparities did not narrow (Song, Rose, Chernew, & Safran, 2017). A large-scale study of ACO quality measures found that ACOs ­serving a higher proportion of minority patients performed worse on 25 of the quality performance measures although they were comparable ­regarding services offered (Lewis, Fraze, Fisher, Shortell, & Colla, 2017). The last concern is the impact of care ­coordination on the doctor–patient relationship. Care coordination refines the role of doctors. They are responsible for that part of patient care for which they have been trained, but they are part of a team where nonphysician providers have voice, control, and responsibility for those aspects of care where they are expert. Historically, physicians controlled both the organization and content of care, which was based on the biomedical model of cure as opposed to care. With pressure to coordinate care through organized systems such as ACOs, some doctors fear that the need to meet agreed-upon goals will distract them from a more holistic view of the patient (Berenson, Burton, & McGrath, 2016). In this view, disruption to the relationship and the loss of continuity are particularly acute when hospitalists take over the role previously held by primary care practitioners (­ Gunderman, 2016). Whether this loss of autonomy will negatively impact the doctor–­patient relationship is unknown.

Physician Payment, Patient Cost and Outcomes The ways physicians are reimbursed influence the ways that they practice medicine (Hillman, Pauly, & Kerstein, 1989); therefore, policymakers

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look to advance payment methods that incentivize physicians to act in ways that are economic and enhance quality. Many factors can influence physicians’ judgments about patient care plans. Historically, physicians were paid on a fee-for-service basis, meaning they were reimbursed for each additional unit of service a patient received. The economic incentives were for physicians to maximize the quantity of services provided to maximize their earnings. As costs became an increasing area of concern the fee-for-service model came under scrutiny. However, research found that the incentives were not so determinant. For example, physicians may be incentivized to overtreat their patients with fee-for-service health insurance and undertreat patients with similar conditions when covered by managed care companies that paid discounted fees (Town, Wholey, Kralewski, & Dowd, 2004). Most MDs, while wary of payment incentives, appear to treat most of the patients similarly. (A notable exception might be when caring for people without insurance.) Also influencing physician behavior is ownership of associated businesses. Physicians who owned equipment or had an ownership stake in ancillary services such as laboratories or hospitals were more likely to provide services that necessitated their use (Schroeder & Showstack, 1978; Stensland & Winter, 2006). There is a consensus among stakeholders about the need to reform physician payment, but no agreement about the best method(s). Early efforts such as relative value scales that set payment based on the relative value of services did not have the intended outcomes of rewarding primary and chronic care providers (Bodenheimer et al., 2007). Leading up to the implementation of the ACA a range of options were considered. Closest to the status quo was the recalibration of fee-for-service medicine to minimize the financial incentives to overor undertreat patients depending on the reimbursement level. Similarly, the use of global payments was recognized as a method to build on the model of capitated payments used by some HMOs. To overcome the incentive to

undertreat, payment was linked to performance measures. A third alternative was to bundle physician payments based on an episode of care. The model that received the most attention was pay for performance of value, a system of payment that rewards physicians and providers for meeting performance measures (Werner & Dudley, 2009). Although there are several hundred pay-for-performance programs in existence, it is a complicated system because there are few good outcome measures and disagreement about how much of a physicians’ pay should be tied to performance or improvement. Under the auspices of the ACA, some physician payment reforms are being tested, including bonuses and/or penalties based on achieving practice-wide quality, outcome, and efficiency standards (RAND, 2013). Most recently, the Medicare and CHIP Reauthorization Act of 2016 (MACRA) calls for a change from volume-based reimbursement, meaning reimbursement made for the quantity of services provided to value-based reimbursement models. Under the proposed system, physicians would be rewarded for increasing quality and controlling costs. In essence, payment rates would be based on data collected in prior years as to the practice’s ability to comply with CMS quality measures based on process, outcomes, and efficiency measures (GAO, 2016). Physicians participating in Medicare and CHIP would be broken into two classifications. Physician practices classified under the advanced alternative payment model (AAPM) could receive a 5% payment bonus from Medicare starting in 2019 and continuing through 2024 if they can achieve predetermined outcomes (Casalino, 2017). To be classified as an AAPM, the practice must take on risk. Large ACOs, Comprehensive End-Stage Renal Disease Care Model, Comprehensive Primary Care Plus (CPC+), and other large group practices are most likely to be certified as AAPMs. The remaining physicians with few exceptions are included in the Merit-based Incentive Payment System (MIPS). Rather than risk sharing, MIPS physicians are subject to penalties (up to –4% a year) and bonuses (up to +9%) based on

Physician Accountability

quality, cost, improvement activities, and information systems metrics. Ultimately what has evolved is a cat-and-mouse system of financial reward for physicians. The largest payers of health services, such as the government and private insurance companies, devise payment methods that will encourage physicians to provide cost-effective and quality care. In return, physicians attempt to protect and increase their incomes. In this regard, MACRA incentivizes physicians is to join larger medical practices that can participate in the AAPMs (Casalino, 2017). Although a large number of physicians are still in practices of 9 or fewer doctors, these practices do not have the resources to invest in the processes required to meet the MACRA standards. At the same time, some early results regarding costs of hospital-owned practices are troubling. They have been found to charge higher prices, generate higher total costs per patient, and not provide better quality (Casalino, 2017).

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Physician Accountability

Having overviewed the medical profession, we need to consider what mechanisms assure that physicians are providing their patients the best care possible. Historically, physicians have been responsible for regulating the practice of their colleagues (Freidson, 1970). Their expertise was in part the basis of their autonomy to define both the content of their work and how the practice of health care was organized. Physicians, for example, not only set the standards of care for persons with cardiac disease, but they also determined who would provide the care and in what settings. As a result, physicians controlled both the supply and demand for health services. Their power, however, was moderated by their fiduciary relationship to their patients—meaning they were obligated to do everything in their power to assure the well-being of their patients. Self-regulation was carried out in multiple ways. The first point of control was (and still

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is) the system of medical education. A subset of physicians is responsible for all facets of this endeavor. They determine the size and composition of medical school classes, and they control decisions related to medical school’s curriculum through their participation on medical school faculty and accrediting bodies (Ludmerer, 1999). Medical education is just the beginning of the accountability structure. A second point of control is government regulation of physicians (Field, 2007). The government is concerned with the public’s safety; therefore, the right to practice medicine is limited to persons who have demonstrated a mastery of the field. All physicians are required to pass national boards and licensure examinations that fall under the auspices of state g­ overnments. Also, states guarantee that physicians keep up with innovations in the field and have set standards for continuing medical education. Authority over the government regulation of physician practice assumes tremendous involvement of the medical profession. The standards used by the state are standards set by the profession, implemented by the profession, and overseen by ­physicians. Likewise, the professional review boards that evaluate physicians for malpractice fall under the auspices of physicians who are employees of the states. Finally, hospitals in which physicians’ practices have a stake in assuring that the physicians are held to the highest standards of practice. Physician oversight by institutional providers is shifting from process to outcome indicators. Hospital trustees review physicians’ credentials before awarding hospital privileges. Hospitals medical boards review all patient deaths to determine whether a physician’s practice adhered to accepted standards of care. Beginning in the 1980s, hospitals began to institute systems of utilization review to assess physician practice relative to their peers and accepted outcome measures. Like hospitals, corporate-owned ­physician practices are also demanding greater accountability regarding the physicians meeting process and outcome standards (Blackstone & Fuhr, 2016).

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Medical Errors Theoretically, a system of self-governance should lead to high-quality care. A review of the literature on medical errors indicates that this is not necessarily the case. Complications are a natural result of medical practice that intervenes in complex human processes, and mistakes are the normal consequence of human activity. The challenge is to identify complications that are preventable—to understand the causes of medical error and document its prevalence. The Institute of Medicine defined medical error as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim” (2000, p. 28). An adverse event is defined as “an injury caused by medical management rather than by the underlying disease or condition of the patient” (IOM, 2000, p. 28). Types of medical errors include the following: ■■

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Diagnostic error, such as misdiagnosis leading to an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results Equipment failure, such as a monitor that fails to function during a procedure Infections, such as nosocomial and postsurgical wound infections Blood transfusion–related injuries, such as giving a patient the blood of the incorrect type Misinterpretation of other medical orders, such as failing to give a patient a salt-free meal, as ordered by a physician Harm resulting from exposure to a medication

Frequency of Medical Errors Estimates regarding preventable deaths due to medical errors (preventable adverse events) vary widely. Depending on how an error is defined, the Institute of Medicine report, To Err Is Human: Building A Safer Health System, indicated that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors (IOM, 2000). The report was intended to bring attention to the issue so that improvements would

be made to secure patient safety. More recent studies continue to find high levels of medical errors. One recent study estimated that errors led to 400,000 premature deaths, which would make it the third leading cause of death in this country, after heart disease and stroke (Makary & Daniel, 2016). Regardless of the definition used, the wide-ranging estimates are an indicator that patient safety continues to be a serious matter of concern.

Causes of Medical Error An array of explanations is offered as to why preventable mistakes happen. These range from malfeasance resulting from personal impairment or greed to a systematic critique of the way U.S. medical professionals are trained and health care is organized. The simplest explanation for medical mistakes is impaired providers. Physicians, nurses, and other practitioners are no less likely to have substance abuse problems than other Americans. There are no recent large-scale studies of substance abuse among physicians, but the best available estimates are that during their practice lifetimes, 8% to 12% of physicians will experience a substance-related problem (Baldiserri, 2007). It is estimated that 112,000 physicians will have an alcohol-related disorder and 64,000 will have a drug-related disorder. Although almost half of the causes of physician misconduct are not specified by state medical boards, 4% are attributed to substance abuse (Harris & Byhoff, 2016). A subtler form of impaired judgment relates to physician understanding of patients and their cultural understanding of health and disease. As we saw with the case of Lia Lee, cultural differences complicated medical care and led to a tragic error. In Lia’s case, many of the problems occurred because Lia’s family did not speak English. For Willie Ramirez, fluency in English was not the problem. The meaning of words, however, in different cultures was. Willie Ramirez was 18 years old. He collapsed outside of his girlfriend’s house after complaining of a severe headache

Physician Accountability

and was taken to the hospital. His family and friends reported to the doctors in the emergency room that Willie was “intoxicado.” The physicians understood this to mean that Willie had overdosed. To Cubans, however, the word is all encompassing. If they had pursued his case further and called in a neurosurgeon, they would have found that Willie was having a brain hemorrhage. He would not have become a quadriplegic (Price-Wise, 2008). More troubling are errors that occur as a part of the usual practice of medicine. Physicians practice within organizations that shape the conditions under which they operate. Ashish Jha tells a story of a patient who lived alone, became disoriented, and was brought to the hospital by a neighbor (2016). He was diagnosed with pneumonia and began a standard course of treatment. The patient’s situation deteriorated, and he was moved to the intensive-care unit (ICU) where he died 2 days later. Following his death, Dr. Jha contacted the patient’s daughter, who lived out of state. She told Dr. Jha that her father had been hospitalized several weeks earlier for pneumonia. The hospital laboratory confirmed that he had a rare bacterium that responded to only a few antibiotics. Further analysis of the patient’s lab results revealed that his pneumonia was caused by the same bacterium. The patient’s death was preventable, but Jha asks what if it was a medical error? The doctors followed the hospital’s protocols, and yet the patient died from lack of information. If the doctors had access to his medical records from the prior hospitalization, or the patient had provided a more complete medical history, this might not have happened. Last is the consideration of industry–physician relationships on patient outcomes. The pharmaceutical industry plays an important role in the development of drugs and medical devices. The industry is interested in selling its products and physicians are the prime targets of their marketing strategies. In 2015, pharmaceutical companies spent over $20 billion on pharmaceutical representatives who work directly with physicians (Salmasi, Ming, & Khan, 2016). The question

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becomes whether pharmaceutical marketing has undue influence on physician prescribing behavior or whether it provides much-needed information to doctors about medical advances and free samples for needy patients. When asked, most doctors do not perceive undue influence. However, their perception is not supported by the data (Grande, 2010). Pharmaceutical companies utilize physician prescribing profiles to identify how best to market their drugs. Such targeting has resulted in a 30% uptake of new drugs. A study of dermatologist prescribing behavior showed that the provision of samples influenced prescribing behavior (Hurley, Stafford, & Lane, 2014). Following pharmaceuticalsupported educational activities, physicians were more likely to prescribe drugs manufactured by the pharmaceutical sponsor than by competing companies (Grande, 2010). Such prescribing behavior has also been shown to cause harm (Waxman, 2005). A congressional hearing about the popularity of drugs with known safety concerns focused on Vioxx, a drug developed by Merck to treat inflammation. In 2000, the Vigor study found that V ­ ioxx was more effective as an anti-inflammatory than its competitor, but patients receiving Vioxx were at four times greater risk for heart attacks. ­Following the initial study, the U.S. Food and Drug Administration voted unanimously that physicians should be made aware to the cardiovascular results. In response to the FDA’s decision, Merck sent the following message to over 3,000 drug representatives, “DO NOT INITIATE DISCUSSIONS ON THE FDA ARTHRITIS ADVISORY COMMITTEE... Alternatively, THE RESULTS OF THE... VIGOR STUDY.” Detail persons were instructed to focus on studies that emphasized the drug’s benefits and disregard more negative findings. Vioxx was not removed from the market until 2004, after a placebo-­controlled study confirmed the original findings. The relation between physicians and the prescription drug industry must also be considered when discussing the opioid epidemic and rising death rates associated with opioid pain relievers (OPR) (Kolodny et al., 2015). Medically

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prescribed OPRs began to rise in the 1980s based on a study of 38 patients that concluded that opiates could be prescribed safely over long periods of time for chronic pain. Their use increased rapidly after the introduction of OxyContin, a slow-release opioid, in 1995. The risks of OPR continued to be minimized, and the benefits exaggerated, in part due to the relation between pharmaceutical manufacturers and the medical profession. OxyContin is manufactured by Purdue Pharma. Purdue Pharma underwrote the campaigns of the American Pain Society and the Academy of Pain Medicine to encourage the use of opioids for chronic pain management. Even now, policy continues to focus on nonmedical OPRs, given the fear that changing medical protocol could threaten the availability of OPRs for medically indicated conditions. Unfortunately, a recent study of overdose deaths found that medical providers were the primary source of opioids for 92% of the decedents at the time of death (Johnson et al., 2013).

Medical Errors and Malpractice To the extent that medical errors can be attributed to individual practice, malpractice suits offer legal redress. Mr. Ramirez was awarded $71 million to pay for full-time medical care for the rest of his life and to compensate him for the severe avoidable injury. Whether this is an excessive settlement is unknown, but many Americans blame malpractice legal actions for rising healthcare costs. According to a 2006 Kaiser Family Foundation Survey, 58% cited malpractice lawsuits as a “very important” cause of medical care inflation (Kaiser Family Foundation, 2006). A lot has changed in the last 10 years. Malpractice accounts for less than 0.05% of healthcare spending (Bixenstine et al., 2014). Malpractice insurance rates have essentially been flat since 2006, and the frequency and severity of claims is at a low (Lowes, 2016). Malpractice may be cyclical, but the current downward trend has been the result of state malpractice reform, physician engagement in risk management, and changing public sentiment (Page, 2015).

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Medical Errors, Physician Practice, and the Barriers to Quality Care

The problem of medical errors provides a window on the structural problems of the healthcare system. First, is an overreliance on the “biomedical” or “treatment-oriented” model of care (Mishler, 1981). Greater attention is paid to disease than prevention. After diagnoses and acute treatment, less focus goes towards managing chronic conditions such as heart disease and diabetes. Even less is spent on advancing public health. The second consequence that follows from the first is a mismatch between patient need and physician supply. Underrepresented communities, including both racial and ethnic minorities and those with low socioeconomic status, have more difficulty getting care. The lack of access contributes to tremendous disparities in health outcomes (Schoen et al., 2013). The third consequence is the inconsistent quality of care. Health outcomes vary by practice setting and type. A study of practice volume found that patients seen in high-volume practices with good oversight were more likely to receive recommended preventive care (Landon, O’Malley, McKellar, Hadley, & Reschovsky, 2014). On the other hand, the same study found that high-volume practices had higher rates of preventable readmissions.

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Overcoming the Barriers to Quality Care

The growing recognition of medical errors, unequal access to care, and the resulting inequitable outcomes have increased efforts to address historic, structural, and organizational barriers to good quality care.

Overcoming the Barriers to Quality Care

One result is a movement to reform medical education. Medical care is too complex to be provided by a single person. It takes a team with broad-ranging expertise to provide necessary treatment (O’Malley, Tynan, Cohen, Kemper, & Davis, 2009). Beginning in 2009, the professional associations representing schools in the areas of dentistry, nursing, medicine, osteopathic medicine, pharmacy, and public health formed the Interprofessional Education Collaborative (IPEC) to identify the core competencies for interprofessional education (IPEC, 2016.) The first set of guidelines was released in 2011. In 2016, the number of institutional members was increased to 15. The Liaison Committee on Medical Education (LCME), the accrediting body for schools offering the MD degree, revised Standard 7 on curricular content to include a new standard: 7.9 Interprofessional Collaborative Skills. The faculty of a medical school ensure that the core curriculum of the medical education program prepares medical students to function collaboratively on health care teams that include health professionals from other disciplines as they provide coordinated services to patients. These curricular experiences include practitioners and students from the other health professions. (LCME, 2015, p.11) Institutional providers have also worked to improve the quality of care. It was hoped that greater standardization would improve care and control costs. In addition to efforts to create structural alignment between providers through ownership or contracting, there has been a steady push for more evidence-based practice. States have made health data more publicly available so consumers can make more informed choices when selecting providers. Organizations like Leapfrog, an employer-based group, seek to improve quality by developing ­incentives to reward quality care based on hospital care data (Leapfrog Group, 2009). The ACA’s

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impact on quality and costs has been dramatic. Since 2010, when Medicare imposed penalties on hospitals that reported hospital-acquired conditions (HACs) greater than the mean, there has been a 21% decline in HACs (AHRQ, 2016). This reflects not only an ­impro­vement in quality of care with an e­ stimated 124,348 fewer deaths over the 5 years of the study, but also s­ avings of $28 billion. Many of the changes that are occurring in HACs, for example, cannot be attributed to any one cause. Many government policies have been influential (AHRQ, 2016). With the recognition that physician financial interests could be in conflict with patient interests, the government began leveraging its huge financial interest and imposed regulations around self-dealing (Mitchell, 2007). Medicare, for example, has ­imposed financial penalties to align better physician incentives with the incentive to provide cost-effective, quality care. Medicare and Medicaid will not reimburse physicians for treating patients referred to facilities where they have an ownership stake. Likewise, the government has identified minimum practice standards for ACOs. The government is providing financial support to hospitals and physician practices to help cover the cost of electronic health records systems, which are essential to understanding the relationship between health delivery and quality outcomes. Despite the changes, many of the underlying incentives in medicine are unchanged. It is still the case that primary care is less financially lucrative than specialized care. It is still the case that the organization of medical care recognizes physicians as team leaders, although their view of health care is more focused on the treatment of disease than the improvement of population health. It is still the case that the healthcare system is based on the assumption that all patients can pay for care and that all institutions can absorb the costs of patients—regardless of ability to pay. There is still the likelihood that vulnerable populations are overlooked by the large corporate practices that are most benefiting from the reorganization of the healthcare system.

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Conclusion: Choices and Interests

This chapter asks questions about the ways physicians influence the provision of health care and patients’ outcomes. The answer in a nutshell: It depends. It depends on who becomes a physician, how they are trained, where they practice, how they are paid, and what exactly they do. The analytic challenge is in understanding and interpreting all of these combinations and their permutations. Do physicians matter as much today as they did during the mid and late 20th century? Yes, physicians still drive much of the organization and delivery of health care. Our system of care is defined by physician expertise and, as a result, is heavily biased toward the type of care most physicians are trained to provide. Given their dominance over the healthcare professions, physicians have been given the legal authority to assure the standard of care. However, the balance of power is shifting towards a transdisciplinary approach with the patient at the center. This requires shared power among all health providers with the patient choice first and foremost. One of the main points made in this chapter is that the fits and starts, lapses and compromises in how this is happening provide an excellent window into how our health system functions in the 21st-century environment. The policy lessons to be derived from this chapter go back to the place where we started— that decisions have winners and losers. In this case, highly specialized care has produced enormous advances in medicine’s effectiveness. At the same time, it has limited access to low-­income and minority populations and rural populations. Policy, however, is negotiated, and the pressure now is to create a more equitable system. Health reform will succeed if it helps to create a system that can assure care that brings together a team of practitioners across all health-related disciplines to provide evidence-based, comprehensive, and continuous care. Such care is highly dependent on involving patients and

their families, and on involving the team of providers who all understand a piece of the complexity of what is needed. It requires physicians willing to engage in this process, which is rapidly happening.

Discussion Questions 1. 2. 3. 4. 5.

How is the role of physicians in the healthcare system changing? Why are there so few black physicians relative to other racial and ethnic groups? What accounts for the decline in solo practice? How would you explain the causes of medical errors? What changes are occurring in the organization and delivery of medical care to incentivize physicians to participate in interdisciplinary team-based care?

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Case Study

CASE STUDY

An Intervention Downstream to Prevent Overdose Death Veronica D. Feeg, Geraldine Moore, and Patricia Eckardt On October 26, 2017, President Donald Trump declared the U.S. opioid epidemic a national public health emergency under federal law. With $57,000 in the Public Health and Social Services Emergency Fund, how that translates to intervention remains to be seen. Drug overdose–related deaths have received more and more policy attention as the nation has faced the epidemic of opioid-related fatalities, with statistics that have shaken politicians and leaders to the core. The number of unintentional drug-overdose deaths exceeds motor vehicle accidents (Warner, Chen, Makuc, Anderson, & Minino, 2011), reaching the third leading cause of premature death and the leading cause of injury death in 2013 (Centers for Disease Control and Prevention [CDC] & National Center for Health Statistics, 2016). According to the CDC, it is associated with more than 40,000 lives lost annually (62,000 in 2016). Over 50% of drugpoisoning deaths are from opioids, including heroin and prescription opioid analgesics (Werner, Chen, & Makuc, 2009). The epidemic has captured the attention of the public as the population of victims has infiltrated quiet communities in red states, blue states, small states, and everyone’s state, reaching headlines in campaigns across the country at all levels, even the race for the U.S. presidency. Tragedies have struck many Americans and became a frequent topic of campaign speeches from all political parties. After President Trump took office, in his first fiscal year 2018 budget commitment submitted to the U.S. Congress, he included $27.8 billion in drug-control efforts (Executive Office of the

President, 2017). His commitment for prevention, treatment, and law enforcement drug-control policy asks Congress to support $1.3 billion in investments for comprehensive addiction and recovery programs, 21st Century CURES Act programs, and other opioid-specific initiatives. According to Richard Baum, Acting Director of the Office of National Drug Control Policy: “By funding critical public health and public safety efforts, [this] budget demonstrates. . . commitment to stopping drugs from entering the country and supporting treatment efforts to address the burgeoning opioid epidemic.” (p. 2). More than half ($15.6 billion) is specified for law enforcement, interdiction, and international initiatives that are coupled with budget requests (over $700 million) for border security and the High Intensity Drug Trafficking Areas (HIDTA) program. Opioid overdose prevention efforts can be classified into two primary types: efforts that aim to decrease the number of individuals at risk of opioid overdose, and efforts that decrease the number of fatal opioid overdoses (Siegler, Tuazon, O’Brien, & Paone, 2014). Other efforts aim to prevent people from transitioning from drug misuse to drug dependence among at-risk individuals. Some interventions focus clearly on eliminating the drug user’s addiction behavior through therapies and drug withdrawal assistance, psychosocial support, and medications used to taper and eliminate use completely. Additional strategies take aim at reducing risky prescribing practices through education of physicians and patients on safe use through specific prescription drug monitoring programs (PDMPs). These different streams of interventions target different points along a chain of drug use increase in the United States today. The public policies that promote these prevention and intervention efforts in the nation’s drug epidemic have emerged from different parties, jurisdictions, and organizational efforts.

The Chain of Opioid Connected Problems The complexity of the rise in opioid prescription practices, opioid use, opioid poisoning, unintentional drug poisoning, drug-overdose deaths, and the associated drug-related public problems of availability of street drugs and crime

CASE STUDIES

Tackling the Opioid Crisis— Upstream and Downstream Policy Approaches:

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makes the entry points for interventions numerous with each focus of prevention as a matter of federal, state, and local policy concern. The points along the chain of the drug epidemic include multiple points for discussion and targeted policy interventions. Drug appetite and availability are a matter of upstream intervention to stop the flow of drugs and individuals seeking them. President Trump’s 2018 budget reflects that dimension with half the resources planned to take aim at the law enforcement aspects of the drug problem. At the end of the chain is the user whose behaviors are caused by or result in numerous mental health problems with addiction. Treatments include social, behavioral, and medical interventions aimed at decreasing dependency or reversing the addiction through withdrawal interventions with medication. In the middle of the chain is a new area of public attention on how the dependency emerged, focusing on opioid-prescribing practices of physicians, and how the increase in legitimate prescriptions for pain and symptom management may have unleashed a population of patients with physiological dependency coupled with psychological need. These legal and accessible pain-killing drugs appear to be responsible for a new demographic of drug-dependent users who do not fit the traditional street drug user profiles (see FIGURE 16-1). Yet, as these upstream, midstream, and downstream points of intervention have failed, resulting in a 200% increase in the rate of overdose deaths (Centers for Disease Control and Prevention [CDC], 2016), the preventable fatalities have become the policymakers clarion call for action. Preventing deaths from opioid overdose is a goal that has become a centerpiece of health policy initiatives at the federal, state, and local levels.

Federal Level Policy For its part, the U.S. Congress has been debating a Comprehensive Addiction and Recovery Act, which includes access expansion among its provisions and which has support from Republican and Democratic sponsors. This kind of comprehensive national effort takes aim at upstream and downstream policy actions focusing on several specific groups, including veterans, women, and families, and culminates in the final intervention of preventing deaths by overdose with incentivizing

wide sources of community responders in an overdose situation. Provisions of the 2016 Act signed into law by President Obama include: 1. Prevention and education •• Task force on pain management •• Awareness campaigns •• Community-based coalition enhancement grants to address local drug crises •• Information materials and resources to prevent addiction related to youth sports injuries •• Assisting veterans with military emergency medical training to meet requirement for becoming civilian healthcare professionals •• FDA opioid action plan •• Improving access to overdose treatment •• National Institute of Health (NIH) opioid research •• National All Schedules Prescription Electronic Reporting Reauthorization Act •• Opioid overdose reversal medication access and education grant programs 2. Law enforcement and treatment •• Comprehensive opioid abuse grant program •• First responder training •• Prescription drug take back expansion 3. Treatment and recovery •• Evidence-based prescription opioid and heroin treatment and interventions •• Demonstration •• Building communities of recovery •• Medication-assisted treatment for recovery from addiction 4. Addressing collateral consequences •• GAO report on recovery and collateral consequences 5. Addiction and treatment services for women, families, and veterans •• Improving treatment for pregnant and postpartum women •• Veterans’ treatment courts •• Infant plan of safe care •• GAO report on neonatal abstinence syndrome (NAS) 6. Incentivizing state comprehensive initiatives to address prescription opioid abuse •• Funding to states to target priorities

Drug use for • Pain relief • Mental high • Social norm

High-dependency physiologic and psychologic addiction

• Drug treatment programs • MAT - Withdrawal support • Education/counseling • Legal/punitive prevention

Downstream interventions

Opioid drug availability – Appetite – Use/dependency – Addiction/death

Drug user appetite • Pain • Social • Behavioral

• Improve SES • Prescription regulation • PDMP • Education/counseling

Midstream interventions

Overdose death

• Opioid overdose reversal medication access • Identification of high risk users • Naloxone use education • Safety prevention plans

Death prevention

SES: socioeconomic status, PDMP: prescription drug monitoring program, MAT: medication-assisted treatment

CASE STUDIES

FIGURE 16.1  Chain of drug dependency: upstream, midstream, and downstream interventions and death prevention efforts.

Prescription misuse, abuse, or drug diversion

Illegal street drugs

• Law enforcement • Border control • Prison, fines

Upstream interventions

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At the federal level, support for agencies whose missions relate to research and services for public health, such as the Centers for Disease Control and Prevention (CDC), and several agencies in the executive branch, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), Centers for Medicare & Medicaid Services (CMS), and the U.S. Food and Drug Administration (FDA), play a role in combating drug addiction as a major component of policy, education, and services. For example, opioid treatment programs (OTPs) are regulated by SAMHSA and are qualified to dispense the controlled substances methadone and buprenorphine to treat addiction to opioids. With an estimated 2.4 million people in the U.S. with opioid use disorder, which includes heroin and prescription drugs, withdrawal as an intervention is so intense it warrants medication-assisted treatment (MAT), which combines behavioral therapy and medications approved by the FDA. According to SAMHSA, the number of OTPs has increased from approximately 1,100 in 2003 to almost 1,500 by the end of 2016, serving over 350,000 in 2015. MAT has been found to reduce morbidity and mortality, decrease overdose deaths, reduce transmission of infectious disease, increase treatment retention, improve social functioning, and reduce criminal activity (SAMHSA, 2017).

On the prevention front to combat opioid overdose deaths, the legal environment has had little federal action; however, states have modified laws to increase access to naloxone (Narcan), including a range of prescription permission to third parties, first responders, and laypersons; dispensing by standing or protocol order; and protections for those who report overdose. In a presentation by Davis, Walley, and Bridger (2015), the federal level of action has included FDA support for speedily approving auto-injector and expediting review of nasal formulations. But more action would be welcome to: (1) move naloxone to an over-the-counter (OTC) medication by initiating processes to deal with labeling and insurance coverage concerns; (2) fund education, evaluation, and research; and (3) require Medicaid, Medicare, and Exchange plans to cover naloxone—even if becomes available over the counter. In a CDC report by Wheeler, Davidson, Jones, and Irwin (2012), the distribution of naloxone and training in its proper administration might have prevented numerous deaths from opioid overdoses (see FIGURE 16-2).

State and Local Level Approaches At the state level, many governors have launched initiatives to address their constituents’ drug-related problems including prevention of

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FIGURE 16-2  Annual crude rates* of unintentional drug overdose deaths and number of overdose prevention programs distributing naloxone — United States, 1979–2010 *Per 100,000 population. Source: Wheeler, E., Davidson, P. J., Jones, T. S., & Irwin, K. S. (2012). Community-based opioid overdose prevention programs providing naloxone – United States, 2010. Morbidity and Mortality Weekly Report, 61(6), 101–105.

Case Study

protection from criminal charges. In 2014, one health department implemented a standing order–based naloxone distribution program, having identified a 300% increase in unintentional prescription drug overdose deaths. Not without hurdles, both states managed the problems that emerged and have made legal changes toward progress. Nonetheless, Davis and colleagues (2015) reported that barriers remain to educate and enhance front-line providers, as well as continuing problems with existing naloxone formulations and administrations that require training. An implementation of a new Maryland law to enable third-party prescriptions of naloxone to individuals who may be able to respond to an overdose is the Baltimore Student Harm Reduction Coalition (BSHRC) overdose education and naloxone distribution (OEND) program, the first community-based, state-authorized training program. In an 8-month pilot period, 250 free naloxone kits were distributed and 3 overdose reversals were reported to BSHRC. According to Lewis, Park, Vail, Sine, Welsh and Sherman (2016), trainings were effective in increasing self-efficacy surrounding overdose prevention and response that persisted at the 12-month follow-up. As of 2014, there were 140 organizations known to provide naloxone kits to laypersons at 644 distinct sites in the United States (Wheeler, Jones, Gilbert, & Davidson, 2015). In a similar implementation project in suburban New York, a school of nursing community health faculty member planned and delivered a naloxone preparedness training program with the local health department support of free kits and educational materials (see BOX 16-1). At the midstream intervention point, states have responded to opioid prescription problems in two ways: (1) launching physician, patient, pharmacist, and other health provider education on prescribing practices, alternative pain control medications, or limiting the opioid prescription amounts; and (2) using state-run databases that collect patient-specific prescription information at the point of dispensing, or prescription drug monitoring programs (PDMPs). Data are transmitted to a central repository where, in most states, authorized users and law enforcement agencies may access them. To increase use of PDMPs and to effectively reduce prescription opioid misuse and overdose,

CASE STUDIES

addiction. In a letter to Congress, the National Governors Association (NGA) pleaded that, while they have developed a comprehensive approach to combating the epidemic that focuses on prevention, intervention, treatment, and recovery; limiting opioid prescription amounts; putting naloxone (Narcan) in first responders’ hands; educating the public and doctors; and increasing access to treatment, this national epidemic requires national solutions (NGA, 2016). Recognizing the potential value of providing naloxone to laypersons, some states (e.g., California, Illinois, New Mexico, New York, and Washington) have passed laws and changed regulations to provide limited liability for prescribers who work with programs providing naloxone to laypersons. In addition, Washington, Connecticut, New Mexico, and New York have enacted Good Samaritan laws providing protection from arrest in an effort to encourage bystanders at a drug overdose to call 911 and use naloxone when available. Additionally, because of high overdose mortality among persons who use drugs, the Global Fund to Fight AIDS, Tuberculosis, and Malaria recommends naloxone distribution as a component of comprehensive services for drug users (Wheeler, Davidson, Jones, & Irwin, 2012). More recently, state policies have been launched to meet the problem of death from unintentional drug overdose, championed by members of the legislature or the governor. For example, many states and local communities have funded opioid overdose reversal medication access and education and 47 states and the District of Columbia have naloxone access laws (The Network for Public Health Law, 2016). Davis, Walley, and Bridger (2015) have reported on the experiences of Massachusetts and North Carolina who have instituted several programmatic, legislative, and regulatory innovations to expand access to overdose prevention education and naloxone rescue kit (NRK) distribution. In Massachusetts, the state legislature passed a law that permits the prescription of naloxone to a family member, friend, or other person and administration of naloxone to a person experiencing an overdose. It also provides protection from charge and prosecution using the Good Samaritan provisions. In North Carolina, the General Assembly passed a law designed to increase naloxone access and

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BOX 16-1  An Intervention Downstream to Prevent Overdose Death Local funding to support the increased availability of naloxone, with education about its use as an intervention to prevent opioid overdose in the community, has provided a variety of organizations with the ability to offer community-based programs to reduce the death-by-overdose tragedies at the local, county, or district level. Based on the principles of primary prevention of opioid deaths, communities have taken on the education and training of first responders and beyond first responders to augment efforts to intervene when a person has been identified at the scene of an opioid drug overdose. Through the layperson modifications in many state laws, local communities can offer to a wide audience the training they may need by self-identifying as a first responder, health professional, or family member of someone who is at risk for overdose. The goal is to save lives; the target audience is individuals who have assumed responsibility to act in an emergent situation when someone has overdosed; the intervention is an educational program to prepare them for rapid action. In a metropolitan area suburban college with a large population of nursing students, the faculty decided to integrate into the community health curriculum an activity to prepare the students—and other students on campus who volunteered—for recognition of overdose signs and symptoms, along with the action of administration of naloxone. The project was first brought to the campus in August 2014 by a community health professor. Students, staff, security, resident hall assistants, and personnel from the athletics department were invited to attend. The first class had 54 participants. The program/training is provided free of charge by the county. The program requires between 1½ and 2 hours for completion. The content of the curriculum includes information on the laws enacted granting nonmedical personnel protection from liability for administering naloxone, and an explanation of three categories of opioids (natural, semisynthetic, and synthetic), as well as the analgesic effect they have on the central nervous system. The progression of a person who has overdosed is described with the when, why, and how to use naloxone, accompanied by a hands-on demonstration. A nurse practitioner is present who oversees the distribution of the kits made available to participants. All nursing students have this training part of the community/public health nursing program, reaching from 145 to 260 students each semester. Approximately 800 students have been trained from 2014 to 2017. Results of the program have been noteworthy. Student feedback is very positive; they feel prepared and ready to act. There have been two “saves” from this training that have been reported back to the trainers. One faculty member, who attended the class with her clinical group, was in a shopping center when people were calling out for help. She found a man unresponsive in his car with drug paraphernalia in the front seat. She administered the naloxone she received only 2 weeks earlier in the class. Perhaps the most remarkable outcome of the project came from one student who shared the harrowing experience she had with a neighbor. She exclaimed, “Do you know what this class has done for me? I saved my neighbor’s life! My neighbor rang my doorbell screaming for help—she knew I was a nursing student—and she told me her son, who is a known drug abuser, was unconscious and she could not arouse him. I grabbed my kit and ran next door. I gave rescue breaths, I administered naloxone and continued with CPR until EMS arrived. Do you know what it was like doing CPR on someone you know? I grew up next to this kid! I just kept thinking of my training and I knew I could do this. I saved him!” With each of these reported lives saved, and the excitement of trained participants who found the personal satisfaction of saving a life, it has been clear that the project is a worthy community-based intervention.

Case Study

Future of Opioid Overdose Interventions Whether or not the future of public health policy related to solving the opioid epidemic problem focuses on upstream preventions, midstream interventions, downstream treatments, or unintentional death reductions, the successes will be measured on the outcomes specific to the point of interventions. If unnecessary, preventable deaths are the ultimate goal of public policy, then the effectiveness of the naloxone training and expansions need continued support at local, state, and national levels. More work needs to be done on the impact of layperson training and expanding the availability of naloxone. This work should be coupled with education and research about safety, for example, people without medical training incorrectly assuming a patient is an unconscious individual due to an overdose and administering naloxone when it is inappropriate. What may be more worrisome is the serious concern that increases users’ sense of safety with naloxone availability, leading them to take more risk. Policy evaluation research needs to be done to assess the unanticipated consequences of widespread availability and the benefit of greater access. Finally, while the prices have decreased in the naloxone injectable forms, there is an important consideration about drug costs and insurance or public payments need to be part of the expansion policies.

Implications for Nurses The opioid epidemic has gained national attention as a real public health problem with tragic consequences. Nurses are often on the front line in caring for the sequelae of drug overdoses, and are the professionals who interact in early stages of addiction and mental health crises. As professionals who need to be armed with the information that can prevent problems downstream, nurses should understand the policies that are local to the problem and recognize the goals of policies enacted to combat the tragic consequences of opioid overdose. Community-based interventions, backed by public policy and support for wide education and training, can reduce the deaths that result from this complex chain of events.

CASE STUDIES

SAMHSA funded projects in nine states from 2012 to 2016 through its PDMP Electronic Health Records (EHRs) Integration and Interoperability Expansion (PEHRIIE) program. Florida, Illinois, Indiana, Kansas, Maine, Ohio, Texas, Washington state, and West Virginia reported a variety of integration and accomplishments in a review by CDC (CDC/NCHS, 2017). The report concluded that the nine state projects resulted in increased PDMP usage to inform clinical decisions and support interventions with patients who may be abusing prescription opioid medications and contributed to a growing body of knowledge of effective practices. At this time, all but one state has established PDMPs, with Missouri remaining the exception. There is evidence that they are valuable, but without access to comprehensive treatment services or standard protocols for what to do when patients with problems are identified, the opioid problem remains (Albright, 2017). According to one study, Patrick, Fry, Jones, and Buntin (2016) reported that: “State’s implementation of a Prescription Drug Monitoring Program was associated with an average reduction of 1.12 opioid-related overdose deaths per 100,000 population in the year after implementation. Additionally, states whose programs had robust characteristics—including monitoring greater numbers of drugs with abuse potential and updating their data at least weekly—had greater reductions in deaths, compared to states whose programs did not have these characteristics. . . [estimating] that if Missouri adopted a prescription drug monitoring program and other states enhanced their programs with robust features, there would be more than 600 fewer overdose deaths nationwide in 2016, preventing approximately two deaths each day” (p. 1324). In a similar target intervention aimed at preventing prescription drug abuse and diversion, the New York State Attorney General introduced a program bill in the State Legislature signed into law that purports to exponentially enhance the effectiveness of New York’s existing PDMP to increase detection of prescription fraud and drug diversion. The Internet System for Tracking Over-Prescribing (I-STOP) Act establishes an online, real-time controlled substance reporting system that requires prescribers and pharmacists to search for and report certain data at the time a controlled substance prescription is issued (New York State, 2017).

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Case Study Discussion Questions 1. Compare and contrast the differences in the two primary types of opioid overdose prevention efforts. Where are those efforts targeted and how do they break the chain? 2. When would an upstream or downstream policy intervention be more appropriate to preventing deaths due to overdose? Give examples. 3. Describe the state- and local-level approaches to address drug-related problems including prevention of addiction. When is important to engage the federal government?

References Albright, B. (2017, May 24). How effective are PDMPs? Behavioral Healthcare Executive, 34–39. Centers for Disease Control and Prevention (CDC). (2016, January 1). Increases in drug and opioid overdose deaths – United States, 2000–2014. Morbidity and Mortality Weekly Report, 64(50 & 51), 1378–1382. Centers for Disease Control and Prevention, National Center for Health Statistics System. (2016, February 16). Deaths: Final data for 2013. National Vital Statistics Report, 64, 2. Davis, C., Walley, A., & Bridger, C. M. (2015, July 1). Lessons learned from the expansion of naloxone access in Massachusetts and North Carolina: 2014 Public Health Law Conference: Intersection of Law, Policy and Prevention. Journal of Law Medicine & Ethics Supplement, 19–22 (Wiley-Blackwell). Executive Office of the President. (2017, May). National drug control budget: FY 2018 funding highlights. Office of National Drug Control Policy. Retrieved from https:// www.whitehouse.gov/sites/whitehouse.gov/files/ondcp /Fact_Sheets/FY2018-Budget-Highlights.pdf Lewis, D. A., Park, J. N., Vail, L., Sine, M., Welsh, C., & Sherman, S. G. (2016). Evaluation of the overdose education and naloxone distribution program of the Baltimore Student Harm Reduction Coalition. American Journal of Public Health, 106(7), 1243–1246.

National Governors Association. (2016, June 21). Opioid addiction. Health & Human Services Committee Letters. Retrieved from https://www.nga.org/cms/nga-letters /opioid-addiction New York State. (2017, March). I-STOP/PMP – Internet System for Tracking Over-Prescribing – Prescription Monitoring Program. Retrieved from https://www.health.ny.gov /professionals/narcotic/prescription_monitoring/ Patrick, S. W., Fry, C., Jones, T., & Buntin, M. (2016). Imple­ mentation of prescription drug monitoring programs associated with reductions in opioid-related death rates. Health Affairs, 35(7), 1324–1332. Substance Abuse and Mental Health Services Administration (SAMHSA). (2017, August 22). The CBHSQ Report. Trends in the use of methadone, buprenorphine, and extendedrelease naltrexone at substance abuse treatment facilities: 2003–2015 (Update). Rockville, MD: Author. Siegler, A., Tuazon, E., O’Brien, D.B., & Paone, D. (2014). Unintentional opioid overdose deaths in New York City, 2005–2010: A place-based approach to reduce risk. International Journal of Drug Policy, 25, 569–574. The Network for Public Health Law. (2016, June). Legal interventions to reduce overdose mortality: Naloxone access and overdose Good Samaritan laws. Edina, MN: Author. Warner, M., Chen, L. H., Makuc, D. M., Anderson, R. N., & Minino, A. M. (2011). Drug poisoning deaths in the United States, 1980–2008. Hyattsville, MD: National Center for Health Statistics. Werner, M., Chen, L. H., & Makuc, D. M. (2009). Increase in fatal poisonings involving opioid analgesics in the United States, 1999–2007. NCHS Data Brief, 22, 1–8. Wheeler, E., Davidson, P. J., Jones, S., & Irwin, K. S. (2012, February 17). Community-based opioid overdose prevention programs providing naloxone – United States, 2010. Morbidity and Mortality Weekly Report, 61(6), 101–105. Wheeler, E., Jones, T. S., Gilbert, M. K., & Davidson, P. J. (2015, June 19). Opioid overdose prevention programs providing naloxone to laypersons – United States, 2014. Morbidity and Mortality Weekly Report, 64(23), 631–635.

CHAPTER 17

Health Information Technology and the Intersection of Health Policy Veronica D. Feeg, Jennifer Withall, and Keith Weiner

OVERVIEW This chapter presents an overview of the federal initiatives that have catapulted the growth of health information technology (HIT) throughout the hospitals and healthcare systems of the United States; the federal role in incentivizing, prioritizing, and regulating electronic medical records (EMRs) and electronic health records (EHRs); and the concurrent patient privacy protection issues that have resulted indirectly from the goals of interoperability and transparency of health data systems. Beginning with funding of the Office of the National Coordinator (ONC) for Health Information Technology and its committees by President Bush in 2004, and the financial investments in the American Recovery and Reinvestment Act (ARRA) of 2009, the federal government laid the groundwork for hospital and health system EHRs. The stimulus bill provided the support and conditions for technology expenditures to achieve meaningful use and interoperability that have become the driver of HIT development. This chapter describes the historic past of the backbone of electronic documentation around which all nurses and health providers have organized care delivery and clinical practice guidelines, as well as alerts, automated data capture, reports, and aggregated standards for patient care. Nursing’s involvement in the interdisciplinary processes to develop norms of documentation including terminologies, workflow, and patient safety initiatives, which are part of the EHRs in hospitals today, influence each organization’s HIT purchase decisions and agendas. Now that patients’ records have become sources of evaluation for payment and resources for patient engagement, policies for protection of personal information mandated by the Health Insurance Portability and Accountability Act (HIPAA) have evolved. With the need for easy communication across

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insurers, providers, and related healthcare entities, security has become a dominant concern for health IT system managers and nurses who are the primary users. Health institutions are mandated by law to promise protection of patients’ personal information, while allowing for the purposive communication that is part of the demands of our complex environments. These painstaking measures to fortify the networks, control for data leakage, and prevent hacking require more than IT staff, and have become part of nursing responsibility as one of many stakeholders in the era of omnipresent HIT devices. With the competing goals of promoting patient engagement and consumer rights to their own information while protecting their privacy, the HIT environment is a landscape of balance among innovation, dissemination, regulation, and patient protection.

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Describe the historical progression of federal policy initiatives and regulatory oversight of health information technology (HIT) in general and in regards to EMR/EHR adoption. Define meaningful use and interoperability with their associated impact on health care. Explain nursing’s role in the development of EHR documentation workflows, and how nursing can continue to increase its visibility as technology continues to evolve. Identify how terminology in nursing is integral to the EHR and foundational to HIT, and how its use promotes the value of nursing practice in patient care. Describe the perceived challenges and benefits of EHR data in practice, education, and research. Discuss the challenges that come with the proliferation of HIT and EHRs in complex environments with the expectation of security and legally enforced ramifications of protected health information (PHI) breaches as specified in the new U.S. Department of Health and Human Services (USDHHS) Omnibus rule related to HIPAA. Summarize the nursing role as a member of the health team in HIT security and protection of patient information, particularly related to use of mobile devices and electronic patient information.

Introduction

Digital technologies are integral to our daily lives and the way we communicate. Health care has always been an information-rich enterprise that demands information technologies to manage the complexity of its delivery systems. The ability to collect, capture, manage, and utilize data for patient care and organizational efficiencies is expanding rapidly. The on-demand EMR/EHRs available wherever and whenever needed have affected all aspects of nursing and healthcare delivery. In addition to monitoring proficiencies and immediate care delivery systems with electronic technologies, HIT has allo­ wed additional innovations, such as telehealth,

to offer unlimited possibilities in transforming the way care is delivered, recorded, communicated, and paid for in the public and insurance payment markets. The power and potential of HIT to improve quality and safety, make care more accessible, and control costs put it at center stage in understanding the interplay between the government and industry. HIT is not a panacea. There are challenges in making a seamless integration of HIT nationally. Policymakers recognized that these systems would undoubtedly impact the cost of care and become a significant burden on hospital budgets. For example, some hospital budgets for HIT now exceed brick-andmortar construction. Experts recognized they would need the kind of federal incentives that

Federal Origin and Influence in Development of HIT

support and grow adoption (Glassman & Rosenfeld, 2015). Thus, hospital and physician EHR systems have evolved symbiotically with federal support, regulation, and payment policies developed to deliver on the promise that HIT would improve health care for the U.S. public. In conjunction with the rapid development of technologies in health care over the past 25 years, nurses have been involved in numerous capacities in their contributions related to the purchase, design, and implementation of computerized documentation systems in hospitals and drive their use in clinical care. The term “nursing informatics” (NI) first appeared in the literature in the 1980s (Ball & Hanna, 1984; Grobe, 1988) and the definition has evolved to the point that the American Nurses Association (ANA) published definitions and scope of practice standards (ANA, 2001, 2008); they continue to monitor, refine, and certify this recognized specialty through the American Nurses Credentialing Center (ANCC). Since then and over time, and with collaborative working memberships in the American Medical Informatics Association (AMIA), Healthcare Information Management and Systems Society (HIMSS), and other distinct informatics nursing groups including the American Nursing Informatics Association (ANIA), organized nursing coalitions, including the Alliance for Nursing ­Informatics (ANI), have brought their voices across academia, practice, industry, and nursing specialties to the field of nursing informatics (Murphy, 2010a). As the technology entered the 21st century, nurses became more involved in the design and functionality of computerized systems to integrate nursing into patient care processes and serve in the growing use of the health information technologies in hospitals and health systems (Zielstorff, McHugh, & Clinton, 1998). Today, the electronic healthcare industry has become instrumental in shaping care processes through their proliferation of platforms. Design of EHR systems must consider the nursing process in initial application and implementation in hospitals to meet regulatory standards

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of documentation and public laws that protect patient privacy. These continue to challenge developers, vendors, sales people, hospital clinical analysts, and end users—the largest single group of which are nurses—to keep up with the ever-changing world of HIT. To be clear, however, the role of the federal government laid the groundwork and launched the development of the EMR and trajectory of EHRs proposed for the nation historically in President George Bush’s 2004 State of the Union Address (Bush, 2004), followed by the creation of the Office of the National Coordinator (ONC) in 2004 (ONC, n.d.).

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Federal Origin and Influence in Development of HIT

Office of National Coordinator In 2004, the unlikely Senate bipartisan partnership of Bill Frist (R), Senate Majority Leader, and Hillary Clinton (D) reported in The Washington Post (Frist & Clinton, August 25, 2004) that if businesses and other sectors have embraced the information revolution to cut costs and improve productivity with their use of information technology, then “we need to realize the full potential of the information revolution to improve the quality of the healthcare system as well” (Editorial, p. A17). Since then, the federal government has become the engine driving much of the EHR growth we see today. It was projected that if nurses and doctors live with the nightmare of struggling under mountains of paperwork managing data, then getting necessary needs into their hands at the right time would result in patient benefits. They also believed that patients would be empowered to make better choices as access to information is increased while ensuring the privacy of systems. Under Executive Order 13335 (2004), President George W. Bush gave Secretary Tommy

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Thompson authority to appoint the first National Coordinator of Health Information Technology, David Brailer. Brailer laid the groundwork for the formidable role that use of electronic health records could play in the modernization of clinical paperwork and digitization of health care. The National Coordinator is responsible for carrying out ONC’s mission and implementing the functions of the ONC. Among the specified roles, the National Coordinator responsibilities include: (1) ensuring that key health information technology initiatives are coordinated across USDHHS programs; (2) ensuring that health information technology policy and programs of USDHHS are coordinated with those of relevant executive branch agencies (including federal commissions and advisory committees) with a goal of avoiding duplication of effort and of helping to ensure that each agency undertakes activities primarily within the areas of its greatest expertise and technical capability; and (3) reviewing federal health information technology investments to ensure federal health information technology programs are meeting the objectives of the strategic plan, required under Executive Order 13335, to create a nationwide interoperable health information technology infrastructure. The vision was to develop a nationwide interoperable health information technology infrastructure that: ■■

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Ensures that appropriate information to guide medical decisions is available at the time and place of care. Improves healthcare quality, reduces medical errors, and advances the delivery of appropriate, evidence-based medical care. Reduces healthcare costs resulting from inefficiency, medical errors, inappropriate care, and incomplete information. Promotes a more effective marketplace, greater competition, and increased choice. Improves the coordination of care and information among hospitals, laboratories, physician offices, and other ambulatory care providers through an effective infrastructure for the secure and authorized exchange of health information.

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Ensures that patients’ individually identifiable health information is secure and protected.

The ONC has two major committees: (1) the Health IT Policy Committee, which recommends a policy framework for the development and adoption of a nationwide health information technology infrastructure that permits the electronic exchange and use of health information; and (2) the Health IT Standards Committee (HITSC), which makes recommendations to the National Coordinator on standards, implementation specifications, and certification criteria. The Standards Committee also serves today to harmonize, pilot test, and ensure consistency with the Social Security Act (ONC, n.d.). The Health IT Policy Committee evolved to create the foundation for requiring adoption of information technology. The Institute of Medicine (IOM) drew attention to the importance of patient safety through its original landmark report, To Err is Human, and subsequent reports highlighting the pivotal role that information technology (IT) must play in improving the quality of our health systems (IOM, 2001). In 2005, a panel of scientists noted that health care lagged behind other industries in its frontline processes and called for U.S. investments in the Nationwide Health Information Network (NHIN) with functionality and interoperability that could be achievable and desirable for the future. This panel proposed a two-component solution: (1) the ability to perform key functions such as computerized physician order entry (CPOE), and (2) interoperability that links providers for the purpose of data exchange (Kaushal et al. & the National Health Information Working Group, 2005). They concluded that HIT is an important tool to improve safety and efficiency of U.S. health care, but its adoption was limited because of lack of financial incentives and national standards. Their work would become part of the national conversation in the evolution of federal involvement in the development of EHRs. The Health IT Standards Committee was charged with making recommendations to the

Federal Origin and Influence in Development of HIT

National Coordinator for Health IT on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information. Initially, the Health IT Standards Committee focused on the policies developed by the Health IT Policy Committee. Over time, the members have produced reports to keep ahead of the rapid growth of the health IT industry and focus ongoing efforts to continue to move in the direction of standardization and interoperability. The Interoperability Standards Advisory (ISA) process represents the model by which the ONC coordinates the identification, assessment, and public awareness of interoperability standards and implementation specifications that can be used by the healthcare industry to address specific interoperability needs. These needs include, but are not limited to, interoperability for clinical, public health, and research purposes. Through their office, the ONC encourages all stakeholders to implement and use the standards and implementation specifications identified in the ISA as applicable to the specific interoperability needs they seek to address. Furthermore, ONC encourages further pilot testing and industry experience to be sought with respect to standards and implementation specifications identified as “emerging” in the ISA. This is an important source of government expectations in the development of EHR languages, processes and ultimately, drivers of care—including nursing care. In summary, the ONC and its committees under the direction of the National Coordinator serve a critical purpose in the federal interests in health information technology, and ultimately the public’s health. It includes an Office of Clinical Quality and Safety, headed by a director, and responsible for working with public and private sector medical organizations to achieve widespread use of health information technology by the medical community with special emphasis in the areas of clinical quality and patient safety. The office staff includes the chief nursing officer (CNO), who advocates for patient care, clinical, and staffing nursing standards at the national level for the ONC. The Office of

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Clinical Quality and Safety also engages with a wide array of clinical stakeholders and provides a clinical-based perspective on ONC policies and activities. This includes clinical issues involving health IT safety, usability, clinical decision support, and quality measurement. The staff of the ONC includes professional nurses, and the ANA has collaborated with the ONC on their eHealth campaign (ANA, 2015a).

The “Stimulus Bill” and the HITECH Act Government attention persisted in 2007 with the funding of the NHIN prototypes, giving the federal affiliation a structure for involvement with HIT. By 2009, in the midst of a national financial crisis, President Barack Obama made it clear that he wanted the federal government to invest in EHRs so that the deadline of 5 years to digitize medical records set by former President Bush could be met. He believed that it would cut waste, eliminate red tape, and reduce the need for repeat expensive medical tests (Obama, 2009). Coupled with the need for federal dollars to be pumped into an economy in recession, Obama believed that the government role would ultimately improve health care and reduce costs by investing in efforts to expand HIT. His solution was through the massive American Recovery and Reinvestment Act (ARRA, 2009), targeting specifically the health information technology obstacles via the Health Information Technology for Economic and Clinical Health (HITECH) Act. Commonly referred to as the “Stimulus Bill,” this landmark legislation allocated $787 billion to stimulate the economy, with $147 billion of those monies earmarked to rescue and reform the nation’s ailing healthcare industry; within those funds, $19 billion in financial incentives targeted specific reform through the use of HIT, namely, the adoption of EHRs. This act would specifically stipulate expectations for those who received funds to progress adoption of EHRs in a meaningful way (Murphy, 2010b).

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The HITECH Act sought to improve American healthcare delivery and patient care through an unprecedented investment in health information technology. The provisions of the HITECH Act were specifically designed to work together to ensure necessary assistance and technical support to providers, enable coordination and alignment within and among states, establish connectivity to the public health community in case of emergencies, and assure that the workforce is properly trained and equipped to be meaningful users of EHRs. While it provided financial incentives to help healthcare providers purchase and implement HIT and EHRs, it delineated clear penalties that would be imposed beyond the year 2015 for both hospitals and physician providers who failed to adopt use of EHRs in a “meaningful way” as defined by the law and attested in summary information to Centers for Medicare & Medicaid Services (CMS). The specific objectives were written to demonstrate that the EHR use has a “meaningful” impact on one of the five initiatives (Murphy, 2010b). Following widely discussed reviews and over 2,000 comments, USDHHS issued the final rule on July 13, 2010 with the criteria for meeting “meaningful use” divided into five initiatives: (1) i­mprove quality, safety, and efficiency, and reduce health disparities; (2) engage patients and families; (3) improve care coordination; (4) improve population and public health; and (5) ensure adequate privacy and security protections for personal health information. Meaningful use is defined by the use of certified EHR technology in a meaningful manner (for example, electronic prescribing), ensuring that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care: CMS grants an incentive payment to Eligible Professionals (EPs) or Eligible Hospitals (EHs), who can demonstrate that they have engaged in efforts to adopt, implement or upgrade certified EHR technology. In order to encourage

widespread EHR adoption, promote innovation and to avoid imposing excessive burden on healthcare providers, meaningful use was showcased as a phased approach, which is divided into three stages [that] span 2011 (data capture and sharing), 2013 (advanced clinical processes), and 2015 (improved outcomes). The incentive payments range from $44,000 over 5 years for Medicare providers and $63,750 over 6 years for Medicaid providers (starting in 2011). Participation in the CMS EHR incentive program is totally voluntary, however if EPs or EHs fail to join in by 2015, there will be negative adjustments to their Medicare/Medicaid fees starting at 1% reduction and escalating to 3% reduction by 2017 and beyond. (CDC, 2017) Under the final rule, there were 14 “core” (required) objectives for hospitals and 15 for providers. The incentives were based on Medicare and Medicaid patient volumes; the provider incentives were fixed per provider. The incentives were paid out over 5 years with the hospitals and providers documenting incrementally measures set forward to continue to qualify. There are varied reports about the success of the program in physician practices, with some reports at over 90% EHR adoption rates, compared to 90% of physicians using paper patient records 10 years ago (Practice Fusion, 2017); undeniably, changes in all health information management throughout the U.S. health system have taken place since the enactment of the HITECH Act. Over the course of implementing the various phases of adopting EHRs that provide meaningful clinical use, the use of quality measures has become a normal expectation among numerous agencies who require reporting—from both payers and providers—largely driven by the federal rules. As these expectations have affected hospitals and physician providers, there has been decreasing concern on the “meaningful use” expectations as the reporting expectations for

Federal Origin and Influence in Development of HIT

payment have taken on new goals in (a) producing quality outcomes through payment mechanisms, and (b) enhancing rules in an evolution of patient protection and privacy implementation through HIPAA (Health Insurance Portability and Accountability Act, 1996). More recently released rules from CMS and the Office of Civil Rights (OCR) are just beginning to be felt nationally. These two sets of rules issued by the federal government will have an impact in the future on nurses who work in physician practices, clinics, agencies, and hospitals where the challenge to promote engagement and consumer involvement in health care must be balanced with the innovations that will evolve and may impact patient information privacy as protected by federal law.

Rules to Improve Quality, Control Spending, and Maintain Access One of the newer areas of federal influence on health information technology development has included the changes in the CMS plans to change how health care is delivered at the provider and system level through incentivizing quality rather than quantity of services. Medicare is on the path to overhaul the way it pays for ambulatory care services with the likelihood of changing all federal payment processes that affect providers in all states with Medicare and Medicaid. CMS has published a final rule codifying the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which directs CMS to replace fee-for-service reimbursement over time with value-based payment approaches. MACRA’s Quality Payment Program, which launched in 2017, creates two parallel payment pathways: alternative payment models (APMs) and the Merit-based Incentive Payment System (MIPS). These systems predict that by adjusting payments according to a scoring system, care will be increasingly incentivized toward quality and not volume based on visits, tests, or unnecessary interventions. A value-based approach

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uses the HIT systems in place for measuring and reporting outcomes in a way that hopes to improve quality. CMS established the year 2017 as a “transition” year as providers become adjusted and innovators develop efficient technologies to assist in the capturing and reporting of physician practice data. Whether or not MIPS can reach its desired outcomes or, instead, stimulate unintended provider responses and system unwelcome effects, is still open to question (Schneider & Hall, 2017).

Rules to Enhance Protections, Enforce Against Breaches, and Penalize HIPAA Violations Inevitably, the elements of access, patient engagement, and healthcare information may change and impact policies around public health issues. One example is the opioid crisis, where the need for communicating sensitive information may be deemed more important than the need to protect the privacy of an individual who could die, warranting adjustments on how and who can be made aware of one’s addiction. The enactment of the HITECH Act included mandated modifications and improvements to be issued over time that would keep a high level of continued review for changes that might impact previously established laws, such as the patient privacy protections promised in HIPAA. As the focus on meaningful use and hopes to proliferate the use of electronically communicated health information have evolved, and as new problems have emerged in the population, new rules from the OCR have been issued with the USDHHS Omnibus Rule of 2013 (HCPro, 2013). For example, the success of telehealth could be undermined if serious privacy and security risks are not addressed, such as sensitive sensors that may expose patients to safety concerns or inadvertently transmit sensitive information about household activities without adequate security. Telehealth involves bidirectional, digital collection and communication of sensitive health information among healthcare

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providers and patients, with the added risk of transfer over a network. These types of situations pose new questions that need to be assessed for risk and security threats (Hall & McGraw, 2014). With new technical issues, as well as the need for continued interpretations of privacy protection in the context of current issues such as President Trump’s statement on the opioid crisis (USDHHS, 2017), the rules that protect people must be carefully considered. The new HIPAA rules are described as “not a tweak” but “sweeping changes” that will impact how patient information is protected and individuals or hospitals are punished if it is not (Levya, 2013). A summary of the USDHHS Omnibus Final Rule (2013) around the four final rules includes: 1.

2.

3.

The final modifications to the HIPAA Privacy, Security, and Enforcement Rules mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act, and certain other modifications to improve the rules to (a) make ­Business Associates of Covered Entities liable for compliance of HIPAA; (b) strengthen the limitations on the use and disclosure of PHI for marketing, fundraising, and selling without ­individual authorization; (c) expand individuals’ rights to receive electronic copies of their health information; and (d) and modify the individual authorization to facilitate research and disclosure of child immunizations to schools. The final rule adopting changes to the HIPAA Enforcement Rule incorporates the increased and tiered civil money penalty structure provided by the HITECH Act. The final rule on Breach Notification for Unsecured Protected Health Information under the HITECH Act, replaces the breach notification rule’s “harm” threshold with a more objective standard.

4.

The final rule modifying the HIPAA Privacy Rule as required by the Genetic Information Nondiscrimination Act (GINA) prohibits most health plans from using or disclosing genetic information for underwriting purposes.

In summary, the federal government has played an intricately connected role in the development of health information technologies and ultimately has become the underlying force behind the evolution of EHRs and documentation of care in hospitals and health care and, therefore a powerful driver in establishing the space where qualified nursing informatics specialists can and will have influence in the design and implementation of information-rich healthcare technologies.

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Nursing and Health Information Technology

The proliferation of EHRs opened the door to many innovations in medical and health care including, but not limited to CPOE, barcodes, and medication administration systems. ­Several top EHR vendors in the country including Cerner and Epic have great promise for patient-­centered care, and work with nurses who understand the importance of nurses using data for ­day-to-day decision making, as well as harvesting data for organization decision making, quality improvement activities, workflow, and safety (Glassman & Rosenfeld, 2015). For example, with multiple providers using CPOE in a carefully constructed way, medication errors and adverse drug events can be prevented. Bar ­coding allows organizations with EHRs to track every phase of the medication process, wristband confirmation, and laboratory results efficiently. Using patient outcome data to monitor quality of care becomes possible. Aggregating big data around nursing research questions of

Nursing and Health Information Technology

importance can be made possible with EHR integration and interoperability established across settings. The aspects of workflow and organization efficiencies make the time and monetary expense of implementing fully automated systems worthwhile. Health information technology holds the potential to transform the quality of care and to establish linkages between nursing care and patient outcomes (Dykes & Collins, 2013). Many nursing organizations including the ANA (2015a) have launched and participated in several HIT initiatives, including: ■■ ■■ ■■ ■■ ■■

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Developing standardized nursing languages Nominating nurse leaders to federal HIT committees and workgroups Developing position statements on HIT initiatives, policy, and standards Participating in HIT alliances, the ANI, AMIA, and HIMSS Developing products that support the consumer eHealth campaign of the ONC for Health Information Technology Coordinating expert panel summit meetings to establish quality measurement models for inclusion in electronic health records

The value proposition of using standardized terminologies in EHRs is now being acknowledged by both the private and public health sectors. With the ongoing developments from the passage of the HITECH legislation, CMS, USDHHS, and other standards-focused groups have continued to call for standardization that the EHR vendors have heeded in their updates and new releases. In addition to mandating vocabulary and interoperability standards for use in certified EHR technologies as part of the ONC committee and HITECH rules, USDHHS continues to target funding for increases that coincide with the government’s health system goals in general, aiming to reduce costs and increase value. With the pressures from purchasers of systems focused on usability and ease of use, in an era that promotes patient participation and consumer engagement in their own health care,

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and with the regulatory hand of the government to protect patient privacy, which includes electronically transmitted personal health information, the HIT industry continuously needs to find the right balance between private stakeholders and the federal government. All nurses are encouraged to get involved in IT and EHR adoption. Nurses involved in identifying criteria for adoption are on the front line of successful implementation. Some institutions employ specialty nurses known as nursing informatists, informatics specialists, or informaticians to aid in communicating between IT professionals and nursing staff. It is imperative for nursing leadership at all levels to fully appreciate the imperative role of participation when decisions about IT and EHRs are made, as these are guaranteed to impact nursing work and workflow. In addition to being the largest single user group of a hospital electronic health systems, nurses have recognized that a standardized coded terminology enables patient data to be used in real-time clinical decision support at the point of care, to be exchanged among disparate EHRs without loss of meaning or accuracy, and to be used in healthcare research for identifying the elements of care provide by clinicians and for meaningful outcomes documentation of patients. In busy environments with high risk for errors that require highly reliable platforms to document rapidly changing situations, the backbone of documentation around which all nurses and health providers have organized care— including timely delivery of medications and execution of tasks, alerts, automated data capture, reports, and aggregated standards for patient care—is the need for a common language to communicate. Nursing’s involvement in the interdisciplinary processes to develop norms of documentation, including terminologies, workflow, and patient safety innovations that have become part of the EHRs, serves both patients and the organization. They shape how care is given and contribute to the decision making

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around purchasing systems, modifying existing technologies, and planning for new applications. There is a need to integrate a nursing terminology standard into the continuing development of programmable terms and relationships around patient care that define the nursing process for vendors of systems. With interdisciplinary interoperable standardized language that is underway at the federal level in the ONC, it will be possible to determine workload, resources, and best practices for outcome measures, as well as indicators of factors that impact on patient care (Saba, 2012).

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Nursing Terminology and the Data of Nursing Care

Since the early development of the Nursing Minimum Data Set and the Nursing Management Minimum Data Set (NMMDS), nursing has made several attempts to standardize terminologies with little success. A variety of nursing terminology groups have sought confirmation of acceptance of their unique sets of commonly used nursing terms; these have led to debates at the federal level and challenges in acceptance of a single source of codes. As of the date of this publication, the ONC adopted criteria linking nursing for the Certification Commission for Healthcare Information Technology, but their version of the criteria no longer includes nursing data. Experts point to several challenges to establishing a common language categorized into four dimensions: knowledge, ­practice, policies/resources, and research ­(Westra et al., 2015). These obstacles must be overcome to make nursing care a legitimate part of the p ­ atient health record. “Nursing has a long tradition of over-reliance on handing down both information and knowledge by word-of-mouth” (Pearson, 2003, p. 271). Despite challenges, there are a variety of reasons

for moving the language of nursing care into the national conversation as patient care management systems and payment of healthcare services in hospitals, homes, community health delivery systems, and long-term care settings will happen without it. The arguments impede progress that to date have slowed down establishing a single source of terminology. To ensure that nursing remains visible and viable in the age of health information technology and EMRs, as well as supportive of national health information exchange and meaningful use requirements, the ANA (2015b) issued a position statement that supported the incorporation of ANA-recognized standardized languages in electronic health records. This language standardization will allow for EMR data to be shared along the care continuum and with other members of the interprofessional team. Standardization will also allow nurses to demonstrate their level of education and expertise. In other words, this is a mechanism in which nurses can quantify the value of their contributions to health care. The ANA-recognized terminologies and data sets, along with their content areas, include (ANA, 2015b): ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

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NANDA Nursing Diagnoses: Definitions and Classification – Diagnoses Omaha System – Diagnoses, Interventions, Outcomes Rating Nursing Minimum Data Set (NMDS) – Clinical Data Elements Nursing Interventions Classification (NIC) – Interventions Perioperative Nursing Data Set (PNDS) – Diagnoses, Interventions, Outcomes Clinical Care Classification (CCC) System – Diagnoses, Interventions, Outcome Ratings Nursing Management Minimum Data Set (NMMDS) – Management Data Elements International Classification for Nursing Practice (ICNP) – Diagnoses, Interventions, Outcomes Nursing Outcomes Classification (NOC) – Outcomes

A National Action Plan: The Macro Perspective on HIT ■■ ■■ ■■

Logical Observation Identifiers Names and Codes (LOINC) – Assessments, Outcomes ABC Codes – Billing Codes Systematized Nomenclature of Medicine Clinical Terms (SNOWMED CT) – D ­ iagnoses, Interventions, Outcomes, Findings

One terminology has passed the operational tests and met the criteria for inclusion in CCC System – Diagnoses, Interventions, and Outcome Ratings. The CCC System provides a standardized hierarchy for the two CCC nursing terminologies (including classifications with ­vocabularies and related knowledge base), which consists of a clearly delineated and digital system of deconstructing the language of nursing (Saba, 2014). This provides an atomic-level coded structure that is within a relational database representing the “essence of care” defined and operationalized for coders, programmers, and clinical analysts to use (Saba, 2012). It was approved as the first national nursing terminology standard by the U.S. Department of Health and Human Services as an interoperable standard for the exchange of information in EHR systems in 2007 (USDHHS, 2007). It has continued to evolve with empirically supported evidence for integration and practical use in a variety of proprietary and public EHRs that link nursing diagnoses (i.e., patient problems that warrant nursing care) and nursing outcomes (i.e., congruent with patient outcomes required by payment systems documentation) via nursing actions (i.e., interventions performed to improve or support the patient condition). It has also been made available through the Unified Medical Language System (U.S. National ­Library of Medicine, n.d.) and harmonized with the recognized nomenclature systems including SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms; Dykes, 2012; H ­ arris et al., 2015) and ICNP (International Classification for Nursing Practice; Coenen, 2012, p. 35), making it available for national and international use (Saba, 2012, p. 31).

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A National Action Plan: The Macro Perspective on HIT

In 2013, the University of Minnesota School of Nursing and its Center for Nursing Informatics hosted a group of 40 national leaders and organization stakeholders including American Association of Colleges of Nursing (AACN), National League for Nursing (NLN), AMIA, HIMSS, ANI, the American Academy of Nursing (AAN) Expert Panel on Informatics; members from research organizations (National Institute of Nursing Research [NINR]), standards organizations (Logical Observation Identifiers Names and Codes [LOINC], Health Level 7 [HL7], Integrating the Healthcare Enterprise [IHE], and the ONC Standards of Interoperability Framework), Robert Wood Johnson Foundation (RWJF), Agency for Healthcare Research and Quality (AHRQ), and the National Quality Forum (NQF), among other key players, at the inaugural Nursing Knowledge: Big Data Research to Transform HealthCare (NK:BDRTH) consensus conference. Stakeholders from across the country met to discuss how to make nursing’s care contributions visible in the digital age, and how to ensure that those contributions were valued. A common nursing language, one that is both shareable and comparable, has the potential to inform nursing interventions by elucidating clinical insights that advance care through analytics and research. It was at this first conference that the group, which was composed of representatives from informatics organiz­ ations, EHR software developers, education and research, federal government agencies, and healthcare delivery systems, developed and adopted a National Action Plan. The National Action Plan was composed of three broad areas: (1) adopting common terminologies and standards; (2) shaping health policy; and (3) educating nurses, nursing faculty, nurse

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executives, nurse informaticists, and other interprofessional care disciplines. The purpose of this invitational conference was to create a national action plan to harmonize existing individual and organizational efforts to ensure that the knowledge and information that nurses generate are consistently integrated into clinical data repositories (CDRs). The ultimate goal was to demonstrate how data can be utilized as a source of insights and evidence to transform health care and improve outcomes for patients. In 2014, the second NK: BDRTH conference brought more than 70 stakeholders from nursing practice, education, information technology, professional nursing, and informatics and standards organizations ­(Westra et al., 2015). The 2014 National Action Plan for Sharable and Comparable Nursing Data for Transforming Health and Healthcare was published to coordinate the longstanding efforts of many individuals. Foundational to integrating nursing data into CDRs for big data science and research is the implementation of standardized nursing terminologies, common data models, and information structures within EHRs. The plan built on existing federal health policies for standardized data that are relevant to meaningful use of EHRs and clinical quality eMeasures (Westra et al., 2015). Since its first meeting, the group continues to work to advance this National Action Plan through the efforts of the original 12 subgroups, which includes: care coordination, context of care, mobile health, nursing value, and the social and behavioral determinants of health workgroups, among others (University of Minnesota School of Nursing, 2017). Over the next years, the conference has continued to grow and expand its reach (University of Minnesota School of Nursing, 2017). In addition to the articulated plan of the Nursing Knowledge: Big Data Science Committee, the buy-in of senior nursing leadership in national and international healthcare organizations, such as the CNO and the chief nursing informatics officer (CNIO) is critical in order to influence future data system adoption and

the integration of a standardized nursing language in the EMR.

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Nursing and the Electronic Health Record: The Micro Perspective on HIT

Documentation is essential: “If it is not documented, it is not done.” Documentation is the “completion” task (i.e., the last step associated with an intervention performed by all healthcare professionals). While some healthcare organizations have adopted the EHR completely, others have disparate documentation systems, including a combination of paper charting and electronic documentation. As healthcare organizations continue to work towards a fully integrated EHR to meet the compliance rules of federal regulations in order to receive payment, it is critical that nurses are involved with design and development of systems, including changes and updates being made to those systems that are already operational. Being a bystander and not participating in these conversations will ultimately yield processes that dictate their clinical workflows and reporting requirements. Nurses, at all levels, need to have a clear understanding of what is being documented, and how that information is being used (Glassman & Rosenfeld, 2015). For example, the National Database of Nursing Quality Indicators (NDNQI) provides metrics that are reported specific to nursing care by more than 2,000 hospitals in the United States (Press Ganey, 2017). These measures are used to evaluate care of identified groups and signal problems to administrators. Clinical nurses are affected and need to understand how these data systems work. It is essential to ensure that there is not a “disconnect” among the interprofessional team (nurses, physicians, therapists, case managers, etc.). It is critical to help guide the capture of

Health IT: The Intersection of Data Security and Health Policy

nursing care and, at the same time, appreciate efforts to focus on communicating and streamlining information. For example, during the Ebola outbreak in the U.S., the registered nurse (RN) collected the correct information, but the record was fragmented and did not communicate to others the need for immediate action that almost resulted in an epidemic of huge consequences. Our fragmented medical records systems need order, and nurses can help provide that order. Nurses as users cannot use “shortcuts” or “workarounds” when the information needs are so great, despite the documentation burden felt by the clinical nurse. With changing innovations, the portability of the workstations on wheels (WOWs) and other personal devices such as rovers, the newer systems can untether the nurse from the nurses’ station and allow the nurse to document in the room or anywhere, thereby allowing the nurse to spend more time at the bedside. But with these innovations come new expectations and regulations on today’s nurse working in complex health environments with massive amounts of data to safeguard. As our healthcare system becomes increasingly technology dependent, robust policies must be in place to protect patient information from data breeches, malware, and other cyberattacks, such as ransomware, that add security and privacy concerns.

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Health IT: The Intersection of Data Security and Health Policy

Nurses, the largest group of healthcare professionals in the United States, use electronic health records containing patients’ sensitive information known by government as PHI. As employee mistakes rank among the top sources of healthcare data breaches, nurses need to be

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knowledgeable about the expectations of federal health policy and recognize security risks to ultimately safeguard their patients’ information entrusted to healthcare entities. Data breaches can result in harm to patients by way of identity theft and fraud. With the full regulatory hand of the law, institutions may suffer financial penalties and harm to their reputation. Such instances have been frequently reported by news outlets (Ong, 2015). Medical informatics has entered a new age. Resistive holdouts notwithstanding, EHRs are nearly omnipresent in the American healthcare system. Legislation and government programs are guiding and accelerating the adoption of electronic health records. There are boundless benefits to providers, healthcare systems, governments, and consumers. However, securing the right of protection of healthcare information is at an increasing risk as electronic health records become more entrenched in our society. Examples of breaches, nefarious and otherwise, are plentiful. At risk are hospitals, healthcare providers, practices, and other segments of the healthcare delivery system that have adopted the use of an electronic health record certified by a federal government–sanctioned organization for the federal government’s regulatory oversight, particularly those without full understanding of security threats. As good stewards of healthcare consumers’ information, healthcare institutions are burdened with painstaking measures to fortify their efforts in the prevention of sensitive information leakage in the new age of pervasive medical informatics. Under threat of crippling fines, healthcare entities such as hospitals and providers must be vigilant in safeguarding protected data while the threat of possible data leakage looms, in part beyond their control. Overall, in an era of promoting consumer engagement, this new paradigm presents a paradox of “data liberalization” for the benefit of patients with an increased risk of harm to the patients’ detriment. Health information technology has lagged far behind the security technology of other industries such as those in the financial sector.

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Speculatively, perhaps this lag may be in part due to healthcare technology being classified as a cost within a healthcare business model. In financial sectors, technology is a requirement to thrive or even survive. But even the financial systems within health care are typically antiquated in comparison to technology typical of the financial industry. To add additional pressures to the mix, the Administrative Simplification Compliance Act of 2001 required that all Medicare claims must be done electronically (Health Data Management, 2003). This transformational piece of legislation forced even the financial portion of health care to advance into embracing modern information technology. In doing so, this legislation sparked a huge wave in the transmitting of electronic protected health information. The patient portal increases the risk of a breach as protected health information and personally identifiable information are now mandated to be displayed in a customer-facing, publically accessible system. Any mistakes such as inappropriate disclosures could be catastrophic. At least between business associates there are agreements that could nullify what would otherwise be violations of HIPAA (Health Information Portability and Accountability Act, 1996). To increase the risk, electronic health record vendors had to rush to meet the meaningful use “Stage Two” specification and bring these features to market (CDC, 2017). Hospitals then rushed to implement and meet a difficult goal. Following this rush, CMS has delayed the requirement. However, many institutions produced hastily implemented systems across the country. Statistics of breaches resulting from the patient portal are not available, as CMS will only publish those settled cases with 500 or more disclosures. Therefore, smaller breach episodes resulting from such hasty activities have yet to be realized. Mobile applications increase the risk of breaches for the simple reason that they are mobile. Such devices are more readily lost or stolen than desktop devices, and thus far more

severe in the exposure of information. A significant portion of nonpaper-based breaches of 500 or more individuals as reported by CMS shows mobile devices most often as the culprit. One of every three nonpaper large breaches involved a mobile device (USDHHS, 2018). The common theme is that these lost or stolen devices were not encrypted. Appropriately configured encryption provides a covered entity with a “safe harbor” provision, essentially considering a breach highly unlikely and therefore not reportable. According to the new USDHHS Omnibus Rule, a well-implemented encryption configuration that renders a device’s information indecipherable by unauthorized personnel should be considered as having a low risk of breach in the event that the device becomes lost or stolen. Therefore, such devices would likely be exempt from mandatory reporting requirements, also known as having safe harbor from regulatory stipulations. Unfortunately, encryption is not a default standard configuration for laptop operating systems. Therefore, the onus is placed upon the healthcare entity to ensure eligibility of the safe harbor provision and ultimately protect patient data. Tablets and smartphones may or may not be protected. Apple’s iOS is encrypted by default, but controls may not be set up correctly to prevent disclosures. Android, the other prevalent mobile operating system, varies from manufacturer to manufacturer in terms of security controls, and only in the future may these devices be encrypted by default. Even Android encryption has been broken by a variety of mechanisms including “deep freeze.” Apple’s latest offering supposedly cannot be decoded by the company themselves, even in the case of a law enforcement request. However, without the mandated use of mobile device management solutions, the variety of configurations leaves mobile devices at risk. According to the Ponemon Institute (2014), 60% of all workplace mobile phone users circumvent security features. Therefore, human behavior must be eliminated from the equation wherever possible to diminish the risk of a breach.

Health IT: The Intersection of Data Security and Health Policy

Security Breaches—Privacy Violations Data security has, at times, been in the news and on the minds of the general public. Headline after headline reminds us of the potential pitfalls of living in a connected world. American intelligence agencies have accused Russia of hacking and other activities to influence the United States 2016 presidential election (Shane, Sanger, & Kramer, 2017). The threat of large data breaches comes less from commonly unencrypted laptops, and more likely from sophisticated and targeted hacking activities. Hacking is commonly associated with malicious intent in the context of cybersecurity. New threats have produced new terms such as ransomware, where a system has been infiltrated and locked until the organization pays a ransom to unlock it and prevent its data from being deleted or destroyed. When combined with the sensitive nature of one’s private health information disclosed to providers with expectation of privacy and the associated legal implications, the public’s trust is threatened should that information appear to be available for others to see. The information is protected by law and should be protected by the providers who need to have information to deliver care. The following selected list suggests considerations for healthcare organizations related to access to ePHI: ■■

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How is ePHI access logged? Is there remote access by healthcare personnel, vendors, and other business associates? Does anyone review or become alerted to potentially inappropriate access? Remember that even trusted employees have been known to have inappropriately disclosed information. Countless examples exist of information sold for a variety of reasons. People have been jailed even after making only a scant profit. Is information segmented in a fashion that limits access based on job role or even physical location? Maybe one hospital unit should not have access to another’s. Maybe

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a physician sees a different set of information than a clerk. Is there an education program for the workforce to help in the understanding of legislation and organization policies to which they must adhere? Are there supplementary security awareness reminders? While ignorance is no excuse for the law, HIPAA does compel entities to keep its workforce informed. Is there a limitation on administrative access or even any access that goes unlogged? Can tampering of information be prevented or at least be discovered? What mechanisms are in place to prevent leaks from nefarious sources? (i.e., viruses, hackers, scammers, etc.) How secure is the information against damage—physical or otherwise? Are there contingency plans in place for periods of inaccessibility? Do you have a disaster recovery, business continuity, and backup plan? Have you tested these plans? Careers have been cut short in disaster scenarios when untested backups fail. What mechanisms prevent accidental disclosure? Is there a data leak prevention system—either comprehensive through a vendor or otherwise via piecemeal? Can employees send patient files over email— internally and externally—where they reside ad infinitum in wait for a potential hacker to come along? We see in this chapter some examples of how email has been captured by nefarious actors. Do you encrypt all data at rest and in motion? An inadvertent disclosure could be as simple as a download to a USB thumb drive that gets lost or an unencrypted stolen laptop. Stolen laptops are a huge source of breaches. Proper encryption means the would-be thief just inherited a brick-shaped laptop for all intents and purposes. Are your security mechanisms reasonable to implement? If not, people will work around them. One company made everyone change their passwords every day. So, all employees

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Chapter 17 Health Information Technology and the Intersection of Health Policy

would gather every morning to choose the group password. Only their username was different. In the case of extremely complicated passwords and different usernames for various systems, employees tend to place notes under their keyboards on tape them to their monitors. Do you have an identity and access management solution in place? While this topic is complex, consider how you ensure that only those with authorization obtain access. Sometimes the solutions are technological in nature (single sign-on, self-service password resets, etc.) and some are administrative (activation and termination notification).

Security Protective Mechanisms It has become necessary for hospitals and healthcare entities to put technological protections,

educational interventions, and punitive policies to address the need to protect patient information and to be in compliance with regulatory expectations. These efforts combine people and products and are designed to prevent, intercept, or threaten punishment of breaches in security. TABLE 17-1 shows an example of how a covered entity (health organization) may implement administrative safeguards, from a policy perspective using U.S. Department of Health and Human Services guidelines, for the administrative, physical, and technical controls of the HIPAA Security Rule using an associated hypothetical institution policy. Physical safeguards are necessary in most hospitals to protect access to computer systems, mobile devices, and other technologies given the increasing demands for authorization of users, monitoring of procedures for backups, and robust disaster recovery plans that impact access

TABLE 17-1  Sample: Levels of Administrative Safeguards Administrative Safeguards Standards

Sections

Implementation Specifications

Security Management Process

164.308(1)

Risk Analysis

Assigned Security Responsibility

164.308(2)

Policy Number

Policy Name

R*

9100-204

Risk Analysis

Risk Management

R

9100-032

Security Management Process

Sanction Policy

R

9100-032

Security Management Process

Activity Review

R

9100-032

Security Management Process

Assigned Security Responsibility

R

9100-033

Assigned Security Responsibility

Health IT: The Intersection of Data Security and Health Policy

387

Administrative Safeguards Standards

Sections

Workforce Security

164.308(3)

Information Access Management

Security Awareness and Training

164.308(a)(4)

164.308(a)(5)

Implementation Specifications

Policy Number

Policy Name

Authorization and/ or Supervision

A

9237 (100-131 and 700-702)

See: Human Resources Policies On Intranet

Workforce Clearance Procedure

A

9237 (100-131 and 700-702)

See: Human Resources Policies On Intranet

Termination Procedures

A

9237 (100-131 and 700-702)

See: Human Resources Policies On Intranet

Isolating Healthcare Clearinghouse Functions

R

9100-034

Isolating Healthcare Clearinghouse Functions

Access Authorization

A

9100-035

Access Authorization

Access Establishment Modification

A

9100-036

Access Establishment and Modification

Security Reminders

A

9100-037

Security Reminders

Protection from Malicious Software

A

9100-004

Protection from Malicious Software

Log-In Monitoring

A

9100-038

Log-In Monitoring

Password Management

A

9100-205

Password Management (continues)

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Chapter 17 Health Information Technology and the Intersection of Health Policy

TABLE 17-1  Sample: Levels of Administrative Safeguards

(continued)

Administrative Safeguards Implementation Specifications

Policy Number

Standards

Sections

Security Incident Procedures

164.308(a)(6)

Response and Reporting

R

9100-039

Response and Reporting

Contingency Plan

164.308(a)(7)

Data Backup Plan

R

9100-040

Contingency Plan

Disaster Recovery Plan

R

9100-040

Contingency Plan

Emergency Mode Operation Plan

R

9100-040

Contingency Plan

Testing and Revision Procedures

A

9100-040

Contingency Plan

Applications and Data Criticality Analysis

A

9100-040

Contingency Plan

R

9100-042

Evaluation

R

9200-331

Business Associate Agreement

Evaluation

164.308(a)(8)

Business Associate Contracts and Other Arrangements

164.308(b)(1)

Written Contract or Other Arrangement

Policy Name

R = Required, A = Addressable. Reproduced from Weiner, K. (2015). Privacy and Security. In K. Ong (Ed.), Medical Informatics: An Executive Primer, 3rd Edition (pp. 245–265). Chicago, IL: HIMSS Publishing.

to the institutions’ technologies. In most hospitals, the complexity of the environments and the likelihood of physical interruptions warrant institutional policy safeguards to guard against unexpected emergencies that can endanger systems to unauthorized access that threatens the physical aspects of data management. TABLE 17-2 shows an example of how a covered entity

(health organization) may implement physical safeguards, from a policy perspective using USDHHS guidelines, for administrative, physical, and technical controls of the HIPAA S­ ecurity Rule using an associated hypothetical institution policy. Technical safeguards to protect access to computer systems, mobile devices, and other

Health IT: The Intersection of Data Security and Health Policy

389

TABLE 17-2  Sample: Levels of Physical Safeguards Physical Safeguards Standards

Sections

Facility Access Controls

164.310(a)(1)

Implementation Specifications

Policy Number

Policy Name

Contingency Operations

A*

9100-044

Contingency Operations

Facility Security Plan

A

9100-015

Facility Security Plan

Access Control and Validation Procedures

A

9100-030

Access Control and Validation Procedures

Maintenance Records

A

9100-045

Maintenance Records

Workstation Use

164.310(b)

Acceptable Use Policy

R

9200-385

Acceptable Use Policy

Workstation Security

164.310(c)

Workstation Security

R

9200-041

Workstation Security

Device and Media Controls

164.310(d)(1)

Disposal

R

9100-031

Device and Media Controls

Media Re-Use

R

9100-031

Device and Media Controls

Accountability

A

9100-031

Device and Media Controls

Data Backup and Storage

A

9100-031

Device and Media Controls

* R = Required, A = Addressable.

Reproduced from Weiner, K. (2015). Privacy and Security. In K. Ong (Ed.), Medical Informatics: An Executive Primer, 3rd Edition (pp. 245–265). Chicago, IL: HIMSS Publishing.

technologies have increased in sophistication and strength. These include such technical programs that use facial recognition, thumbprints, palm prints, and other bioidentifiers. In most hospitals, the large number of users and complexity of user needs to access information

seamlessly warrant institutional technical policy safeguards to guard against cyber intrusions or unauthorized access. TABLE 17-3 shows an example of how a covered entity (health organization) may implement technical safeguards, from a policy perspective using USDHHS guidelines,

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Chapter 17 Health Information Technology and the Intersection of Health Policy

TABLE 17-3  Sample: Levels of Technical Safeguards Technical Safeguards Standards

Sections

Access Control

164.312(a)(1)

Implementation Specifications

Policy Number

Policy Name

Unique User Identification

R*

9100-043

Unique User Identification

Emergency Access Procedure

R

9100-047

Emergency Access Procedure

Automatic Logoff

A

9100-219

Automatic Logoff

Encryption and Degradation

A

9100-029

Encryption and Degradation

Audit Controls

164.312(b)

Audit Controls

R

9100-048

Audit Controls

Integrity

164.312(c)(1)

Mechanism to Authenticate Electronic Protected Health Information

A

9100-046

Mechanism to Authenticate Electronic Protected Health Information

Person or Entity Authentication

164.312(d)

Person or Entity Authentication

R

9100-049

Person or Entity Authentication

Transmission Security

164.312(e)(1)

Integrity Controls

A

9100-050

Integrity Controls

Encryption

A

9100-029

Encryption

* R = Required, A = Addressable.

Reproduced from Weiner, K. (2015). Privacy and Security. In K. Ong (Ed.), Medical Informatics: An Executive Primer, 3rd Edition (pp. 245–265). Chicago, IL: HIMSS Publishing.

for administrative, physical, and technical controls of the HIPAA Security Rule using an associated hypothetical institution policy.

Mandating Standards for the Protection of PHI From a health policy perspective, mandating standards for the protection of patient

information, oversight, strong enforcement, and the allocation of government resources to bolster health cybersecurity are necessary to protect patient information. The perceived threat from industry incidents may have a measured response in programs to mitigate risk. However, the HIMSS report indicates that such programs are not uniformly implemented (Ong, 2015). Only through mandates and support

Discussion Questions

of the healthcare industry’s efforts can a more solid paradigm to the safeguarding of patient information emerge. From the clinical usability perspective, the burden of security should be removed from the user base where possible. Their obligation to be compliant with security measures may lead to increasing reliance on flawed human behavior as a security mechanism. Compliance is more likely to occur when compliance becomes turnkey, convenient, and of an added value. Technological advances such as biometric logon as a single point for all applications may be a solution, but is not without shortcomings. Password management can sometimes become a nightmare for end users—especially for clinicians providing direct patient care. The challenge is to walk the tightrope between convenience and security while addressing both responsibly.

▸▸

in HIT security and protection of patient information in a technological era of ubiquitous data communication, use of mobile devices, and electronic patient information. It is essential in their roles as “users” in hospital information systems that nurses understand the practice aspects of data use that federal policy has grown—accuracy, timeliness, awareness of alert and decision assistance, organizing workflow, interoperability, engaging patients in their own health care, and requiring unencumbered use of patient ­information—while balancing the first line of defense of security breaches as the largest single user group in protecting patient information that federal policy regulates.

Discussion Questions 1.

Conclusion

The intersection of health policy and health information technology discussed in this chapter presents nursing with challenges that come with the proliferation of HIT and EHRs in today’s complex environments. It is imperative that nurses recognize the pivotal role that health policy plays on their practice through the manifest drivers in EHRs that hold the “essence of care” in nursing documentation. While it might not be obvious to nurses that the health information systems with which they work will affect how they give care, record it, and communicate it, it is essential that they balance the need for efficient and seamless technologies with the expectation and legally enforced ramifications of PHI as specified in the new USDHHS Omnibus Rule related to HIPAA. Nurses play a significant role in the healthcare delivery system. Clinical nurses, as well as unique specialists such as nursing informatists, are integral members of the health team in HIT design, implementation, and evaluation in relation to patient care, as well as vigilant players

391

2. 3.

4. 5.

6.

How has public policy historically influenced the development of the EMR/ EHR systems that are used in hospitals today? Why would the implementation of electronic records be any concern of the federal government? Discuss how using HIT can facilitate nursing research and subsequent healthcare policy recommendations. What is the impact of HIT on the translation of findings into practice and policy? Discuss the number of ways the federal government incentivizes, regulates, and influences healthcare delivery in the U.S. today. What are the practice and ethical implications of a fragmented EMR/EHR system? How does the utilization and incorporation nursing terminologies in the EMR change the conversation about the “value of nursing” among the discipline of nursing as well as other disciplines? Discuss the competing goals of developing seamless communication of health information among providers and across devices, allowing patients to access their own health information, and securing patient health information.

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Chapter 17 Health Information Technology and the Intersection of Health Policy

Glossary of Acronyms Used in Health ­Information Technology (HIT) Policy AHRQ Agency for Healthcare Research HITSC Health IT Standards and Quality Committee ANSI American National Standards HL7 Health Level Seven Institute International APM Alternative Payment Model ICNP International Classification for ARRA American Recovery and Nursing Practice Reinvestment Act IHTSDO International Health CCC Clinical Care Classification Terminology Standards CCHIT Certification Commission for Development Organization Health Information Technology ISA Interoperability Standards CDSS Clinical Decision-Support System Advisory CE Covered Entity ISO International Standards CHIP Children’s Health Insurance Organization Program LOINC Logical Observation CMIO Chief Medical Information or Identifiers Names and Codes Chief Medical Informatics Officer MACRA Medicare Access and CHIP CNIO Chief Nursing Information/ Reauthorization Act Informatics Officer MIPS Merit-Based Incentive CPOE Computer-Based Physician Payment System Order Entry MMA Mobile Medical Applications CI Clinical Informatics MU Meaningful Use CRI Clinical Research Informatics NHIN National Health Information DSRIP Delivery System, Reform Network Incentive Payment Program NIST National Institute for EHR/EMR Electronic Health Record/ Standards and Technology Electronic Medical Record NI Nursing Informatics ePHI Electronic Protected Health NMDS Nursing Minimum Data Set Information NMMDS Nursing Management GINA Genetic Information Minimum Data Set Nondiscrimination Act NDNQI National Database of Nursing HHS Health and Human Services Quality Indicators HI Health Informatics OCR Office of Civil Rights HIE Health Information Exchange ONC Office of the National HIM Health Information Management Coordinator HIPAA Health Information Portability PHI Protected Health Information and Accountability Act PNDS Perioperative Nursing HIT Health Information Technology Data Set HITECH Health Information Technology for SNOMED CT Systematized Nomenclature of Economic and Clinical Health Act Medicine – Clinical Terms

AHIMA

Offices, Organizations, and Resources ­Associated with HIT Policy American Health Information AIS Association for Information Management Association Systems http://www.ahima.org/ https://aisnet.org/

References

AMIA ANI ANIA ARMA ATA HIMSS IMIA OJNI

American Medical Informatics Association https://www.amia.org/ Alliance for Nursing Informatics https://www.allianceni.org/ American Nursing Informatics Association https://library.ania.org/ania/ Association for Information Management Professionals https://www.arma.org/ American Telemedicine Association http://www.americantelemed .org/home Healthcare Information and Management Systems Society https://www.himss.org/ International Medical Informatics Association http://imia-medinfo.org/wp/ Online Journal of Nursing Informatics http://ojin.nursingworld .org/MainMenuCategories /ANAMarketplace /ANAPeriodicals/OJIN/

References American Nurses Association (ANA). (2001). Scope and standards of nursing informatics practice. Washington, DC: American Nurses Publishing. American Nurses Association (ANA). (2008). Nursing Informatics: Scope and standards of practice. Silver Springs, MD: Nursebooks.org. American Nurses Association (ANA). (2015a). Health IT initiatives. Retrieved from http://www.nursingworld.org /MainMenuCategories/ThePracticeofProfessionalNursing /Health-IT American Nurses Association (ANA). (2015b). Nursing informatics: Scope and standards of practice. 2nd Ed. Silver Springs, MD: American Nurses Association. American Nurses Association, (n.d.). Position statement on the inclusion of recognized terminologies supporting nursing practice within electronic health records and other health information technology solutions. Retrieved from http://www

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.nursingworld.org/DocumentVault/Position-Statements /Practice/Inclusion-of-Recognized-Terminologies.pdf American Recovery and Reinvestment Act of 2009 (ARRA) (2009). Retrieved from https://www.congress.gov /bill/111th-congress/house-bill/1 Ball, M., & Hannah, K. (1984). Using computers in nursing. Reston, VA: Reston Publishers. Bush, G.W. (2004, January 22). 2004 State of the Union address. Retrieved from http://stateoftheunionaddress. org/2004-george-w-bush Centers for Disease Control and Prevention (CDC). (2017). Meaningful use. Retrieved from https://www.cdc.gov /ehrmeaningfuluse/introduction.html Centers for Medicare and Medicaid Services (CMS). (2016) The Medicare Access & Chip Reauthorization Act of 2015: Path to Value. Retrieved from https://www.cms .gov/Medicare/Quality-Initiatives-Patient-Assessment -Instruments/Value-Based-Programs/MACRA-MIPS -and-APMs/MACRA-MIPS-and-APMs.html Clark, J., & Lang, N. (1992). Nursing’s next advance: An internal classification for nursing practice. International Nursing Review, 39(4), 109–111, 128. Coenan, A. (2012). Harmonizing nursing terminologies: CCC System and ICNP. In V. Saba (Ed.), Clinical Care Classification (CCC) System, Version 2.5 User’s Guide. New York, NY: Springer Publishing Company. Department of Health and Human Services (USDHHS). (2007). January 12 Letter of Secretary of Michael O. Leavitt. Retrieved from http://www.hhs.gov/healthit /documents/m20070123/012207letter.html Dykes, P. C. (2012). Mapping CCC Nursing Concepts /Terms Using SNOMED CT. In V. Saba (Ed.), Clinical Care Classification (CCC) System, Version 2.5 User’s Guide. New York, NY: Springer Publishing Company. Dykes, P. C., & Collins, S. A. (2013). Building linkages between nursing care and improved patient outcomes: The role of health information technology. Online Journal of Issues in Nursing, 3(18). Executive Order 13335 (2004) 69 FR 24059 (https://www .gpo.gov/fdsys/pkg/FR-2004-04-30/pdf/04-10024.pdf) Frist, W. & Clinton, H. (August 25, 2004). How to heal health care. The Washington Post. Glassman, K., & Rosenfeld, P. (2015). Data makes the difference: The smart nurse’s handbook for using data to improve care. Silver Spring, MD: American Nurses Association. Grobe, S. (1988). Nursing informatics competencies for nurse educators and researchers. In Petersen, H. E. & Gerdin Jelger, U. (Eds.), Preparing nurses for using information systems: Recommended informatics competencies. New York, NY: National League for Nursing. Hall, J., & McGraw, D. (2014). For telehealth to succeed, privacy and security risks must be identified and addressed. Health Affairs, 33(2), 216–221. Harris, M. R., Langford, L. H., Miller, H., Hook, M., Dykes, P. C., & Matney, S. A. (2015). Harmonizing and extending

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standards from a domain-specific and bottom-up approach: An example from development through use in clinical applications. Journal of the American Medical Informatics Association, 22(3), 545–552. HCPro, Inc. (2013, March). HHS releases HIPAA omnibus rule: Finally ... it’s final. Briefings on HIPAA. Retrieved from www.hcpro.com/content/289432.pdf Health Data Management. (2003). Medicare mandates electronic claims. Retrieved from http://www.healthdatamanagement. com/news/8919-1.html Health Insurance Portability and Accountability Act (HIPAA). (1996). Retrieved from https://www.hhs.gov/hipaa/for -professionals/privacy/laws-regulations/index.html and https://aspe.hhs.gov/report/health-insurance-portability -and-accountability-act-1996 HITECH Act Enforcement Interim Final Rule. (2013). 45 CFR Parts 160 and 164. Washington, DC: U.S. Government Printing Office. Retrieved from https://www.gpo.gov /fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press. Kaushal, R., Blumenthal, D., Poon, E., Jha, A., Franz, C., & Middleton, B. .  . . National Health Information Working Group. (2005). The costs of a national health information network. Annals of Internal Medicine, 143, 165–173. Levya, C. (2013, February 3). The HIPAA Omnibus rule summary. In HIPAA survival guide (4th ed.). Tampa, FL: 3Lions Publishing. Retrieved from http://www .hipaasurvivalguide.com/hipaa-omnibus-rule.php MACRA. H.R. 2. Medicare Access and CHIP Reauthorization Act of 2015. 114th Congress (2015–2016). Retrieved from https://www.congress.gov/bill/114th-congress/house -bill/2/text Murphy, J. (2010a). Nursing informatics: The intersection of nursing, computer, and information sciences. Nursing Economic$, 28(3), 204-207. Murphy, J. (2010b). The journey to meaningful use of electronic health records. Nursing Economic$, 28(4), 283-286. Obama. B. (2009). President-elect speaks on the need for urgent action on an American Recovery and Reinvestment Plan. Speech at George Mason University, Fairfax, VA, January 8, 2009. Retrieved from http://www.presidency .ucsb.edu/ws/index.php?pid=85360 Office of the National Coordinator for Health Information Technology (ONC) (n.d.). About ONC: What we do. Retrieved from https://www.healthit.gov/newsroom /about-onc Ong, K. R. (2015). Medical informatics: An executive primer (3rd ed.). Chicago, IL: HIMSS Publications. Pearson, A. (2003). The role of documentation in making nursing work visible. International Journal of Nursing Practice, 9(5), 271.

Ponemon Institute© Research Report. (March, 2014). The Cost of Insecure Mobile Devices in the Workplace! Sponsored by AT&T, Independently conducted by the Ponemon Institute, LLC. Retrieved from https://www .ponemon.org/local/upload/file/AT%26T%20Mobility%20 Report%20FINAL%202.pdf Practice Fusion. (2017, March 1). EHR adoption rates: 20 must-see stats. Retrieved from https://www.practicefusion. com/blog/ehr-adoption-rates/ Press Ganey. (2017). Nursing quality (NDNQI). Retrieved from http://www.pressganey.com/solutions/clinical-quality /nursing-quality Saba, V. K. (2012). Clinical Care Classification (CCC) System, Version 2.5 User’s Guide. New York, NY: Springer Publishing Company. Saba, V. K. (2014). Overview of Clinical Care Classification: A national nursing standard coded terminology. In V. K. Saba & K. A. McCormick (Eds.), Essentials of nursing informatics (6th ed.). New York, NY: McGraw-Hill. Schneider, E., & Hall, C. (2017). Improve quality, control spending, maintain access: Can the Merit-based Incentive Payment System deliver? New England Journal of Medicine, 376(8), 708–710. Shane, S., Sanger, D., & Kramer, A. (2017, January 27). Russians charged with treason worked in office linked to election hacking. The New York Times (Online). University of Michigan School of Nursing. (2017). 2017 Nursing Knowledge: Big Data Science Conference. Retrieved from https://www.nursing.umn.edu/centers /center-nursing-informatics/news-events/2017-nursing -knowledge-big-data-science-conference U.S. Department of Health and Human Services. (2009, November). HITECH Act enforcement interim final rule. USDHHS Office for Civil Rights. Retrieved from https:// www.hhs.gov/hipaa/for-professionals/special-topics /HITECH-act-enforcement-interim-final-rule/index.html U.S. Department of Health and Human Services. (2013, January 25). Modifications to the HIPAA privacy, security, enforcement, and breach notification rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; other modifications to the HIPAA rules. Federal Register, 78(17); 45 CFR parts 160 and 164. Washington, DC: U.S. Government Printing Office. Retrieved from https://www.gpo.gov/fdsys/pkg /FR-2013-01-25/pdf/2013-01073.pdf U.S. Department of Health and Human Services. (2017). How HIPAA allows doctors to respond to the opioid crisis. USDHHS Office for Civil Rights. Retrieved from https:// www.hhs.gov/sites/default/files/hipaa-opioid-crisis.pdf. U.S. Department of Health and Human Services. (2017, October 27). HHS Office for Civil Rights issues guidance on how HIPAA allows information sharing to address the opioid crisis. Press release. Retrieved from https://

References www.hhs.gov/about/news/2017/10/27/hhs-office-civil -rights-issues-guidance-how-hipaa-allows-info-sharing -address-opioid-crisis.html U.S. Department of Health and Human Services. (2018). Breach portal: Cases currently under investigation. USDHHS Office for Civil Rights. Retrieved from https:// ocrportal.hhs.gov/ocr/breach/breach_report.jsf U.S. National Library of Medicine. (n.d.). Unified Medical Language System (UMLS). Retrieved from https://www .nlm.nih.gov/research/umls/

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CASE STUDIES

CASE STUDY The HIPAA Evolution – From Elevators to Electronic Records Keith Weiner

Introduction Privacy and security legislation has evolved over the past few decades from tangential rules stemming from an insurance-centric law to a vast economic transformation, and later followed by a sizable rule finalizing a collage of ingredients from its predecessors. What was once emphasized in nursing schools and practice, confidentiality meant that patients’ conditions or situations could not be “discussed in the elevator,” a metaphor for making clear that patients’ information was protected by those providers who held it in confidence. The new age of patient privacy evolved with the Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, mainly to improve access to health insurance and care. However, it became synonymous among healthcare workforce members with the patient privacy and security components that were enforced (HIPAA, 1996). Subsequently, HIPAA Privacy and Security Rules provided guidance for the safeguarding of protected health information (PHI), which included information in the electronic form. PHI is essentially patient health information as defined by U.S. Department of Health and Human Services (USDHHS) and containing specific data elements. In addition to the original passage of the law, a review of the rules of HIPAA was built into the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2008 (USDHHS, 2009) and has continued to have updates that have since given the rules of 1996 more teeth in compliance and enforcement (USDHHS, 2013).

HIPAA Rules in Action The HIPAA established rules and consequences for the protection of health information privacy (Gilley, 2009). This Act permitted the USDHHS to enact the Privacy and Security Rules of 2003 (Zana, 2009). The U.S. Department of Health and

Human Services Office for Civil Rights (OCR) is tasked with enforcing these rules. Both the rules and the enforcement capabilities have been further strengthened under the USDHHS Final Rule of 2013 (Strauss, 2013). The OCR conducts periodic audits of healthcare entities, responds to reports of potential healthcare-related privacy and security issues, invokes penalties, and provides remediation guidance for breaches and infractions (HCPro, 2013). HIPAA has placed a layer of rules that users of health information data and personal health information in healthcare organizations and practices, especially physicians and nurses, must heed in their active provider roles. The USDHHS summarizes the HIPAA Privacy Rule as follows: The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients’ rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections. (HIPAA, 1996) Paper-based systems could be easily tucked away from prying eyes with little chance of unwanted exposure if protected. Traditionally, charts could be copied, faxed, tampered with, or viewed without the likelihood of access being tracked. While this modality seems safe contrasted against a backdrop of sensational cybersecurity headlines, large and small, paper-based breaches have occurred and continue to remain a risk. But these pale in comparison with the proliferation of new technologies and social media activities, where providers such as physicians and nurses, who are human, interact with mountains of PHI and its electronic versions (ePHI), which may be vulnerable to security breaches and privacy violations.

Case Study

their profession. The new rules have introduced an increased vigor in regulation and enforcement, prompting numerous educational programs and efforts to teach healthcare entities how to mitigate breaches and avoid penalties and shame. The following diagram illustrates how the USDHHS OCR facilitates the privacy and security activities of covered entities in pursuit of compliance with the HIPAA Security Rule (FIGURE 17-1). The agency reaches stakeholders through its position of balanced policy, public access arm, compliance tools, and enforcement roles.

Monitoring Compliance Hospitals and healthcare organizations are compelled to monitor and secure protected information from tampering and breaches. They are compelled to report any breaches in security, which must be submitted to the USDHHS. As required by section 13402(e)(4) of the HITECH Act, the Secretary must post a list of breaches of unsecured PHI affecting 500 or more individuals. These reports are public and can be accessed on the internet to identify breaches by location in defined time periods by hospitals (USDHHS, 2018). TABLE 17-4 shows an example of the search done for reportable breaches at a particular hospital in March 2017 (including only more than single

How DHHS Office of Civil Rights Facilitates Privacy and Security Activities

Balanced policy

Public awareness

Compliance tools

Privacy

Access

Security rule risk analysis

Complaints and higher penalties under HITECH

Security

YouTube

Mobile devices video

Breach reporting

ONC collaborations

Audit

De-identification guidance

State attomey generals

FIGURE 17-1  USDHHS Office for Civil Rights facilitates privacy and security.

Enforcement

CASE STUDIES

Healthcare organizations and practices (healthcare entities) now have the added responsibility of oversight of the wide range of computerized technologies in health and the ubiquitous systems of tracking health information. With the electronic health record (EHR), data can be made available via multiple sources, people, and systems. Along with this liberalization of information and massive accessibility come the mechanisms by which to track, restrict access, and monitor for inappropriate access. It is a “brave new world” with an increase in both benefits and risks. Information technology departments, under the direction of leaders of the healthcare organization, must undertake key prevention strategies in an era of regulation and the proliferation of health information technology. These key endeavors now include active risk assessment with the traditional maintenance and incident response/management of system disasters, including encryption for both information at rest and in motion, as well as disaster recovery strategies. In 2013, the USDHHS created a large “Omnibus Rule” that modified the HIPAA Security Rule and HITECH, among other rules. While much ground was covered for healthcare administrators and security staff, nurses should be made aware of the basics that may impact their patients and

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Chapter 17 Health Information Technology and the Intersection of Health Policy

CASE STUDIES

TABLE 17-4  Example: Cases Currently Under Investigation at the Time of the Search Location of Breached Information

Subtotal

Percentage

Desktop Computer Count

142

7.95%

Desktop Computer, Electronic Medical Record Count

7

0.39%

Desktop Computer, Electronic Medical Record, Laptop Count

2

0.11%

Desktop Computer, Electronic Medical Record, Network Server Count

3

0.17%

Desktop Computer, Email, Laptop, Network Server Count

6

0.34%

Desktop Computer, Email, Network Server Count

2

0.11%

Desktop Computer, Laptop Count

11

0.62%

Desktop Computer, Laptop, Other Portable Electronic Device Count

4

0.22%

Desktop Computer, Network Server Count

13

0.73%

Desktop Computer, Other Count

2

0.11%

Desktop Computer, Other Portable Electronic Device Count

4

0.22%

Desktop Computer, Paper/Films Count

8

0.45%

Electronic Medical Record Count

70

3.92%

Electronic Medical Record, Laptop Count

2

0.11%

Electronic Medical Record, Network Server Count

8

0.45%

Electronic Medical Record, Other Count

6

0.34%

Electronic Medical Record, Other Portable Electronic Device Count

2

0.11%

Electronic Medical Record, Paper/Films Count

5

0.28%

Email Count

145

8.12%

Email, Laptop Count

2

0.11% (continues)

Case Study

399

Subtotal

Percentage

Email, Laptop, Network Server Count

2

0.11%

Email, Network Server Count

5

0.28%

Email, Other Count

2

0.11%

Email, Other Portable Electronic Device Count

5

0.28%

Laptop Count

293

16.41%

Laptop, Network Server Count

4

0.22%

Laptop, Other Count

2

0.11%

Laptop, Other Portable Electronic Device Count

16

0.90%

Laptop, Other Portable Electronic Device, Paper/Films Count

2

0.11%

Laptop, Paper/Films Count

8

0.45%

Location: Breached Information Is Not in the HIPAA Breach-Report Count

21

1.18%

Network Server Count

257

14.39%

Network Server, Other Count

5

0.28%

Network Server, Paper/Films Count

2

0.11%

Other Count

175

9.80%

Other Portable Electronic Device Count

53

2.97%

Other Portable Electronic Device, Paper/Films Count

2

0.11%

Other, Other Portable Electronic Device Count

45

2.52%

Other, Paper/Films Count

9

0.50%

Paper/Films Count

409

22.90%

TOTAL BREACHES

1786

100.00%

CASE STUDIES

Location of Breached Information

CASE STUDIES

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Chapter 17 Health Information Technology and the Intersection of Health Policy

events). This table demonstrates a sample report of these breaches that are under investigation by the OCR reported within the last 24 months of the date searched. This kind of report is known in the industry as the “Wall of Shame.” Analysis can help determine risk landscape and trends from unprepared accidents to well-coordinated incidents from hackers. Health organization administrators can use these reports constructively to improve the institution’s profile of privacy protection policies. Prior to 2015, the “Wall of Shame” had predominately displayed incidents of unencrypted drives, USB sticks, laptops, and even desktops that have either been lost or stolen. In breach settlements, the OCR would often site deficiencies such as no encryption technology implementation, no clear policy of encryption, insufficient workforce training/security reminders, and no risk assessment. Encryption or “scrambling” entire computers, mobile devices, USB sticks, and every other repository of information appeared to be the panacea. If it was encrypted, lost or stolen devices were considered harmless. Adoption of encryption technology proliferated as awareness among healthcare stakeholders grew. Today, encryption has become an important element in the promise of secure systems and patient protected information. In 2015 the tide of breaches changed toward the targeted exploitation of vulnerabilities (weak links in security). While hacking incidents were not new, the frequency and amount of patient records had eclipsed prior breaches and changed the threat landscape. Anthem’s 2015 data breach saw 78.8 million records stolen by a foreign government. In addition to the $115 million settlement, Anthem must pay $260 million in security improvements and remediation as a result. That is $375 million in disclosed cost and untold millions more from other costs commonly associated with data breaches (California Department of Justice, 2017)! This is no longer a confidentiality breach committed by gossip in the elevator. Contrast this alarming and expensive data breach threat with the 2017 Healthcare Information and Management Systems Society (HIMSS) cybersecurity survey. Only 13% of respondents stated that their organization did not have any cybersecurity staff and 29% had no specific budget allocation for cybersecurity (HIMSS, 2017).

In essence, security rules have tightened up and enforcement for noncompliance has significantly increased. Penalties can be up to $1.5 million per violation with final settlements now showing multiples of that maximum in practice. The fine does not include costs incurred to the healthcare entity, typically an institution or provider, including legal fees, remediation activities, and reputation damage, among other costs too challenging to tabulate. Information about violations and penalties are released to the public if the violation affects 500 or more individuals. The USDHHS OCR has been charged with enforcement of these penalties by the law and also mandated to perform audits, which could result in penalties. Hospitals are bracing for potential threats and preparing themselves to prevent problems.

What Nurses Need to Know Nurses should know that current regulations require workforce training and periodic security reminders. As workforce members, they may receive training in varying formats, as the rule is not prescriptive. While security protections are mostly built into the healthcare computer infrastructure, nurses are an integral part of safeguarding PHI. While refraining from discussing patients in public may have sufficed prior to the proliferation of the EHR, the concern now has shifted to professional behaviors that may affect the risk to protecting patient data. Hospitals have evolved from merely posting privacy reminders in elevators to offering nurses cybersecurity basic training. One example of “real” training may be through simulated “phishing” or fraudulent emails delivered to nurses in a controlled manner, analyzing the responses, and providing education where needed. The premise of such an exercise is that, should security measures not be sufficient, a nurse falling prey to a fraudulent email may potentially result in hospital computer systems failing or patient data being stolen. Another aspect that may affect nurses is that data may be safeguarded in ways that affect how information may be moved among systems. Whereas emailing patient information at one time may have been accepted in certain circles, mechanisms are often put into place to either require the use of secure email systems or prevent correspondence altogether. Patient information residing on a computer or removable media (USB drive or memory

Case Study

Case Study Discussion Questions 1. How does stolen patient information differ from financial data? In what ways could the theft impact the victim? In what ways could the information be exploited by the criminal? 2. Ransomware is the locking of computer systems for ransom. What effect could this have on patient care? What is the impact to the community that the hospital serves? 3. Discuss ways that having patient information on a personal device or email outside of accepted institutional practices could lead to a breach of information. 4. The USDHHS Office for Civil Rights (OCR) may perform periodic audits or respond to a violation. What effect do you think an audit and/or fine would have on the institution? 

References California Department of Insurance. (2017, January 6). Investigation of major Anthem cyber breach reveals foreign nation behind breach. Retrieved from http://www .insurance.ca.gov/0400-news/0100-press-releases/2017 /release001-17.cfm Gilley, A.M. (2009). The Praeger handbook of human resource management. Westport, CT: Praeger Publishers. Retrieved from http://www.books24x7.com/marc.asp?bookid =37908. HCPro, Inc. (2013, March). HHS releases HIPAA omnibus rule: Finally ... it’s final. Briefings on HIPAA. Retrieved from www.hcpro.com/content/289432.pdf Healthcare Information and Management Systems Society (HIMSS). (2017). 2017 HIMSS cybersecurity survey. Retrieved from http://www.himss.org/sites/himssorg/files/2017 -HIMSS-Cybersecurity-Survey-Final-Report.pdf Health Insurance Portability and Accountability Act (1996). Retrieved from https://aspe.hhs.gov/report/health -insurance-portability-and-accountability-act-1996 Nightingale, F. (1946). Notes on nursing: What it is, and what it is not. New York, NY: Appleton-Century. Ong, K. R. (2015). Medical informatics: An executive primer (3rd ed.). Chicago, IL: HIMSS Publications. Strauss, L. J. (2013, May-June). Overview of the HIPAA final omnibus rule. Journal of Health Care Compliance, 15(3), 53–56. U.S. Department of Health and Human Services. (2009, November). HITECH Act enforcement interim final rule. USDHHS Office for Civil Rights (OCR). Retrieved from https://www.hhs.gov/hipaa/for-professionals/special -topics/HITECH-act-enforcement-interim-final-rule/index .html U.S. Department of Health and Human Services. (2013, January 25). Modifications to the HIPAA privacy, security, enforcement, and breach notification rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; other modifications to the HIPAA rules. Federal Register, 78(17); 45 CFR parts 160 and 164. Washington, DC: U.S. Government Printing Office. Retrieved from https://www .gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf U.S. Department of Health and Human Services. (2018). Breach portal: Cases currently under investigation. USDHHS Office for Civil Rights. Retrieved from https://ocrportal. hhs.gov/ocr/breach/breach_report.jsf U.S. Department of Health and Human Services. (n.d.) Breach portal: Notice to the Secretary of HHS breach of unsecured protected health information. USDHHS Office for Civil Rights. Retrieved from https://ocrportal.hhs.gov/ocr /smartscreen/main.jsf Zana, E. (2009, August). HHS delegates authority for HIPAA Security Rule to OCR. OMW Health Law. Retrieved from https://omwhealthlaw.com/ocr/

CASE STUDIES

stick) should be encrypted, or scrambled in a manner that cannot be accessed if physically stolen. Therefore, USB drives or memory sticks may be prohibited or require encryption for usage. The USDHHS “Wall of Shame” contains many entries with sizable fines for devices or drives that were either lost or stolen. If they are encrypted properly, the information is typically considered safe even if lost or stolen. From the patient perspective, the new rule offers greater attention to information protections and gives them more control over their own health information. Patients are now informed that they will receive communication if their health data are breached. Marketing, fundraising, and the sale of PHI now have restrictions put into place. Patients may also receive copies of their EHR upon request. There are other considerations and protections in terms of research, genetic information, and provisos for the withholding of information to insurance companies when paying out of pocket. While the USDHHS Omnibus Rule is quite extensive, with significant implications to the healthcare industry, the key element from the nurses’ perspective can be summarized as the modernization of measures to protect patient privacy. Florence Nightingale (1859/1946) provided written guidance to nurses about keeping tight-lipped. While the mechanisms have grown more intricate, Nightingale’s principles remain apropos in the era of the information age.

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CHAPTER 18

Political Power of Nurses: Harnessing Our Values and Voices Donna M. Nickitas

OVERVIEW Nurses play a pivotal role influencing the definitions of health, social values, and society’s expectations for health and well-being. While nursing practice is evolving in response to changes in society with regards to health, technology, and policy, there remains the continued push to improve the nature and quality of healthcare services, reduce the costs of health care, and advance the health of the nation. In 2015, the United States spent 17.8% of its gross domestic product (GDP) on health care at the cost of $3.4 trillion (Martin, Hartman, Washington, & Catlin, 2017). A recent Commonwealth Fund report by Schneider, Sarnak, Squires, Shah, & Doty (2017) found that the U.S. ranks last on overall performance, access to care, equity of care, efficiency, and quality outcomes in comparison to other industrialized countries. The U.S. is the only high-income county lacking universal health insurance coverage (Schneider et al., 2017). Without universal coverage, desired healthcare outcomes are unattainable for many. Lack of insurance coverage often results in inadequate health promotion, disease prevention, and management of chronic disease, leading to delayed diagnosis, incomplete adherence, and poor coordination of care. Accessible and timely interventions may mitigate many of these challenges. Schneider et al. (2017) noted that the U.S. had made efforts to expand coverage through the 2010 Affordable Care Act for more than 20 million Americans. Regardless of expanded insurance coverage, incomplete and fragmented insurance coverage still accounts for the relatively poor performance of the United States on healthcare outcomes, affordability, administrative efficiency, and equity (Schneider et al., 2017). However, nurses can help reverse the nation’s course of the declining health (continues) © Anthony Krikorian/Shutterstock

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

OVERVIEW

(continued)

of its citizens and residents by advocating for population-focused health care (Robert Wood Johnson Foundation [RWJF], 2017). Nurses guided by the American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (2015) recognize an ethical obligation to care for every person with respect, dignity, compassion, and fairness. The Code of Ethics provides a moral imperative for the nurse who is seeking effective ways to address health disparities and distribute resources. Nurses are well positioned to meet primary population healthcare needs by addressing lack of access to affordable care, health equity, and social determinants of health. Social determinants include such factors as unequal access to healthcare, poverty, lack of housing, transportation, education, stigma, and racism (Nickitas, 2017). The evidence of nursing’s impact on access, quality, and costs is not always entirely understood or incorporated into public or health policy. Nurses must use their political power to leverage evidence, advocate for high-risk vulnerable populations, and build relationships across health sectors and roles to bring a nursing perspective that improves changes at the service line and system levels of care. This chapter examines the contributions of nursing as a profession to health policy and the contemporary roles that nurses provide through optimizing healthcare delivery, promoting patient safety through innovative, cost-effective care models and methods that result in an improvement in our nation’s population health status. Nurses must be prepared to influence health policy with relevant knowledge and evidence needed to transform policy at all levels of the profession: practice, education, research, and leadership. Pappas (2013) challenges nurses to ask: Where do we fit in the care equation and how will nurses improve overall population health and achieve better experiences and lower costs? The reply to Pappas’ challenges for nurses to improve the health of populations and advance national, regional, and local health policy is that nurses must be engaged advocates. “They [nurses] are well-positioned to identify issues affecting the health and well-being of individuals, discern patterns across patient populations, link patients with community resources, and develop broad-based intervention” (Robert Wood Johnson Foundation, 2017, p. 4). Nurses have a responsibility and obligation to advocate for improved systems of care and healthcare infrastructure to promote and monitor health policies. When nurses use their influence, education, and training they help eliminate outdated regulations and organizational and cultural barriers to provide greater efficiencies, amend provider shortages, and increase professional satisfaction (Institute of Medicine, 2010). All nurses, regardless of professional title or position, must harness the values of the profession and use their voices to advocate for universal coverage to achieve the best possible health and well-being for the U.S. population (Robert Wood Johnson Foundation, 2017). Being influential in the policy arena means nursing’s value and voice must matter! When nurses use their political power, they remain strong and find the strength and moral courage to reaffirm their knowledge, values, and actions to improve health and health care where we live, work, and play. Nurses are beacons of hope for the hopeless, are voices for those who cannot speak or will not speak out against health disparities, and support one another during unsettling times, as federal policy looks to target the pillars of the Affordable Care Act (ACA), shrink government programs, and roll back regulations surrounding health reform (Nickitas, 2016a). To address the uncertainty around the dismantling of health reform and other potential political hurdles, nurses must understand how to engage in the policy process. The American Nurses Association Code of Ethics for Nurses with Interpretive Statements (2015) provides renewed meaning for nurses’ ethical obligation to care for every person with respect, dignity, compassion, and fairness. By being diligent in guarding the public’s health and welfare through advocacy, action, and power, nurses harness their values, voices, and vision to practice to their full scope of education and training to achieve population-focused nursing.

Origins of the Nursing Profession

405

OBJECTIVES ■■

■■ ■■

■■

▸▸

Explore ways in which nurses contribute to health policy by harnessing their professional values and voices. Explain the critical role nurses play in leading change to improve health and health care. Discuss ways nurses create new approaches in the direction of the Triple Aim in achieving better care for individuals, better health for populations, and lower per capita costs. Analyze the economic, ethical, and social implications of health policy for population-focused nursing care, and effectively advocate for policy change.

Origins of the Nursing Profession

From its beginning, nursing was defined as having “charge of the personal health of somebody . . . moreover, what nursing has to do . . . is to put the patient in the best condition for nature to act upon him” (Nightingale, 1860, p. 126). This early definition of nursing, written by Florence Nightingale, included many of the concepts still considered relevant today; this was remarkable considering how undeveloped professional nursing was in the mid to late 1800s. Nightingale was strategic in her thinking about the importance of the observational skills of nurses and the impact of the environment on health. She recognized health promotion and health maintenance as essential responsibilities of nursing. Until the late 19th century, nursing was seen as conventional employment for women, and nurses were viewed as second-class citizens with ill morals and weak character. To overcome the negative societal views of nursing and to improve the qualities of potential nurse recruits, efforts were made to establish proper preparation for nurses. A physician, Ann Preston, organized the first training program for nurses in the United States at Philadelphia’s Woman’s Hospital in 1861. This training program was open to women “who wished greater proficiency in their domestic responsibilities” (Stevens, 1989, p. 17). The choice to use hospitals as the site for training nurses expanded rapidly in the late 1800s as hundreds of new hospitals were built under the

aegis of religious orders, ethnic group industrialists, and elite groups of civic-minded individuals who looked for efficient ways to staff their wards. Because student nurses were a continuously renewable source of low-cost workers to staff the wards, even some of the smallest hospitals maintained nursing schools (Stevens, 1989). Hospital nursing school programs, therefore, were primarily sequences of on-the-job training rather than academic courses. World War I had a profound effect on the nursing profession. Before the war, nursing was divided into three domains: public health, private duty, and hospital. Public health nursing was an elite pursuit and was recognized as instrumental in the campaign against infectious diseases, such as tuberculosis, and in promoting population health, such as infant welfare. By 1920, more than 70% of nurses worked on private duty; about half of those worked in patients’ homes and half worked for private patients in hospitals. Hospital nurses were primarily those in training. The war emphasized the drama and effectiveness of hospitals, and it soon codified hospitals as the center of nursing education in the increasingly specialized acute care medical environment. The war experience established nurses as dedicated associates in hospital science. Nursing leaders promoted the idea of upgrading nursing through high-quality hospital nursing schools, preferably associated with universities. The choice to idealize the role of nurses as dedicated and deferential to physician specialists in the hospital marginalized the independent role of nurses in social medicine and public

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

health. The social medicine and public health aspects of nursing were subjugated to the image of nursing as a symbol of patriotism, national sacrifice, and efficiency. As World War II brought increased specialization to the field of nursing and, ultimately, funding for the educational preparation of nurses, they began to specialize during the 1950s. Because of the short supply of nurses after World War II, hospitals began to group the least physiologically stable patients in one nursing unit for intensive care, where the more competent nurses cared for the sickest patients. This arrangement did not lower the need for nurses but, instead, created the need for a critical care nurse specialty as the need for staff nurses continued to grow. To increase the workforce, the U.S. Congress passed the Nurse Training Act of 1964 and the Health Manpower Act of 1968. The Nurse Training Act of 1971 added substantially to the federal support of nursing education (Lamm, 1996). Nevertheless, state funding provided the largest support for nursing schools, 80% of which are in colleges and universities.

Courtesy of the National Library of Medicine

▸▸

Nursing Definitions: Past and Present

The definitions of nursing in the early 20th century focused on nursing functions and were holistic. Virginia Henderson wrote one of the most

widely accepted definitions of nursing in this era: “Nursing may be defined as that service to an individual that helps him to attain or maintain a healthy state of mind or body” (Harmer & Henderson, 1939, p. 2). She later refined her definition into one that is perhaps best known in the world because of its adoption by the International Council of Nurses: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. Moreover, to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1960, p. 3) In 1952, Hildegard Peplau added an important dimension to the definition of nursing by expressing it in interpersonal terms. Peplau (1992) stated that “the goals of nursing are currently in transition; its major concerns fifty years ago had to do with getting sick people well; today, nursing is more concerned with ways for helping people to stay well” (p. 6). Nursing theory developed during the 1950s and 1960s continued to refine the definition of nursing. In the contemporary sphere of nursing, the current definition emerges from the 2003 edition of the American Nurses Association’s (ANA) Nursing’s Social Policy Statement: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. (American Nurses Association [ANA], 2010, p. 41) This definition of nursing provides a framework for nursing practice and curriculum development, and it defines the boundaries, functions,

Nurses and Policy

and purpose of the profession. It includes the four essential characteristics of nursing: human responses or phenomena, theory application, nursing actions or interventions, and outcomes (ANA, 2010.) A clear understanding of the boundaries of nursing is needed as allied health professionals and unlicensed assistive personnel are added to the patient care arena. Policymakers need to understand the distinct contributions nursing makes and how these contributions can impact healthcare policy. With this goal in mind, nurses must work with key policymakers to promote crucial conversations about economic and social policies that are cost effective and improve the health of individuals, families, communities, and populations. Nurses must know how to tip the levers of change through advocacy and social activism to advance the science of the profession, strengthen nursing education, and bring transformational change to nursing and health care.

Achieving Better Value Achieving better value is a driving priority toward expanding definitions of health, paying for visionary care that builds patient engagement, and beginning to shift from episodic individual care to continuous group and population health approaches. Value is defined as the health outcome, achieved per dollar spent (Porter, 2010). To obtain better value and desired health outcomes, there must be decreases in the necessary expenditures and fundamental changes in how care is delivered. Nurses are integral in leading and achieving value, but they must learn to leverage all the necessary resources needed to transform practice and increase value and quality. By using an analytic strategy known as cost-effectiveness analysis, nurses can generate new knowledge through the examination of costs and effectiveness of two or more comparable healthcare interventions. In this way, data from multiple sources are analyzed, and a ratio attributable cost per new intervention is compared to standard care (Stone, 2017). To improve health outcomes by developing and

407

disseminating evidence, nurses demonstrate that they can inform practice and future health policies. In fact, the American Nurses Association has urged the U.S. Congress to “listen to nurses when considering the best way to move forward on transforming America’s health care system” (Fitting, 2017). Today, nurses are pursuing innovative models of care to improve the nation’s health, including strengthening primary care and supporting healthcare delivery systems to provide effective care coordination. For example, in 2006 the American Academy of Nursing (AAN) recognized that nurses across the country had developed and implemented nurse-designed models of care that promoted health and managed illness across diverse and underserved populations. The Academy called these nurse designers Edge Runners (Mason, Jones, Roy, Sullivan, & Wood, 2015). Edge Runners are practical innovators who see beyond the status quo and dare to employ new and creative methods to solve health challenges. The American Academy of Nursing has recognized 65 Edge Runners who have created 49 nurse-designed models of care or inventions (American Academy of Nursing, n.d.) and are transforming healthcare delivery for providers and improving health outcomes for patients (TABLE 18-1). They have successfully demonstrated significant clinical and financial results, as well as the sustainability and replicability of their program or intervention. Edge Runners’ achievements ensure their ingenuity will continue to benefit providers and patients throughout the healthcare system (Mason et al., 2015).

▸▸

Nurses and Policy

Nurses are demonstrating leadership by becoming more involved in political advocacy to advance nursing and nurse workforce issues to the national health agenda. Only through active participation and action by nurses themselves will the professional status and recognition of nursing improve.

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

TABLE 18-1  Select Edge Runner Models of Care* Outcomes and Supporting Evidence

Program

Description

Aging in Place Project

Through registered nurse (RN) care coordination, health promotion, and early illness recognition, program aims to provide more and higher-quality services at home, allowing people to “age in place” and avoid or delay hospitalizations by creating Sinclair Home Care.

Reduced hospitalizations; maintained mobility and independence, involvement in life and community activities; and earlier hospice.

Eight regional centers on aging funded by the state’s share of the Master Tobacco Settlement Primary care clinic with a partner hospital and interprofessional team; program is person centered and assists the older adult to achieve optimal functioning and management of chronic illness.

90% of Arkansans age 65 and older are within 60 miles of a center.

Group healthcare delivery including health assessment, education, and support by a credentialed health provider began with Centering Pregnancy; now extended to parenting, diabetes, and other areas. Group participants meet regularly with their care provider and other group participants for up to 2 hours.

33% reduction in preterm birth, higher patient satisfaction with increased breastfeeding rates, and improved knowledge and readiness for birth and parenting.

Twelve-session parenting program designed to reduce behavior problems in young children by strengthening parenting skills; created in partnership with black and Latino parents from different economic backgrounds to help parents tailor effective parenting strategies to their goals and values.

Decreases in child behavior problems and parent reliance on corporal punishment.

(www.agingmo.com)

Arkansas Aging Initiative (www.arkansasaging .org)

Centering Pregnancy and Healthcare (www .centeringhealthcare .org)

Chicago Parent Program (www.chicago parentprogram .org/)

Costs lower than for nursing home care (Marek, Stetzer, Adams, Popejoy, & Rantz, 2012; Rantz et al., 2011).

Health professionals in Arkansas report a change in practice following aging-focused education. Will be replicated in Oklahoma through funding by Reynolds Foundation (Beverly et al., 2007; McAtee, Crandall, Wright, & Beverly, 2009).

Significant cost reductions and cost effectiveness demonstrated in two randomized clinical trials (Novick et al., 2013; Picklesimer, Billings, Hale, Blackhurst, & Covington-Kolb, 2012).

Program costs about $37 per child per session, with a potential return on investment exceeding 900% (Breitenstein et al., 2012; Gross et al., 2009).

Nurses and Policy

409

Outcomes and Supporting Evidence

Program

Description

Coping Skills Training Helping Youths and Their Families Deal with Diabetes

A cognitive behavioral intervention for small groups of youths in early teens with type 1 diabetes. Focus is on improving coping skills and social problem solving, communication skills, stress management, and cognitive behavioral modification; ultimate goal to improve peer, school, and family relationships and enhance self-management.

Lower glucose and insulin levels; better choices of foods.

!Cuídate¡

Culturally specific program to reduce the rates of pregnancy and sexually transmitted diseases, including HIV, among Latina youth through abstinence and condom use; beliefs are used to frame abstinence and condom use as culturally accepted and effective ways to prevent unplanned pregnancy and sexually transmitted diseases.

Decrease in reported sexual intercourse; less likely to report multiple partners; more likely to use condoms consistently.

(www.selectmedia .org/programs /cuidate.html)

Curriculum is included in CDC’s Diffusion of Effective Behavioral Intervention (DEBI) Program. Creating Opportunities for Parent Empowerment (COPE) (www.copeforhope .com/index.html)

Eleventh Street Family Health Services (www.drexel .edu/11thStreet)

Parents and grandparents demonstrated improvements in healthier nutrition choices, improved stress management skills, increased physical activity, and improved interpersonal relations (Grey, Boland, Davidson, Li, & Tamborlane, 2000; Grey et al., 2013).

Simulated economic analysis of sexual risk reduction programs indicates that evidence-based programs to encourage safer sexual behavior provide substantial benefit cost ratio (about $2.50 for every dollar spent) and reduces teen pregnancy (Feutz & Andresen, 2013; Villarruel, Zhou, Gallegos, & Ronis, 2010).

Educational–behavioral skills-building intervention with informational CDs and workbook that teaches parents about the appearance and behavioral characteristics of premature infants; activities show parents how to help meet child’s needs, enhance quality of parent-child interaction, and facilitate infant’s development.

3.8-day shorter hospital length of stay; 8-day shorter length of stay for infants less than 32 weeks’ gestation.

FQHC that delivers primary care and family- and community-­centered services emphasizing health promotion to a largely poor, black community in North Philadelphia; uses a broad transdisciplinary team with clinical services sustained through a partnership with the Family Practice & Counseling Network.

Reduced preterm births (2.5% compared with 15.6% overall in Philadelphia).

Cost savings of $4,864 per infant. For infants weighing less than 1,500 g, net cost savings were $9,864 per infant (Melnyk et al., 2004, 2006).

Improved quality of life with fitness program; decreased unnecessary medical specialty visits. 100% use of self-care plans and increased self-efficacy for patients in Living with Chronic Illness Program (Gerrity, 2010). (continues)

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

TABLE 18-1  Select Edge Runner Models of Care*

(continued)

Outcomes and Supporting Evidence

Program

Description

Family Health and Birth Center (FHBC)

Freestanding birthing center, part of Developing Families Center of Washington, DC; meeting primary healthcare, social service, case management, child development, and early childhood education needs of underserved individuals and childbearing and child-rearing families. Redefines “perinatal” as time from preconception through the child’s 2nd year of life.

Reduced rates of preterm birth, low birth weight, and cesarean section rates.

Nurse-managed health center serves the seriously mentally ill in Chicago with coordinated physical and mental health service of primary and preventive care, education, behavioral and mental health care in four clinics and in homes; coordinates care with interdisciplinary freestanding psychiatric rehabilitation organization.

Lower blood pressure, total ­cholesterol, low-density ­lipoprotein cholesterol, blood sugar, ­hemoglobin A1c, and weight.

Evidence-based model of hospital-to-home transitional care led by advanced practice nurses in conjunction with patient’s entire healthcare team, targeting patients at risk for poor post discharge outcomes in order to improve post discharge outcomes; in partnership with a major insurer (Aetna) targeting their Medicare Advantage consumers.

Reduces rates of rehospitalization, longer intervals before initial rehospitalizations, shorter hospital stays, and better patient satisfaction.

Evidence-based nurse home visitation program that improves health, well-being, and self-sufficiency of low-income, first-time parents and their children; nurses and clients make a 2-year commitment, with 14 visits planned during pregnancy,

Reduction in preterm delivery for women who smoke; fewer hypertensive disorders of pregnancy; decrease in smoking; fewer injuries among children.

(www.communityof hopedc.org/fhbc)

Integrated Health Care (IHC) (www.nursing.uic .edu/faculty -practice#overview)

Making Transitional Care More Effective and Efficient (www.transitional care.info/)

Nurse-Family Partnership (www.nursefamily partnership.org/)

Higher rates of breastfeeding at discharge and at 6 weeks. Reduced costs for the DC area’s healthcare system by more than $1.6 million in 1 year (Benatar, Garrett, Howell, & Palmer, 2013; Lubic & Flynn, 2010).

Stabilized or improved mental health (McDevitt, Braun, Noyes, Snyder, & Marion, 2005).

Average savings of approximately $5,000 per Medicare patient (McCauley, Bixby, & Naylor, 2006; Naylor et al., 2004).

Reduction in emergency visits for accidents and poisonings from birth to age 2.

Nurses and Policy

Program

On Lok Senior Health Services (www.onlok.org/)

Living Independently for Elders (LIFE) (www.lifeupenn.org/)

Family Practice and Counseling Network (FPCN) (www.fpcn.com)

SeniorWISE (Wisdom Is Simply Exploration) (http://gjmcdougall. people.ua.edu/seniorwisereg-projects. html)

Description

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Outcomes and Supporting Evidence

28 visits during infancy, and 22 ­visits during the toddler stage.

Program had highest return on investment among all home visiting and child welfare programs evaluated (Eckenrode et al., 2010; Kitzman et al., 2010).

On Lok is an original Program for All-­Inclusive Care of Elders (PACE, a capitated program under Medicare and Medicaid) in San Francisco area.

Cost of care 15% lower than under the traditional fee-for-service care system; Congress authorized the rural PACE provider grant program.

LIFE (Living Independently For Seniors) is a PACE model operated in Pennsylvania; PACE aims to keep older adults healthy, independent, and out of nursing homes and hospitals using a network of centers combined with clinics and day services. An interprofessional team formulates, coordinates, and provides the services and activities.

One of three programs researchers identified as models of long-term care that are effective, efficient, and less expensive than traditional longterm care (Friedman, Steinwachs, Temkin-Greener, & Mukamel, 2006; Mukamel et al., 2007).

System of three nurse-run health centers located near public housing in Philadelphia based on a “one-stop shopping” model where patients receive primary and behavioral health care, podiatry, optometry, and dental care all on the same day; patients can be transported to and from the health center by the health center van.

70% of pregnant patients received prenatal care in first trimester; 85% of children by age 2 were fully immunized.

Intervention focuses on modifying risk factors and improving the everyday memory function of older adults; learning to deal with anxiety linked to memory lapses; use of attention-focusing, memory strategy training, repeated practice, relevant modeling, and realistic expectations; delivery where older adults live, recreate, and work.

Reduces out-of-pocket expenditures for hospitalization, nursing home care stays, outpatient treatment, home care, and prescription medications (McDougall et al., 2010; McDougall, Makert & Becker, 2012).

63% of patients with diabetes had HbA1c under 9 (Collins, 2013). Has realized a financial surplus in 18 out of 19 years.

(continues)

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

TABLE 18-1  Select Edge Runner Models of Care*

Outcomes and Supporting Evidence

Program

Description

Wise Health Decisions

Self-care management wellness program by RNs built around Wise Health Decisions Worksite Wellness Clinics; identify employees with or at risk for chronic conditions. Individualized teaching/coaching services are based on screening results conducted at each appointment.

(www.clinicalsolutions-llc.com)

(continued)

Significant reduction in claims and lower health premium increases. Significant reduction in risk levels across blood pressure, blood sugar, cholesterol, and weight measures sustained over time. Return on investment for clients using cost avoidance estimates and claims data: for every $1 spent, $3-$7 saved in first year (Wise Health Decisions from Clinical ­Solutions, n.d.).

CDC 5 Center for Disease Control and Prevention; FQHC 5 federally qualified health center; HIV 5 human immunodeficiency virus; RN 5 registered nurse. * A complete list of American Academy of Nursing’s Edge Runners can be found at www.aannet.org/edge-runners. Reproduced from Mason, D. J., Jones, D. A., Roy, C., Sullican, C.G., & Wood, L. J. (2015). Commonalities of nurse-designed models of health care. Nursing Outlook, 63(5) 540-553. Copyright 2015, with permission from Elsevier.

Nurses must articulate in clear ways the reasons that nursing matters to the overall health and well-being of the patient, family, commu­ nity, and population they serve. It is essential for nurses to educate policymakers about important health issues and policies that ensure citizens and residents have access to a range of high-quality, affordable coverage options, so they access the services they need, regardless of preexisting conditions. The implications for health policy present new challenges for registered nurses (RNs) as they know first hand the brokenness of our healthcare system and care for patients, families, and communities, whether or not they are insured. Nurses must be nimble in responding to shifting legal, legislative, and/or regulatory priorities of care delivery, as well as professional issues including the scope of practice. There is substantial evidence that the public continually ranks the nursing profession highly for their honesty and ethical integrity. For 16 consecutive years the Gallup survey organization has

rated nursing the most trusted profession in the U. S. (Norman, 2016). If they want the public to know what nursing is, nurses need to to communicate a precise definition of nursing. Barrett (2002) states, “Nursing is a basic science, and the practice of nursing is the scientific art of using knowledge of unitary human beings who are in mutual process with their environments for the well-being of all people” (p. 51). “It is time to claim that what nurses do is based on what nurses know, and the essence of the broad knowledge is an education in discipline-specific nursing knowledge” (Barrett, 2017, p. 29). It is precisely this knowledge that allows nurses to act responsibly in caring for society (the public). As trusted providers who listen acutely and communicate efficiently, nurses have an enormous opportunity to express their voice to influence policy and the decision-making processes. When nurses are more engaged, they are uniquely prepared to generate crucial conversations with others about healthcare policy with skill and respect.

The Nursing Workforce

Although nurses are trusted providers, the public may not fully understand or appreciate the expert knowledge base, complexity, and intellectual capacity needed in a health delivery system where care and treatment are measured for their quality, effectiveness, and costs. To advance the nation’s health and lead change, nurses must ensure the public knows what nursing is, as well as what nurses do. Nurses represent the largest segment of the healthcare workforce and play a huge role on the front lines of care in our schools, hospitals, community health centers, long-term care facilities, and other places. Their perspective and influence must be felt more at decision-making tables. To bring the power of the nursing perspective front and center, the Nurses on Boards Coalition (NOBC) was formed to represent national nursing and other organizations working to build healthier communities in the United States by increasing nurses’ presence on corporate, health-related, and other boards, panels, and commissions. The Coalition’s goal is to help ensure that at least 10,000 nurses are on boards by 2020, as well as raise awareness that all boards would benefit from the unique perspective of nurses to achieve the goals of improved health, and efficient and effective healthcare systems at the local, state, and national levels. The NOBC was created in response to the landmark 2010 Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, which recommended increasing the number of nurse leaders in pivotal decision-making roles on boards and commissions that work to improve the health of everyone in the U.S. The Robert Wood Johnson Foundation and AARP initially brought the groups together as part of their collaborative effort to implement the recommendations of the IOM report through the Future of Nursing: Campaign for Action. (www. nursesonboardscoalition.org/about/). Many understand the role of the nurse in the hospital, but many more do not see the increasingly diverse roles and responsibilities nurses have across the continuum of care. Therefore, nurses must hold policymakers accountable for

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issues and policies relevant to the profession and public. The struggle for a more significant voice, inclusion, accountability, and representation is an ongoing process of citizen engagement, including negotiation and confrontation, all of which require evidence, knowledge of health policy, and the application of tools, such as access to information and social media. The Pew Research Center (2018) asserts that social media has affected much of our life, including our work, politics, political deliberation, communication patterns, health information sharing, civic life, news consumption, and communities, just to name a few. Through active citizen engagement and participation, nurses can harness their power and political influence (FIGURE 18-1).

▸▸

The Nursing Workforce

Registered nurses (RNs) represent the largest profession within the U.S. health workforce, with over 2.9 million RNs employed in 2016 (Bureau of Labor Statistics [BLS], U.S. Department of Labor, 2017). The BLS forecasts that the demand for RNs will result in 3.3 million nursing jobs by 2026. The largest employers of registered nurses are included in TABLE 18-2. Employment of registered nurses is projected to grow 15% from 2016 to 2026, much faster than the average for all occupations. Buerhaus, Skinner, Auerbach, and Staiger (2017) suggest that projected growth is due to the nation’s 78 million baby boomers aging and becoming beneficiaries of the Medicare program. Of these recipients, three in four over age 65 will have multiple chronic diseases, which will increase the overall demand for RNs as well as the complexity and intensity of nursing care that will be required to manage this group of medically complicated individuals. Although nurses are the largest health workforce, they are not always at the forefront of the current policy engagement, dialogue, or implementation processes pertaining to the agenda. The world’s populations must have access to

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

What’s at stake for nurses and patients without the Affordable Care Act ACCESS

COST

QUALITY

WORKFORCE

FIGURE 18-1  What is at stake for nurses and patients without the Affordable Care Act? Reproduced from American Nurses Association. (n.d.). What’s at stake for nurses and patients without the Affordable Care Act. Retrieved from http://www.nursingworld.org/MainMenuCategories/Policy -Advocacy/HealthSystemReform/ANA-Infographic-What-Nurses-and-Patients-Stand-to-Lose-without-the-Affordable-Care-Act.pdf

TABLE 18-2  Top Areas of Employment for RNs Employment Sector

Percentage

Hospitals: state, local, and private

61%

Ambulatory healthcare services

18%

Nursing and residential care facilities

7%

Government

5%

Educational services: state, local, and private

3%

Reproduced from U.S. Department of Labor, Bureau of Labor Statistics. (2018). Occupational Outlook Handbook: Registered nurses. Retrieved from https://www.bls.gov/ooh/healthcare/registered-nurses.htm

the right nurse, with the right education and competencies, at the right place, to provide the right care on time. When nurses themselves inform and disseminate their scientific findings and evidence widely and with others, then, and

only then, will global leaders and other healthcare stakeholders understand why they must invest in nursing to improve healthcare outcomes, gender equality, and economic growth (Nickitas & Ferguson, 2017). In fact, the National Council of State Board of Nursing’s (2017a) 2017 Environmental Scan reports that “making the health care delivery system safer and more efficient for the future is a global aim for responsibility for health care providers and the expectations and standards for delivery systems as they become increasingly congruent from nation to nation” (p. 4). The World Health Organization (WHO, 2018) launched the Global Health Workforce Network for stakeholder consultation, dialogue, and coordination of health workforce policies in support of the Global Strategy on Human Resources for Health 2030, and the recommendations of the High-Level Commission on Health Employment and Economic Growth (Global Health Workforce Network). Healthcare organizations; governments; international organizations such as the International Labor Organization, WHO, and the International Council of Nurses; as well as national, regional, and local professional nursing organizations and entities must continue to invest in nursing and raise the profile of nurses to

Transforming the Care Delivery System

ensure greater attention to policies that invest in, improve, and increase the global nursing workforce and excellence in nurse staffing.

▸▸

■■ ■■

The IHI triple aim Population health

Transforming the Care Delivery System

Because of healthcare reform under the Affordable Care Act (ACA), a new care delivery system has shifted away from an acute care model to a preventive care model focused on population health that includes payment models to emphasizing teamwork, care coordination, and value. This shift has influenced how hospitals are reimbursed for services from the Centers for Medicare & Medicaid Services (CMS) to a reimbursement model built on pay for performance and a value-based reimbursement approach, which places financial incentives around patient outcomes. Some examples include accountable care organizations (ACOs), bundled payments, and other innovative financing approaches; new models of primary care, such as patient-centered medical homes; sanctions for avoidable events, such as hospital readmissions or infections; and the integration of information technology are having wide-reaching impact on improving patient experience of care and reducing costs while aligning with a focus on improving the health of populations (IHI Triple Aim) (Institute for Healthcare Improvement, 2014). The Institute for Health Improvement (IHI) has developed a framework that describes an approach to optimizing health system performance (2014). IHI says new designs must be developed to simultaneously pursue three dimensions known as the “Triple Aim” (FIGURE 18-2): ■■

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Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of health care

It is important that nurses focus on excellent patient care outcomes and identify nursing practice that aligns with the Triple Aim. Policymakers and stakeholders must be informed

Experience of care

Per capita cost

FIGURE 18-2  IHI diagram The IHI Triple Aim framework was developed by the Institute for Healthcare Improvement in Boston, Massachusetts (http://secure-web.cisco.com/1iT80FMEwqNbQ7pu5OLNBG3f24mT3sSTtKheGfK5mivJ PUmVgbkp4DoGomXewYhDKRb1yzPC32xuA4Sy7gFR-uZrZUZjTsPEb4YDZKrjpLmdhdKomOSUFKJrloO GnNrYCAa6d_ySKqjl4UzcTAvxDrejS4cHPc_g7LOVz81d_pm9E-KAACE_vVcPnaNS5l62qeVMffBDigY9p H62GHzrpRofvzpm-fq-PQH79uqwk539y0RQA7zKXXH7ygCrYRzSbxFWl_McLvYZhKJe6NQ8hXQ /http%3A%2F%2Fwww.ihi.org).

about the education–quality relationship of nursing and how the nursing profession adds value to the overall healthcare delivery system. Nurses must understand and be encouraged to support mechanisms that stimulate the economical use of healthcare services, while promoting those who do not have the means to share in costs. By stabling or reducing the per capita cost of care and quality for populations, it lessens the pressure on publicly funded healthcare budgets and provides communities with opportunities to invest in new ways to reduce costs and improve healthcare outcomes. By focusing on patient care outcomes and innovative approaches to help transition from high-volume care to high-value care and shift the balance of attention from the hospital to the community, nurses are engaged in redesigning health care to achieve the Triple Aim of better experiences within the healthcare system, better population health, and lower costs. The Institute for Healthcare Improvement (2014) believes it is essential to harness a range of community determinants of health, empower individuals and families, substantially broaden the role and impact of primary care and other community-based services, and assure seamless journey through the whole system of care throughout a person’s life.

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

The American Nurses Association (2016) offers the following Principles for Health Systems Transformation: ■■

■■

■■

■■

Develop a partnership between the government and private sector to share healthcare costs. Reward payment systems that improve quality and the appropriate, efficient use of resources. Provide payment for beneficiaries paying for a portion of their care to provide an incentive for the efficient use of services while ensuring that deductibles and copayments are not a barrier to receiving care. Support federal subsidies based on an income-based sliding scale to assist individuals to purchase insurance coverage.

The continued uncertainty of the economic climate, changing demographics, and other pressures facing healthcare delivery systems demand that cost reduction is driven by improvements in clinical and operational quality. The U.S. Department of Health and Human Services has moved to share savings within healthcare delivery systems by linking quality outcomes and global payments under Medicare (Centers for Medicare & Medicaid Services, 2015). This provides significant incentives for developing relationship-based care with individuals, families, and communities that foster patient engagement and health promotion. Nurses must give considerable attention to measuring health; reforming payment policies; and increasing transparency of patient, family, and community engagement. These measures are essential to promoting the health of populations adversely affected by disparities and ensuring equitable allocation of healthcare resources (National Quality Forum, 2017).

▸▸

Pathways to Nursing as a Career Choice

As healthcare needs grow more complex, the career pathway of nursing has evolved into the

following career choices: registered nurse (RN), advanced practice registered nurse (APRN), clinical nurse specialist (CNS), and clinical nurse leader (CNL). Each of these professional roles requires unique educational preparation and training.

Professional Registered Nurses RNs are typically prepared for professional practice through different levels of nursing education. To achieve the RN title, an individual must graduate from a state-approved school of nursing—either a 4-year university program or a 2-year associate’s degree program—and pass a state RN licensing examination called the National Council Licensure Examination (NCLEX) for Registered Nurses. The 4-year university-based bachelor of science in nursing (BSN) degree provides the nursing theory, sciences, humanities, and behavioral science preparation necessary for the full scope of professional nursing responsibilities. It also provides the knowledge base necessary for advanced education in specialized clinical practice, research, or primary health care. A 2-year program granting an associate’s degree in nursing (ADN) prepares individuals for a defined technical scope of practice. Set in the framework of general education, the clinical and classroom components prepare ADN graduates for nursing roles that require nursing theory and technical proficiency. Many RNs whose first degree is an ADN return to school during their working life to earn a bachelor’s degree or higher.

Advanced Practice Registered Nurses Advanced practice registered nurses (APRNs) are registered nurses who must complete a master’s or doctoral degree program, and have advanced clinical training beyond their initial professional registered nurse preparation. Didactic and clinical courses prepare nurses with specialized knowledge and clinical competency to practice in primary care, acute care, and

Pathways to Nursing as a Career Choice

long-term healthcare settings. APRNs are prepared by education and certification to assess, diagnose, and manage patient problems; order tests; and prescribe medications. APRNs are highly valued and are an integral part of the healthcare system. They include certified nurse practitioners (NPs), certified nurse–midwives (CNMs), clincial nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs). Each APRN has a unique history and context. The title distinguishes one’s academic achievement and the professional level of one’s practice. Although education, accreditation, and certification are necessary components of an overall approach to preparing an APRN for practice, the licensing boards governed by state regulations and statutes are responsible for setting practice within a given state. In the United States, more than 250,000 APRNs practice in the four roles (NP, CRNA, CNM, and CNS). In 2014, the number of certified nurse practitioners was 222,000 (American Association of Nurse Practitioners, 2016). The types of APRNs include the following: ■■

■■

■■

■■

Certified nurse–midwives provide prenatal and gynecological care to normal healthy women; deliver babies in hospitals, private homes, and birthing centers; and continue with follow-up postpartum care. Clinical nurse specialists provide care in a range of specialty areas, such as cardiac, oncology, neonatal, pediatric, and obstetric/ gynecologic nursing. Certified registered nurse anesthetists administer more than 65% of all anesthetics given to patients each year and are the sole providers of anesthesia in approximately one-third of U.S. hospitals. Nurse practitioners (NPs) provide primary, acute, and speciality health care to patients of all ages from infants to olders adults. They assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans—including prescrbing medication (see TABLE 18-3).

417

The majority of APRNs (95.2%) prescribe and have been in practice more than 12 years. Ninety-six percent of APRNs have graduate degrees, and 83% hold advanced certification in primary care (American Association of Nurse Practitioners, 2016). APRNs, who are growing in number, are well positioned to step further into the primary care arena (Academy of Medical-Surgical Nurses et al., 2016). When allowed to practice to the full extent of their education and training, Barnes and others (2016) found that APRNs have a 13% greater likelihood of working in primary care in states that allow full-practice authority, and that they are 23% more likely to be caring for Medicaid patients if the state allows full reimbursement for their care. APRNs have expanded in numbers, as well as their responsibilities and capabilities. Yet, they continue to experience resistance by the American Medical Association (AMA) who has sought to impede access to care by qualified providers. Specifically, at the AMA’s recent House of Delegates Interim meeting, the association adopted an amended resolution to create a national strategy to obstruct state and national policies that would allow “nonphysician” providers, including advanced practice registered nurses (APRNs), from practicing fully, regardless of their education, clinical training, and certification. The Institute of Medicine (currently the National Academy of Medicine) calls for the removal of barriers that prevent APRNs from full practice authority in its pinnacle report Future of Nursing: Leading Change, Advancing Health (2010). This report has served as the platform for widespread efforts to examine scope of practice policies for nearly 8 years by stakeholders both within and outside of professional nursing. Additionally, the Federal Trade Commission has urged states to review laws and regulations that stifle competition in the healthcare sector, as these impose unnecessary and burdensome restrictions on APRN practice, which can negatively affect patients (Federal Trade Commission, 2014). Each state independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry into advanced

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

TABLE 18-3  Distribution, Top Practice Setting and Clinical Focus Area by Area of NP Certificationa Area of Certificationb

Percentage

Top Practice Setting

Top Clinical Focus

Acute Care

6.6%

Hospital inpatient clinic (28.8%)

Surgical (17.1%)

Adultc

16.2%

Hospital outpatient clinic (16.6%)

Primary care (37.9%)

Adult – Gerontology Acute Care

2.1%

Hospital inpatient clinic (38.4%)

Surgical (14.8%)

Adult – Gerontology Primary Carec

4.5%

Hospital outpatient clinic (21.4%)

Primary care (48.0%)

Familyc

62.4%

Private group practice (20.9%)

Primary care (50.0%)

Gerontologyc

2.3%

Long-term care facility (21.3%)

Primary care (49.5%)

Pediatric – Primary Carec

4.8%

Hospital outpatient clinic (22.4%)

Primary care (59.3%)

Psychiatric/Mental Health – Adult

1.8%

Psychiatric/mental health facility (20.0%)

Psychiatric (97.6%)

Psychiatric/Mental Health – Family

2.4%

Psychiatric/mental health facility (31.6%)

Psychiatric (100.0%)

Women’s Healthc

3.5%

Private group practice (17.4%)

OB/GYN (74.7%)

a

2017 AANP National Nurse Practitioner Survey. NPs may be certified in more than one area. c Primary care focus. Reproduced from American Association of Nurse Practitioners. (2018). NP fact sheet. Retrievedf rom https://www.aanp.org/all-about-nps/np-fact-sheet. b

practice, and the certification examinations accepted for entry-level competence assessment. It is imperative that APRNs be afforded the opportunity to practice to the top of their license and provide care to patients, families, and the community without restriction. CRNAs currently number more than 45,000 (Phillips, 2017). In 2015, the American Midwifery

Certification Board reported 11,210 CNMs. The number of CNSs is more difficult to estimate because they were not recognized in some states until recently, and still are not recognized in a few states (Newland, 2016). The increasing specialization of nurses is demonstrated in the evolving role of CNSs and CNLs. The role of NPs evolved to meet demands for increased

Current State of the Profession

access to primary health care; the role of the CNS was developed in response to the specialized nursing care requirements of increasingly complex medical needs. Like a physician specialist, CNSs are advanced practice specialists with in-depth knowledge and skills that make them valuable adjunct practitioners in specialized clinical settings. CNSs play a unique role in the delivery of high-quality nursing care. In addition to direct patient care, CNSs also engage in teaching, mentoring, consulting, research, management, and systems improvement. Able to adapt their practice across settings, these clinicians significantly influence outcomes by providing expert consultation to all care providers and by implementing improvements in healthcare delivery systems. Furthermore, the growing body of research on CNS outcomes shows a strong correlation between CNS interventions and safe, cost-effective patient care. CNS practice has been directly linked to reducing hospital costs and lengths of stay, reduced frequency of emergency room visits, improved pain management practices, increased patient satisfaction with nursing care, and fewer complications in hospitalized patients (Fulton & Baldwin, 2004; National Association of Clinical Nurse Specialists, 2013). Unfortunately, the constraining forces of today’s practice environment of mounting financial pressure, limited nursing resources, and changing technology, along with higher patient acuity and shorter lengths of stay, have tested the very core of the profession’s values and contributions to quality care.

▸▸

Specialization and the Evolution of Nursing Roles

The increasing specialization of nurses is demonstrated in the evolving role of the CNS and CNL. Just as the role of the NP evolved over several decades to meet demands for increased access to primary health care, the roles of the CNS and

419

CNL were developed in response to the specialized nursing care needs of increasingly complex medical needs. In today’s healthcare system, nurses are critical caregivers who have a profound effect on the lives of patients and their families. They also play an essential role in the quality of care patients receive. A CNL is a master’s-prepared generalist who puts evidence-based practice into action and serves as a central liaison between the patient and all other healthcare providers. CNSs play an important role in the provision of nursing care that does not duplicate the emerging role of the CNL. In terms of focus, CNLs are educated as generalists, whereas CNSs are prepared for specialty practice. To understand the role of the CNL, it is important to differentiate the duties of CNLs and CNSs. A CNL coordinates and implements client care, whereas a CNS designs and evaluates patient-specific and population-based programs. A CNL evaluates and implements evidence-based practice, whereas a CNS has the added responsibility of generating new evidence. The CNS and CNL roles are distinct and complementary (Spross et al., 2004). The American Association of Colleges of ­Nursing (AACN; 2016) envisions that these clinicians will work collaboratively to ensure that patients receive the best possible care. Nurses are needed both at the point of care and in advanced practice roles to deliver care that is growing intensely more complicated.

▸▸

Current State of the Profession

Nursing Regulation Government oversight provides nursing regulation through administrative and legislative bodies within each state. Nursing as a health profession must be regulated because it may pose a risk of harm to the public if it is practiced by someone who is unprepared and incompetent (Nickitas, 2016b). It is important for nurses to realize that the public may not have sufficient

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices

information and experience to identify an unqualified healthcare provider and is vulnerable to unsafe and incompetent practitioners. Therefore, to protect the public’s health and interest, each state establishes its own board of nursing, which is responsible for the regulation of nursing practice, including the scope of practice. It is important to note that the boards of nursing (BONs) that comprise the National Council of State Boards of Nursing seek to protect the public’s health and welfare by assuring that safe and competent nursing care is provided by all licensed nurses (National Council of State Boards of Nursing, 2017b). Boards of nursing from each state in the union achieve this mission by identifying the standards for safe nursing care and issuing licenses to practice nursing (National Council of State Boards of Nursing, 2017b). Boards of nursing are authorized to enforce the Nurse Practice Acts (NPA) of each state and develop administrative rules, regulations, and other responsibilities of the act. The definitions of the NPA are the legal definition of nursing in that state. The legislatures of all states and territories have enacted an NPA. The NPA itself is insufficient to provide the necessary guidance for the nursing profession; therefore, each NPA establishes a board of nursing that has the authority to develop administrative rules or regulations to clarify the law or make it more specific. All rules and regulations undergo a process of review before enactment. After they are enacted, rules and regulations have the full force and effect of law (National Council of State Boards of Nursing, 2016a). The specific details of the NPA differ among states; however, they all must include the following (National Council of State Boards of Nursing, 2016b): ■■ ■■ ■■ ■■ ■■

Authority, power, and composition of a board of nursing Education program standards Standards and scope of nursing practice Types of titles and licenses Requirements for licensure

■■

Grounds for disciplinary action, other violations, and possible remedies

Every nurse must be informed and educated about the practice of nursing in his or her state. It is a right granted by a state to protect those who need and require nursing care. The guidelines of the NPA and its rules provide safe parameters within and protect patients from unprofessional and unsafe nursing practice. The act is a dynamic document that evolves and is updated or amended as changes in the scope of practice occur.

Licensure State boards of nursing regulate the nursing practice, including the scope of nursing practice. In each state, the model NPA describes the scope of practice for RNs, licensed practical/ vocational nurses (LPNs/LVNs), and APRNs. Licensure is one type of regulation. It is the process by which boards of nursing grant permission to an individual to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice safely (National Council of State Boards of Nursing, 2011). Licensure is required when the regulated activities are involved; it requires specialized knowledge and skills, as well as independent decision making. The responsibilities of a licensed nurse include an understanding of, and adherence to, the laws and rules that govern nursing as outlined in the nurse practice act and regulations (National Council of State Boards of Nursing, 2017b). It is essential to note that each nurse is responsible for reviewing the nursing law and rules by locating the state practice act and regulation in the state where registration and practice occurs. Nursing includes the following in the intent of licensure: ■■ ■■

A specified scope of practice may be performed legally only by licensed individuals. Title protection is granted to those individuals who meet the legal and educational

21st-Century Nursing: Evolving Roles for Nurses

■■

standards of the profession. Licensed individuals adhere to professional codes of conduct. The authority to take disciplinary action is granted to protect the public if the licensee violates the laws or rules.

The National Council of State Boards of Nursing (NCSBN) is an independent, not-for-profit organization through which boards of nursing act and counsel together on matters of common interest and concern affecting public safety, and welfare, including the development of nursing licensure examinations (National Council of State Boards of Nursing, 2017a). The National Council of State Boards of Nursing provides education, service, and research through collaborative leadership to promote evidence-based regulatory excellence for patient safety and public protection (National Council of State Boards of Nursing, 2010).

▸▸

Enhanced Nurse Licensure Compact

The Nurse Licensure Compact (NLC) has been in operation for more than 15 years. It allows RNs and LPN/LVNs to have one multistate license in their home state with the ability to practice in their home state and other NLC member states without additional license. The NLC model enables ease of practice across state borders both in person and electronically. This mobility is critical for nurses practicing in different states via telehealth and nurse educators teaching in different states via distance education. In 2015, the NLC had 25 member states; however, not all other states were willing to become members because of differing state licensure requirements. Today, there is an enhanced NLC (eNLC) with uniform licensure requirements including criminal background checks. A similar compact, the Advanced Practice Registered Nurse Compact (APRN Compact) allows APRNs to have

421

a multistate license with the ability to practice in their home state and other APRN Compact member states without obtaining any additional APRN state licenses. To become a member of the eNLC, a state must pass the eNLC language in its state legislature.

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21st-Century Nursing: Evolving Roles for Nurses

Creating a future that recognizes the evolving role of RNs will require sustained attention in nursing education, practice, education, research, and leadership. The Future of Nursing suggests nurses should be full partners with other healthcare professionals in redesigning health care in the United States (Institute of Medicine [IOM], 2010). Recommendation 7: Prepare and enable nurses to lead change to advance health. Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses. (IOM, 2010, p. 5) For example, nurses must be recognized and supported as leaders in the transformation of health care in the ambulatory care setting (IOM, 2010). They have expertise in the development, implementation, and sustainability of quality measures and clinical practice improvement. American Academy of Ambulatory Care Nursing (AAACN, 2017) Task Force members have published the following recommendations for registered nurses to consider as they make efforts to redefine health and primary care, advocate for changes in the reimbursement

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structure for health care, and address newly expanded roles for nurses across the continuum of care, particularly as they relate to ambulatory healthcare services and population health: ■■

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RNs must practice at the top of their license, education, and expertise to affect the quality and cost through patient engagement, care coordination, enhanced teamwork, resource reduction, improved access, and quality and outcome improvement. Faculty and schools of nursing must design undergraduate and graduate curricula to prepare nurses for new roles in ambulatory care. Health facilities must implement ambulatory care nurse residencies for new nurses and experienced nurses new to ambulatory care practice. Government and insurance carriers must recognize the impact on cost reduction an RN can provide under new reimbursement models that are linked to improved outcomes. RNs must lead, participate in, and support performance improvement activities designed to promote and enhance quality and safety, improve efficiency in care delivery, and evaluate the impact on patient outcomes. Researchers must build the science of ambulatory care nursing by engaging in the development of new knowledge and innovation to build the evidence base needed to support the quality practice. (p. 40)

Expanding nursing’s influence through knowledge development, evidence, and research provides power and leadership by giving the nursing profession a voice to exercise expertise in patient care and public health issues. Nursing research contributes to the discipline of nursing science and improves the nation’s health. The NINR provides funding for research into new opportunities to integrate physical, social, and behavioral sciences and design latest technology and tools that add new knowledge of care across the lifespan. This knowledge is essential to the present and future health of the nation.

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Nursing research seeks to address care coordination and management of patients during illness and recovery, reduce risks for disease and disability, promote healthy lifestyles, enhance the quality of life for those with chronic illness, and promote care for individuals at the end of life. It is through funding from NINR that nursing research helps to advance nursing practice, improve patient care, eliminate health disparities, and attract new students to the profession. It is important to note that NINR has been part of the future of the nation’s healthcare system by providing grants, research training, and interdisciplinary practice and education. The demand for RNs will continue to grow at a higher rate. This growth is primarily due to the increased number of older adults who require more healthcare services. These demands of rapid population growth, increasing diversity and number of foreign-born residents, and aging of the population over the next several decades will challenge the healthcare system. To meet this challenge, nurses will need to provide new models of care that are flexible, proactive, responsive, and cost effective.

Educational Remedies (Increase Number of Schools and Accelerated Programs) To meet the more complex demands of today’s healthcare environment, academic nurse leaders across all schools of nursing are working

21st-Century Nursing: Evolving Roles for Nurses

together to increase the proportion of nurses with a baccalaureate degree. These leaders are beginning to partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan. Accelerated nursing programs are available in 46 states plus the District of Columbia and Puerto Rico. In 2012, there were 255 accelerated baccalaureate programs and 71 accelerated master’s programs available at nursing schools nationwide (Nursing Certification Programs, 2018.). Also, 25 new accelerated baccalaureate programs are in the planning stages, and seven new accelerated master’s programs are taking shape (AACN, 2012). Accelerated baccalaureate programs offer the quickest route to licensure as an RN for adults who have already completed a bachelor’s or graduate degree in a nonnursing discipline. Fast-track baccalaureate programs are often completed within 11 and 18 months, including prerequisites. Fast-track master’s degree programs take about 3 years to complete. Graduates of accelerated programs are prized by nurse employers who value the many layers of skill and education these nurses bring to the workplace. Employers report that these graduates are more mature, possess strong clinical skills, and are quick studies on the job. In 2004, 13% of the nation’s RNs held either a master’s or doctoral degree as their highest educational preparation. The current demand for master’s- and doctoral-prepared nurses for advanced practice, clinical specialties, teaching, and research roles far outstrips the supply. The focus must remain on four key areas: establishing strategic partnerships and resource alignment, formulating policy and regulation, increasing faculty capacity and diversity, and redesigning educational curricula (National Council of State Boards of Nursing, 2017b). Increasing enrollment in baccalaureate nursing programs is a critical first step to correcting an imbalance in the nursing student population

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and reversing our nation’s diminishing supply of nurse educators. In almost all jurisdictions, nursing faculty must possess a graduate degree to assume a full-time teaching role. Because the overwhelming majority of nurses with master’s and doctoral degrees began their education in baccalaureate programs, efforts to alleviate the faculty shortage must focus on expanding enrollments in 4-year nursing programs (National Council of State Boards of Nursing, 2017b).

Professional Remedies (Change Status of Nurses) The role of nursing leadership is fundamental to overturning the misconception that nurses act as subordinates in providing patient care. This misconception is based on the traditional nurses’ role of taking physicians’ orders. This view of nursing has not been overturned entirely in the

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public eye because of a lack of nursing leadership. Recruitment efforts focus mainly on the role of nurses in helping sick patients, assisting physicians, and bringing direct care to patients, but nothing is mentioned about the role of nursing as a leadership profession to improve healthcare administration, develop healthcare policy, and influence medical practice. To change the general opinion of nursing, nurses must understand the multiple career choices they have and the meaning of their education. Nursing is no longer a profession that merely follows physicians’ orders; instead, it has nurses on the front line participating in initiatives to lead healthcare reform and suggest ways to improve access, cost, and quality.

For example, advanced practice nurses have developed initiatives around new infrastructure care models that focus on primary care, chronic care management, care coordination, and wellness (see examples in TABLE 18-4). These include the Transition Care Model (TCM) designed by Mary Naylor, director of the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative and professor at the University of Pennsylvania School of Nursing. Under this model, APRNs serve as primary care coordinators to help older patients avoid hospitalizations and promote longer-term positive health outcomes. A transitional care nurse, who is an advanced practice nurse, is assigned to a patient upon admission into the hospital. This

TABLE 18-4  Nurses Influencing Policy Sylvia Trent-Adam, PhD, RN, FAAN

Deputy Surgeon General, as well as Chief Nurse Officer of the U.S. Public Health Service Commissioned Corps (USPHS). Rear Admiral Trent-Adams was appointed Acting Surgeon General in May 2017 to oversee the USPHS, and is the leading spokesperson on public health in the federal government.

Gale Adcock, MSN, RN, FNP-BC, FAANP, FAAN

Representative Adcock, currently in her second term in North Carolina House of Representatives, is the first APRN to serve in the NC legislature. She has sponsored eight bills that are now state law.

Patricia Brennan, PhD, RN, FACMI, FAAN

In August 2016, Dr. Brennan was appointed by the National Institutes of Health to be the Director of the National Library of Medicine. As head of the world’s largest medical library, she oversees all aspects of a vast collection used by scientists and health professionals around the world.

Barbara Damron, PhD, RN, FAAN

Dr. Damron was appointed Cabinet Secretary of the New Mexico Higher Education Department by Governor Susana Martinez in 2014. Previously, she served as a professor and scientist at the University of New Mexico Cancer Center and directed its Office of Community Partnership & Cancer Health Disparities.

Patricia Grady, PhD, RN, FAAN

Dr. Grady has served as Director of NIH’s National Institute of Nursing Research (NINR) since 1995. An internationally recognized researcher focused on stroke, she oversees an annual NINR budget of approximately $150 million, which primarily funds the work of nurse scientists.

Policy as a Tool to Influence Nursing Professionalism and Nursing

TABLE 18-4  Nurses Influencing Policy

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(continued)

Bethany Hall-Long, PhD, RN, FAAN

In November 2016, Dr. Hall-Long was elected Lieutenant-Governor of the state of Delaware. She had previously served 14 years in the General Assembly, where she chaired the Senate Health and Social Services Committee. Dr. Hall-Long is also a professor at the University of Delaware School of Nursing.

Erin Murphy, MA, RN, FAAN

Formerly a surgical nurse, Ms. Murphy has represented District 64A in the Minnesota House of Representatives since 2006. Among her committee assignments are Health and Human Services Finance and Health and Human Services Reform.

Modified from American Academy of Nursing. (2017). Transforming health care policy and practice through nursing knowledge: Annual report 2016-2017. Retrieved from http://www.aannet.org

nurse meets with the hospitalized patient daily while he or she is admitted to coordinate service and evaluate medications; in addition, the nurse conducts an in-depth assessment of the patient’s and the family’s goals and initiates communication and collaboration with the patient’s care providers, including the primary care physician, to develop an appropriate evidence-based transition care plan. Upon discharge, the nurse and other members of the healthcare team work with the patient to implement the care plan, reassess the patient, and collaborate with the patient’s other caregivers. Within a day of being released from the hospital, the nurse visits the patient’s home. The TCM focuses on continuity, evidence-based practice, coordination across the board, and improved outcomes. This model has been shown to increase patient satisfaction and improve patient physical function and quality of life (Naylor et al., 2009). Another example of expert care coordination and meeting the needs of particular populations is that of Ruth Watson Lubic. Lubic founded two certified birth centers: the Maternity Center Association in New York City, and the Family Health and Childbirth Center in Washington, DC. These programs offer prenatal and labor and delivery care for women who have low-risk pregnancies. The care provided at these birth centers has demonstrated significant cost savings for childbearing women, reduced the cesarean rate in 2005 compared with the rest of New York City (15% versus 28%), and significantly lowered the

rates of premature and low-birth-weight babies, resulting in $1.2 million in cost savings. If this nurse-driven innovation were converted to a nationwide model, the potential savings could be almost $13 billion for Medicaid-funded deliveries. Finally, the federal government will fund the newest model of care on the healthcare landscape. President Obama pledged $8.6 billion over 20 years for the Nurse-Family Partnership. This partnership pairs a nurse with a low-income first-time mother. Over two decades, the program has shown significantly better pregnancy outcomes, reductions in high-risk and subsequent pregnancies, fewer injuries among children, reduced child abuse, and fewer language delays among children. The program has generated a $5.70 return for every dollar invested, and a net benefit to society of $17,000 to $34,000 per family served (Lee, Aos, & Miller, 2008).

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Policy as a Tool to Influence Nursing Professionalism and Nursing

Contemporary nursing practice requires that nurses be well prepared to engage healthcare consumers, their families, and others about

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nursing’s contributions to health care. Every patient care encounter is an opportunity for nurses to demonstrate their critical thinking, compassion, and professional expertise. These meetings allow the public to understand better “just how nurses save lives, alleviate suffering and even keep down healthcare cost” (Buresh & Gordon, 2006, p. 21). Nurses have a professional obligation to articulate how intellectually demanding and complex nursing care is and to demonstrate how they have developed and implemented innovative models of care that promote the goals of health reform: expanding access, improving quality and safety, and reducing costs. When nurses provide thoughtful insight and passion about nursing, the public gains an accurate image of nurses. It is only through compelling and complete descriptions of the work of nurses that others come to value and appreciate that work. Changing the status of nursing means making the profession more visible to the public and policymakers. It requires that nurses inform and educate politicians and leaders of healthcare delivery organizations about how patient-centered, safe, and efficient care contributes to slowing the rate of total healthcare expenditures. Nurse leaders must take responsibility to educate nurse clinicians so they can take advantage of changes in payment policies by making sure the contributions of nurses are visible. This requires using pay-for-performance measures and bundling hospital payments to patient-centered practices of its nursing staff. By linking hospital performance to nurse performance, nurses demonstrate increased understanding of the economic implications of their clinical and administrative practice. The time has come to fully recognize nursing’s social relevance as the nation addresses healthcare reform legislation. The economic, political, and social forces behind healthcare reform favor the interests and advancement of the nursing profession. This allows nurses to to design, implement, and advocate for healthcare policy that addresses issues of social justice and health equity and become strong influencers in policy formation.

Healthcare policy, whether it is created through governmental actions, institutional decision making, or organizational standards, creates a framework that can facilitate or impede the delivery of healthcare services. Thus, engagement in the process of policy development is central to creating a healthcare system that meets the needs of its constituents. Political activism and a commitment to policy development are central elements of professional nursing practice; therefore, the nursing profession and masters and doctoral graduates must assume a broad leadership role on behalf of the public and the profession (Ehrenreich, 2002). Health policy influences multiple care delivery issues, including health disparities, cultural sensitivity, ethics, the internationalization of healthcare concerns, access to care, quality of care, healthcare financing, and issues of equity and social justice in the delivery of health care. Nurses can become potent influencers in policy formation and have the capacity to analyze the policy process. As leaders in the practice arena they provide a critical interface between practice, research, and policy. Preparing nurses with the essential competencies to assume a leadership role in the development of health policy requires the ability to contrast the major contextual factors and policy triggers that influence health policy making at various levels. For example, nurses can take the following actions to participate in the policy process: ■■

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Critically analyze health policy proposals, health policies, and related issues from the perspective of consumers, the nursing profession, other health professions, and other stakeholders in policy and public forums. Demonstrate leadership in the development and implementation of institutional, local, state, federal, or international health policy. Influence policymakers through active participation on committees, boards, or task forces at the institutional, local, state, regional, national, or international levels to improve healthcare delivery and outcomes.

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Educate others, including policymakers at all levels, regarding nursing, health policy, and patient care outcomes. Advocate for the nursing profession within the policy and healthcare communities. Develop, evaluate, and provide leadership for a healthcare policy that shapes healthcare financing, regulation, and delivery. Advocate for social justice, equity, and ethical policies within all healthcare arenas.

The goal is to create a healthcare delivery system that ensures high-quality care at the exact time when the patient needs it. Nurses are creating model programs in acute care, primary care, and public health settings that are improving the health status of individuals while reducing costs (Hassmiller, 2009). These programs promote the goals that policymakers seek for health reform, including expanding access, improving quality and safety, and reducing costs (Robert Wood Johnson Foundation, 2009). They address problems related to both the supply and demand for nursing services that may be solved with educational, professional, and institutional remedies.

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Conclusion

Healthcare policy is created through governmental actions, institutional decision making, or organizational standards that establish a framework that facilitates or impedes the delivery of healthcare services. Engagement in the process of policy development is central to creating a healthcare system that meets the needs of its constituents. Nurses must have capacity to engage proactively in the development and implementation of health policy at all levels, including institutional, local, state, regional, federal, and international levels. This chapter is dedicated to preparing the next generation of nurse leaders and advocates to purposefully and effectively contribute to shaping public policy. Political activism and a commitment to policy development are fundamental elements of professional nursing practice. As the largest segment of the healthcare

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workforce, nurses need to be full partners with other health professionals to achieve significant improvements in both the delivery and health policy arenas. As professional partners, nurses have the knowledge and demonstrated expertise to provide innovative models of care delivery, as well as the financial, technical, and political savvy to close clinical and economic gaps within a healthcare delivery system (Nickitas, 2010). An increasingly complex healthcare system with rising societal demands requires a nursing workforce that must be flexible and able to adapt to changes in the environment. There are a variety of ways for nurses to engage in grassroots opportunities, professional development, and networking that can ensure they are well prepared to participate in healthcare and public policy reform and the policy-making process. Buerhaus, Potter, Staiger, and Auerbach (2008) suggested that nurses must intensify efforts to “increase the capacity of nursing education programs so that (a) the aging RNs who will retire from the workforce during 2015–2020 can be replaced, and (b) the total supply of RNs can be increased to meet the increasing demand for healthcare” (p. 249). This increased effort will mean a commitment to a better-prepared workforce where nursing education curricula place greater emphasis on evidence-based nursing practice and where quality, safety, geriatrics, chronic conditions, and nursing care extend beyond the acute hospital setting into nonacute care settings. With the adoption of information technologies, expanded use of care delivery models (including population health-focused nursing, care coordination, and transitional care), and a better-prepared nursing workforce, nurses have increased autonomy, productivity, and satisfaction and society benefits overall.

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Congressional Budget Office (CBO): reports and analyses of congressional budget and cost issues. http://www.cbo.gov/ Office of Management and Budget (OMB): information about the president’s budget proposals and management policies. http:// www.whitehouse.gov/omb/ The White House: information about executive branch initiatives and policies. http:// www.whitehouse.gov/ U.S. Government Accountability Office (GAO): studies and reports about how to ensure accountability of the federal government and improve its performance. http://www .gao.gov/ U.S. House of Representatives: information about members of the House of Representatives, House committees, and legislation. http://www.house.gov/ U.S. Senate: information about members of the Senate, Senate committees, and legislation. http://www.senate.gov/

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Agency for Healthcare Research and Quality (AHRQ): information about grants available for colleges of nursing. http://www.ahrq.gov/ Bureau of Health Professions: information about grants available from the Division of Nursing. http://bhpr.hrsa.gov/nursing/ Bureau of Labor Statistics: economic and labor statistics of the U.S. workforce. http:// www.bls.gov/home.htm Centers for Disease Control and Prevention (CDC): information about protecting the health and safety of people, and credible information to enhance health decisions. http://www.cdc.gov/ Centers for Medicare & Medicaid Services (CMS): information about the agency that administers Medicare and Medicaid. http:// cms.hhs.gov/ Federal Register: rules, proposed rules, and notices of federal agencies and organizations,

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as well as executive orders and other presidential documents. http://www.gpo.gov /fdsys/browse/collection.action?collection Code=FR Health Care 411: weekly audio and video programs featuring the latest research findings from the Agency for Healthcare Research and Quality. http://www.health -care411.ahrq.gov/ Indian Health Service (IHS): information about grants available for colleges of nursing, scholarships, and loan repayment programs for nursing students. http://www.ihs .gov/ National Institute of Nursing Research (NINR): information about extramural research programs, training opportunities, the advisory council, and The Outreach newsletter. http://www.nih.gov/about/almanac /organization/NINR.htm National Institutes of Health (NIH): information about grants available to colleges of nursing, links to various NIH institutions, and the latest health information. http:// www.nih.gov/ NIH Guide: The NIH Guide is available on the NIH’s Office of Extramural Research (OER) website. http://grants.nih.gov/grants /oer.htm U.S. Department of Education: information about projects sponsored by the U.S. Department of Education and student financial assistance. http://www.ed.gov/ U.S. Department of Health and Human Services (USDHHS): information about grants available for colleges of nursing and current USDHHS research. http://www.hhs.gov/ U.S. Department of Homeland Security: information about the mission and purpose of homeland security. http://www.dhs.gov/ U.S. Department of Labor: information about workforce issues and policies. http://www .dol.gov/ U.S. Department of Veterans Affairs: information about the veterans’ health system and services. http://www.va.gov/

References

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Access Healthcare Services: leading nurse staffing agency, servicing healthcare facilities in all 50 states. http://www.accesshealth -careservices.com American Council on Education (ACE): represents broad higher education policy concerns, regulatory issues, budget, appropriations, student aid, and testimony. http://www.acenet.edu/Pages/default.aspx Congressional Quarterly (CQ): information and insight about government and politics. http://www.cq.com Johnson and Johnson Campaign for the Future of Nursing: information about careers in nursing. http://www.discovernursing .com/ MEDLINE: This site, sponsored by the National Library of Medicine, is one of the most comprehensive bibliographic databases online. It contains bibliographic citations and author abstracts from the past 4 years from biomedical journals published in the United States and foreign countries. The database covers many fields, including nursing and the healthcare system. More than 33,000 records are added each month with material from special list journals, like the International Nursing Index. http://www.nlm .nih.gov/pubs/factsheets/medline.html National Academy of Medicine (NAM): information and advice concerning health and science policy. https://nam.edu/ National Library of Medicine (NLM): information about grants available to colleges of nursing, research activities, and NLM services. http://www.nlm.nih.gov/ Nursing Jobs: Offers permanent, per diem, or travel nursing jobs. http://www.nursing -jobs.us/ Robert Wood Johnson Foundation (RWJF): information about research grants to study healthcare issues. http://www.rwjf.org/en /about-rwjf.html

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Roll Call: news about Capitol Hill and politics in Washington. http://www.rollcall.com/ The Joint Commission: information about the safety and quality of care provided to the public due to healthcare accreditation. http://www.jointcommission.org/ The Washington Post: news about Washington, national politics, and policy. http:// www.washingtonpost.com/ U.S. Library of Congress: information about how to research at the Library of Congress. http://www.loc.gov/

Discussion Questions 1.

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Describe how nurses can use their knowledge, perspective, experiences, and skills as communicators to change public policy at all levels of government. What are the most critical questions facing nursing for which policymakers need evidence to inform their decision making? What is the role of government in advancing the impact of nursing on performance improvement and patient outcomes? Discuss how nurses can position themselves to lead change to improve health and health care and drive policy.

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Case Study

CASE STUDY

Lisa J. Sundean, Assistant Professor, University of Massachusetts Boston; former Director, Connecticut Nursing Collaborative-Action Coalition

Purpose Describe policy issues associated with building a nursing workforce data infrastructure.

Background Predictions about healthcare professional shortages continue to threaten the United States’ already fragile healthcare system. These predictions, combined with changing population demographics and steadily increasing complex healthcare needs, are evidence that the demand for licensed, qualified healthcare professionals is imperative. Ensuring the vital and necessary capacity of the healthcare workforce is predicated on accurate workforce data to inform and guide strategies for education and deployment of the right mix of professionals to meet population healthcare needs and to build a culture of health (Buerhaus, Skinner, Auerbach, & Staiger, 2017; Robert Wood Johnson Foundation [RWJF], 2017). The development and sustainability of a national healthcare workforce data infrastructure was identified in the Affordable Care Act with the naming of the National Healthcare Workforce Commission (NHWC); however, the NHWC was never funded, leaving this critical information channel closed (National Academies of Sciences, Engineering, and Medicine, 2016; Spetz, Cimiotti, & Brunell, 2016). The Institute of Medicine (recently renamed the National Academy of Medicine [NAM]) recommended the development of a nursing workforce data infrastructure in the 2010 report The Future of Nursing: Leading Change, Advancing Health. This recommendation was re-emphasized in the 2016 NAM follow-up report, Assessing Progress on the Institute of Medicine Report, The Future of Nursing. Nurses comprise the largest proportion

of the United States healthcare workforce with more than 4.3 million registered nurses and more than 1 million licensed practical/vocational nurses (Budden, Moulton, Harper, Brunell, & Smiley, 2016). Thus, understanding the mix and balance of nurses’ demographics, education, work habits, and specialty practice areas across the United States are critical to understanding how population healthcare needs can be met now and into the future. Nursing organizations and supporters recognize the high stakes for meeting population healthcare needs and coordinating efforts to collect, analyze, synthesize, and distribute nursing workforce data in meaningful and timely ways. These coordinated efforts align with the focus on building a culture of health (RWJF, 2017). Specifically, the aging of the United States’ population, exploding behavioral health needs across the age spectrum, access to primary health care, and population health needs of deep urban and remote rural areas require the attention of highly educated nurses. Similarly, external factors resulting from changing payer models, environmental exposures, population migration, lifestyle behaviors, and economic factors affect health and require astute professionals to meet the ensuing challenges. The social determinants of health also guide professional agendas and models of care to address healthcare challenges (Martsolf et al., 2016; RWJF, 2017). Meeting the healthcare needs of communities begins with understanding the trends and patterns of the nursing workforce. Despite national recommendations, the NHWC has not been activated, leaving the quest for a coordinated national nursing workforce data infrastructure to be led by interested nursing organizations across the country. Notably, the Future of Nursing: Campaign for Action, with Action Coalitions in every state throughout the nation and in partnership with Robert Wood Johnson Foundation and AARP, and the partnership between the National State Forum of Nursing Workforce Centers and the National Council of State Boards of Nursing have spearheaded efforts to advance the development of an infrastructure for nursing workforce data. Efforts from these partnerships have been complemented by a host of universities, grassroots organizations, nursing membership organizations,

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The Quest for a Nursing Workforce Data Infrastructure

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and individual researchers in various combinations to heed the call for an infrastructure inclusive of nursing workforce data collection, analysis, and distribution (AARP, RWJF, 2016). Building a nursing workforce data infrastructure and utilizing the data are a professional obligation with policy implications aimed toward adequately meeting the needs for healthcare access and quality outcomes (Spetz, Cimiotti, & Brunell, 2016).

Triumph and Tribulation Building this infrastructure relies less on developing data sources than on improving upon and coordinating the many sources and types of data, managing implementation strategies, and managing the assumptions of forecasting models. For example, Spetz (2015) provides a comparison of several sources of national nursing workforce data and forecasting models. Depending on data collection strategies and forecasting assumptions, workforce predictions can vary widely, providing only a modicum of practical value (Spetz, 2015; Spetz, Cimiotti, & Brunell, 2016). Auerbach, Buerhaus, and Staiger (2017) point to similar uncertainties, yet offer forecasts for nursing capacity in nine national regions. Findings point to variations in nursing capital throughout the United States, with New England being most vulnerable to nursing shortages. Predictive models rely on combinations of nursing workforce demographics, supply and education data, employer demand data, and population data. Sources and accuracy of these data across geographic areas and time periods vary with resulting inconsistencies in the confidence attributed to predictive models (Auerbach, Buerhaus, & Staiger, 2017; NAM, 2016; Spetz, 2015). However, progress is being made through grassroots efforts at the national level and within individual states to wrangle in disparate data processes. The National Forum of State Nursing Workforce Centers has partnered with the National Council of State Boards of Nursing to develop and implement a national minimum data set for nursing supply. Survey questions, however, are implemented inconsistently across states, leading to disparate data that cannot necessarily be compared. The National Nursing Workforce Survey is a sample survey implemented via the same partnership on a biannual basis. Major findings

from this survey are reported publicly and give a very focused view of the nursing workforce from national and state-specific perspectives. Limitations of sample surveys apply, however (Budden et al., 2016). Complete sample survey data sets are offered only to the 16 Forum member states who are afforded the opportunity to analyze state data with greater specificity. Education data are often collected at the state level through the state boards of nursing as a mechanism of regulatory oversight. Expanded nursing education data collection has been implemented in various states through various means. Many state Action Coalitions, as part of the Campaign for Action and funded through the Robert Wood Johnson Foundation, have focused on collecting nursing education data to follow nursing education progression toward and exceeding the baccalaureate degree. Aligning with the goal to increase the number of registered nurses with a baccalaureate degree or higher, states collecting and analyzing nursing education data demonstrate progress nationally on achieving this goal (AARP, RWJF, 2016). Employer-demand data for nurses are typically collected through labor sources either at the state or national level. This variable is most vulnerable to external forces and can change rapidly based on the economic climate. Caution, therefore, is important when basing nursing workforce predictions on employer demand. More recently, the Health Resources and Services Administration (HRSA) has developed a microsimulation model based on population health variables in defined geographic areas, which can be combined with nursing workforce supply data variables to predict nursing workforce needs. This model offers an innovative way to predict nursing needs based on population factors and is consistent with the contemporary focus on population health. However, the model is dependent upon the accuracy of populations data and nursing supply data to make accurate predictions (Spetz, 2015). The three nursing data foci—supply, education, and demand—have multiple sources, strengths, and limitations. While the recommendation for building a nursing workforce data infrastructure is based on solid rationale, the machinations of such a process are challenging. At state levels, the quest to build this infrastructure is often left to grassroots efforts.

Case Study

Building an Infrastructure for Connecticut Nursing Workforce Data

state to better understand the capacity of nursing programs, faculty capacity, and areas of concern. For example, concern has been raised over the age of nursing faculty and the threat of pending retirements, combined with low production of new nursing faculty. This discovery, based on the data, leads CT nursing education programs to strategize on ways to replenish the faculty pipeline to accommodate the increasing numbers of nursing student applicants and enrollees, and ultimately, to ensure the necessary volume of nurses needed to provide high-quality health care in the state. To address post-licensure education data, CNC-AC partnered with Quinnipiac University School of Nursing to procure state-aggregated data from the American Association of Colleges of Nursing (AACN). Pre-licensure education data define the pipeline of new nurses entering the CT nursing workforce and the disposition of existing CT nursing faculty. Post-licensure data define the preparation of nurses to fill the faculty pipeline, to engage in nursing research, to lead evidencebased practice research, and to provide access to primary care and care across the continuum at the nurse practitioner level. Post-licensure data also provide information about academic progression in RN-BSN and RN-MSN programs. The breakdown of data for graduating nurse practitioner specialty areas uncovers opportunities to meet specific population health needs across the state. Funding through the RWJF State Implementation Program grant was used by CNC-AC to support these data efforts in addition to in-kind services via university partners. The education data do not provide information about the migration of nursing graduates into or out of the state, or the education of nurses from proprietary online programs. Therefore, caution must be exercised when drawing conclusions about the education data analyses. The most striking information gleaned from the data are the threat of an aging nursing faculty and the low diversity of faculty and students by race/ethnicity. On a positive note, 90% of nurse practitioner graduates from CT programs are prepared to provide primary care, a strong contribution to the CT population. This information has been used in strategic conversations regarding Healthcare Provider Shortage Areas and Federally Qualified Health Centers, as well as strategic

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Connecticut (CT) holds two distinctions relative to nursing workforce data: the Connecticut Nursing Collaborative-Action Coalition (CNC-AC) has been twice funded by RWJF State Implementation Program grants to focus, in part, on data infrastructure development; and the Connecticut Center for Nursing Workforce, a program of the Connecticut League for Nursing, is a subscribing member of the National Forum of State Nursing Workforce Centers. These two distinctions have brought focus and funding to the imperative for building a statewide nursing workforce data infrastructure. The latter distinction is critical for gaining access to raw data from the National Nursing Workforce Sample Survey. The CNC-AC is a key collaborator for convening multiple partners to develop the necessary infrastructure. A work group of the CNC-AC convened to strategize the process, identify partners and data stewards, and to clarify vital data questions. Collection of detailed pre-licensure nursing education data began in Connecticut in 2013. This process was guided by collaborative work between the CT League for Nursing Deans and Directors Council and the State Board of Nurse Examiners (SBEN). The willingness of the SBEN to add an expanded data set to the regulatory survey for nursing education was a critical data milestone. The mandatory SBEN data survey, implemented via the CT Department of Public Health, created a fortuitous venue for capturing pre-licensure data for registered nurses and licensed practical nurse programs. Although the Deans and Directors Council also crafted a post-licensure survey, it was not implemented since the SBEN does not have regulatory oversight over these programs. Beginning in 2014, the CNC-AC began analyzing pre-licensure nursing education data inclusive of faculty and student data. Following the first year of education data analysis, the CNC-AC entered into partnership with the University of Connecticut School of Nursing to perform annual analysis of pre-licensure data. With grant funds from RWJF, the CNC-AC produces annual infographic and detailed reports based on nursing education program analyses. These reports have been used widely throughout the

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planning and resource allocation for nursing education programs in the state. The quest for nursing workforce supply data was boosted in 2014 when Governor Dannel Malloy mandated electronic relicensure for nurses. This mandate created an electronic portal for data collection and abstraction via the CT Department of Public Health. Such a portal could be utilized to implement a survey of all licensed registered nurses in CT. Prior to this, nursing workforce supply data were collected via hard copy format at the point of relicensure; however, these data were never accessed and never analyzed. In 2015, through key partnerships with the CT Department of Public Health, the CNC-AC, and the CT Center for Nursing Workforce, a program of the CT League for Nursing, the national minimum data set for nursing workforce supply was implemented electronically as a mandatory survey at the time of electronic nursing relicensure. This survey offered the hope of capturing the universe of licensed nursing supply data to define such variables as demographics, education, practice settings, hours of practice, salaries, and specialty certifications. The CT Department of Public Health implements the survey, but does not have the resources to perform analysis. The CNC-AC data work group identified the CT Department of Labor as a key partner to steward the data in collaboration with the CT Department of Public Health. This arrangement was made through a memorandum of understanding allowing transfer of data between the state agencies and analysis by the CT Department of Labor. The CNC-AC is responsible for distributing the data reports to interested stakeholders. These key partnerships, defined through formal processes, comprise the infrastructure for CT nursing workforce supply data. After 6 months of electronic data collection, and with high hopes for a seamless system of data capture, it was determined that data collection and abstraction had not been as efficient as expected. The analysis only yielded opportunities for improvement. Although nurses are mandated to relicense electronically in CT, and although they are mandated to enter the survey prior to relicensing, answers for only the most basic demographic questions were forced. This left the majority of survey questions unanswered, to the extent that the analysis was meaningless. Continuing efforts

are being made to rectify the issues but with little progress. The state of CT being in fiscal crisis, most state agencies are operating on unprecedented lean budgets with diminishing resources to allocate toward nursing workforce data. Fortunately, as a subscribing member of the National Forum of Nursing Workforce Centers, the CT Center for Nursing Workforce has access to raw data from the National Nursing Workforce Sample Survey, which is implemented biannually. With disappointing returns from the state relicensure survey, the CT Department of Labor agreed to analyze the sample survey data. Though the sample survey does not provide the universe of data originally hoped for, the data are useful for reporting with a high level of confidence. A robust analysis from the 2015 sample survey revealed several striking data points about the supply of CT nurses and consistent with the education data analysis. Notably, CT nurses are aging rapidly. The Executive Director of the CT League for Nursing, Marcia Proto, notes that retiring nurses are often replaced with more than one new nurse to account for the loss of experience, expertise, and knowledge. The economics of this threat are staggering, especially considering the number of new nurses that must be produced to replace experienced retiring nurses. Awareness created through the data analysis allows schools of nursing and practice sites to work collaboratively and innovatively to develop solutions. Employer-demand data for nursing has not been forthcoming in CT. The CT Department of Labor confirms the challenges of obtaining accurate employer-demand data. Given these challenges, the HRSA forecasting model for nursing is being considered as a viable alternative. Because the sample survey data can introduce errors in forecasting (Spetz, 2015), CNC-AC hopes to continue working with the CT Department of Public Health to improve upon the relicensure minimum data set survey for nursing workforce supply to improve the quality of data for entry into the HRSA forecasting model. In the absence of employer-demand data for nursing, the HRSA model, based on population health needs, is a promising model to inform requirements for healthcare provider capacity. Relying on multiple grassroots efforts, CT nursing education and national sample survey supply data syntheses have been running relatively

Case Study

Summary Grassroots efforts to report nursing workforce data over the past 3 years have informed and guided allocation of resources for nursing education and practice settings. Without ongoing commitment to advance the work of CNC-AC and the CT Center for Nursing Workforce, and to embed this infrastructure within the state, such efforts will be thwarted. More importantly, an aging CT population and complex health needs in rural and urban settings, cannot be guaranteed quality health care from the appropriate mix of licensed nurses.

Case Study Questions 1. How does the lack of state and federal policies regarding nursing workforce data coordination impact the goal to create a national culture of health? 2. What are the different perspectives and interests among government agencies, employers of nurses, and nursing entities (organizations, associations, university/ college programs) regarding nursing workforce data? How can these different perspectives and interests be coordinated and for what purpose(s)? 3. When thinking about the healthcare needs of populations, communities, and individuals, what are the policy implications of a well-coordinated nursing workforce data infrastructure? Nationally? At the state level? What are the population health risks of a poorly coordinated nursing workforce data infrastructure? 4. What are the advantages/disadvantages of nursing workforce forecasting models based on employer demand versus population need? 5. How can a sustainable nursing workforce data infrastructure inform solutions for health care in the United States? How can a sustainable nursing workforce data infrastructure contribute to building a culture of health in the U.S.?

References AARP, Robert Wood Johnson Foundation (RWJF). (2016). National nursing workforce data meeting: white paper. Future of Nursing: Campaign for Action. Retrieved from https://campaignforaction.org/resource/national -nursing-workforce-data-meeting-white-paper/ Auerbach, D. I., Buerhaus, P. I., & Staiger, D. O. (2017). How fast will the registered nurse workforce grow through 2030? Projections in nine regions of the country. Nursing Outlook, 65(1), 116–122. doi:http://dx.doi.org/10.1016/j .outlook.2016.07.004 Budden, J. S., Moulton, P., Harper, K. J., Brunell, M. L., & Smiley, R. (2016). The 2015 National Nursing Workforce Survey. Journal of Nursing Regulation, 7(1), S2–S90. Buerhaus, P., Skinner, L. E., Auerbach, D. I., & Staiger, D. O. (2017). Four challenges facing the nursing workforce in the United States. Journal of Nursing Regulation, 8(2), 40–46. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://iom

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smoothly for several years. However, there are many opportunities for improvements and the sustainability of this infrastructure is precarious. No progress has been made in rectifying the data collection and abstraction issues in the relicensing supply data survey. With the state of CT in fiscal crisis, the CT Department of Public Health cannot guarantee continued implementation of the education data survey. Although the partnerships among the CNC-AC, the CT Center for Nursing Workforce, the University of CT School of Nursing, the Quinnipiac University School of Nursing, and the CT Department of Labor remain solid, key data sources are not guaranteed in perpetuity. Beyond the mandate for electronic relicensure, the CT government has not demonstrated appreciation for or support in developing the necessary data infrastructure. The forecasts of Auerbach, Buerhaus, and Staiger (2017) point to deep nursing shortages in the northeast. Coupled with CT census data revealing an aging population, and rural and urban population health risks, the need for accurate and useful nursing workforce data is critical. Although efforts to coordinate and build a nursing workforce data infrastructure continue in earnest, its sustainability is fragile. Furthermore, RWJF funding for the CNC-AC to pursue this project is not renewable and no further funds have been identified. Without understanding the trends and patterns of the nursing workforce and education pipeline and the pipeline for nursing faculty, accurate strategic planning cannot be conducted. Even with key partnership development, the lack of fruitful data collection, funding, and state support place efforts to build a sustainable CT nursing workforce data infrastructure in jeopardy.

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.nationalacademies.org/Reports/2010/The-Future -of-Nursing-Leading-Change-Advancing-Health.aspx Martsolf, G. R., Gordon, T., Warren, M. L., Mason, D., Sullivan, C., and Villarruel, A. M. (2016). Innovative nursing care models and culture of health: Early evidence. Nursing Outlook, 64(4), 367–376. National Academies of Sciences, Engineering, and Medicine. (2016). Assessing progress on the Institute of Medicine report The Future of Nursing. Washington, DC: The National Academies Press.

Robert Wood Johnson Foundation. (2017). Building a culture of health. Retrieved from http://www.cultureofhealth.org/ Spetz, J. (2015). Economics of health care and nursing. Too many, too few or just right? Making sense of conflicting RN supply and demand forecasts. Nursing Economics, 33(3), 176–185. Spetz, J., Cimiotti, J. P., & Brunell, M. L. (2016). Improving collection and use of interprofessional health workforce data: Progress and peril. Nursing Outlook, 64(4), 377–384. doi:http://dx.doi.org/10.1016/j.outlook.2016.03.001

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Shirley Girouard (A former state legislator, city councilor, and lobbyist for advanced practice and a state nurses association shares her personal experience in advocacy work for organized nursing at the state level).

Purpose Entice students and nurses at all levels of education in efforts to positively influence health policy at the local and state level.

Making a Difference There are a variety of ways to improve the health and health care of individuals, communities, and populations. Sustained change requires policy change and “buy-in” at every level. For example, in politics, a policy is local whether it is private or public policy. The local environment where the policy is developed or responded to is where the “rubber meets the road.” This case study describes the engagement of one nurse at local and state levels and offers opportunities for all nurses to engage in improving health and health care through policy changes and responses. When we chose nursing as a career, we did so because we wanted to make a difference. In the beginning, most of us thought of this primarily as making a difference in patient outcomes, helping the families of our patients, and (sometimes) in our communities with health and wellness activities. Like most nurses, I gave little thought to public or private sector policy, despite the fact that my professional, educational, credentialing, and accrediting organizations have, for many years, emphasized the importance of professional nursing and the role of the nurse in society and health care. From the very beginning of the profession, Florence Nightingale attempted to influence public health and improve nursing science. As a pioneer, she developed survey instruments, always vetted by other experts and pretested on appropriate cases. She was also a pioneer in the graphical

presentation of data; in a time when research reports were only beginning to include tables, Nightingale was using bar and pie charts, which were color coded to highlight key points (e.g., high mortality rates under certain conditions). Her keen understanding of the policy process included not only to get the science right but also to make it comprehensible to lay people, especially the politicians and senior civil servants who made and administered the laws. These approaches are as relevant today as they were in Nightingale’s time as nurses seek to make a difference. Although I (usually) voted, I did not see myself as able to make much of a difference beyond the patient’s side. All this changed one day when I attended an American Nurses Association (ANA) workshop on policy and politics and had lunch with two of the speakers and a colleague who had been politically active in another state. My introduction to grassroots activism became a way to infuse health into local issues that were important to me. The lunchtime conversation was about concerns the nurses at the table had about patients and families—how to help them cope with complex, chronic health problems—and issues associated with limitations on advanced practice nursing in our state. I left the table with the group’s encouragement to run for a seat in the state legislature! I was a relative newcomer to the community where I lived, a candidate of my party had not been elected to the legislature in 8 years, and I had minimal (high school campaign and nursing school protest activities) experience in the political arena. With a nurse running my nurse-supported campaign (and an MD as my fiscal agent, so it was interprofessional), I won! This was a life-transforming experience—I was later a city councilor, and a part-time lobbyist for advanced practice nurses and the state nurses association, and I went on to pursue a doctorate in health and social policy. I experienced several important “aha” moments during the early days of my active involvement in policy and politics: ■■

I had a lot to offer given my nursing and healthcare knowledge, especially as seen through the patient and family experience. For example, who knows better than a nurse that a patient (and her family) with extensive burns will need physical, psychosocial, and

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Making a Difference Through Grassroots Activism

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Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices financial support at home? These “grassroots” perspectives were understood by most local or state policymakers. The public respects nurses and the voice of the nurse was persuasive, especially when grounded in evidence and research and illustrated by actual stories. My nursing skills of assessment, diagnosis, outcomes identification, implementation, and evaluation combined with an ethical perspective were quickly transferred to the political/policy process. Patient-centeredness could easily be “person-centeredness” and applied to members of the public, city counselors, or state bureaucrats. Interpersonal skills used effectively with patients/families were not so different from interpersonal skills needed to engage with those in the policy arena. If we could convince a patient to undergo a painful procedure, it was easy to convince a city counselor or state representative to vote positively on a healthcare issue. What happened to patients and families was influenced by local, state, and federal private and public policies and how communities and states responded to policies at other levels.

Advocacy, politics, and policy are now integrated and embedded in my personal and professional lives. Having been engaged in public and private sector activities at the local, county, state, and national levels in efforts to make health and health care better for all, there are meaningful (and fun) opportunities for every one of us to fulfill our social contract with society. It is also important to note that what happens with patients, families, and our communities are essential elements to bring about change. There is no magic—except for the magic of being a nurse—to becoming influential and making a difference. The first step to fulfill your professional obligation and assure that your motivation to make lives better for our patients is to appreciate the incredible knowledge, skills, and attitudes (KSAs) that you, as a nurse, have to offer. What you know about health and health care and the impact of all types of policy decisions on people is incredible and must be shared to influence the organization

and delivery of health and related services. As an adult acute care (medical-surgical) clinical nurse specialist I found I knew a lot about the impact of housing and the environment on health outcomes that was useful in my role as a city councilor and state representative. My self-confidence grew; I found it was easier to step up and speak out. Advocating for my patients was easy—as I gained confidence in other areas, I found my advocacy could reach beyond the patient’s side and extend to regional, state, and global influence. Offer your expertise. Know what you know and share your knowledge and skills with others. Be sure to identify yourself as a nurse when you attend a city or town meeting. Speak up when housing issues or health services budget allocations are being made, or policy changes are proposed at a school board or parent-teacher meetings. Share your expertise about how nursing services in schools can improve health and well-being of students and faculty. Consider writing an op-ed piece or letter to the editor of your local paper. All of these above-stated activities provide ways for nurses to share their expertise. Here is a more recent example. I presently serve on a task force for a state initiative to transform practice. I heard about this task force at a local meeting. After the meeting, I went to the state’s website and saw they were looking for people interested in serving as advocates. I stopped what I was doing and immediately sent a letter offering to help. Shortly after sending this letter, I was appointed by the lieutenant governor. Working with other patient advocates, insurers, and providers, we established standards to improve structures and processes to better coordination. Join with colleagues who care. Be a dues-paying member of your professional and specialty state organizations so your dollars can work to improve health and health care through their advocacy efforts Volunteer to write expert testimony and case studies related to your expertise. Serve on government affairs committees. Attend rallies, marches, and fundraisers for causes and people you believe in. During the past year, I have “marched for science’ with students and faculty carrying a college of nursing banner and signs that say nurses use evidence for better patient care. Also, I support several nursing and healthcare organizations and volunteer at events such as the New England legislators conference

Case Study

Provide evidence, including evidence that shows how nursing KSAs make a difference. Private and public policymakers need evidence and stories that illustrate how policy impacts patients’ lives and their health outcomes. Back your suggestions and criticisms with the “so what.” Show what nurses do that makes a difference and showcase our role as patient advocates. Your experiences locally can be extremely helpful for any and all organizations within your community. What nurses do at the point-of-care practice (think evidence-based practice) can make all the difference, for example, providing the evidence for school board decisions to promote healthfully eating and exercise. As trusted providers, operating from a scientific base, nurses’ voices will be heard. I am working with colleagues in service to reduce the number of missed appointments among colonoscopy and stroke patients. Recognizing the need to reduce missed appointments, and being armed with scientific evidence of best practices to change this phenomenon, made a real impact ensuring patients keep their assigned appointments. Also, I have engaged undergraduate and graduate students in the design and implementation of evidence-based practice and research projects related to this issue to increase our understanding (evidence) to change policies with the organization and in the insurance industry. Evaluate and hold policymakers accountable for policy decisions. Evaluation and accountability in healthcare organizations (and to improve health outcomes, which have been increasing in recent years) still need nursing input. Nurses are best equipped to examine the impact of various policy decisions where it matters—with patients, families, and communities. When speaking to policymakers in your organization, community, or state, tell them what impact a policy you propose (or oppose) will have on their constituents (your patients). When discussing possible changes in the Affordable Care Act, other advocates and I made sure the practice transformation group considered what would happen to those who lost insurance in our state and how we might maintain both coverage and positive outcomes. We share local concerns with our Washington representatives as well so they can advocate for our residents. As nurses, we should keep in mind implications for providers and organizations as policies change. For example, declining local revenues may result in the loss of

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(taking care of children there with their parents) making sure everyone—kids, legislative staff, and legislators—knew I was a nurse. Engage with your local elected officials. Contact your local elected official or their staff about your concerns; identify yourself as a nurse, provide stories and evidence about your position, offer to help them with related policy statements, give a few hours and a few dollars to the campaigns of those who support your positions (remembering it is likely there may be some issues on which you may not always agree). Attend political rallies and events carrying signs that you are a nurse. Several of my professional associations provide me with easy methods to contact my elected officials. During the past year, there have been many state and national policy issues of significance to health, health care, and the nursing profession. Thus, I have sent more than 30 letters— easy since they were written, I only need to customize! I routinely contribute (small amounts) to the campaigns of nurse candidates across the country as well as other local, state, and national candidates who support the issues important to me as a nurse. During election years, I always try to spend a few hours working for a candidate—a great way to get to know like-minded people and to relax by stuffing envelopes or sending emails after a hard day of patient care! Join boards and volunteer with agencies or organizations. It is surprisingly easy to get more engaged—contact local and state agencies and tell them you are a nurse and would like to work with them in any way you can. Investing a few hours a month can lead to critical networks and direct contributions to improving health and health care in your community and state. Given my interest in the care of older adults, I volunteered with a senior service organization and sat on their board. In addition, I gave classes on end-of-life planning to residents of a senior housing complex and served on their advisory board. All I did was mention I was interested and then used my nursing KSAs to provide programs and provide consultation on important healthcare issues. As discussed above, identify yourself and express interest in joining boards, etc. Be careful not to do too much—once your reputation for contributing becomes known, you may have more opportunities than you can use (you can always get colleagues to join in)!

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school-based clinics and school nurses. We need to be sure that if such changes occur, they are understood and evaluated. Policymakers and the public must be kept informed about the outcomes associated with policy change.

Summary If not you, who? In the words of Dr. Lisa Simpson (2017), President and CEO of Academy Health at the 2017 Annual Research Meeting, “. . .this is a VUCA world—volatile, uncertain, complex and ambiguous. . .” Organizations today are full of disruptive change. Sounds like a day in the life of a nurse! Just as we use our KSAs to deal with the volatility, uncertainty, complexity, and ambiguity facing our patients, families, and communities, we must use our knowledge, skills, and attitudes to guide and influence policy decisions in our healthcare organizations, community agencies, government agencies, and in the private sector as well. Nurse understand and appreciate that being a professional is a long-term commitment.

This commitment includes being an advocate who participates in grassroots activism to improve health and health care for all.

Case Study Questions 1. What is the relationship between private and public policy at the national, state, and local levels? 2. Where can nurses intervene to influence the direction of health policy at the state or local level? 3. What strategies and activities can influence health and health care at the state and local level? 4. How can every nurse get engaged? 5. If not nursing/you, then?

Reference Simpson, L. (2017, June 25). Plenary session introduction [Video file]. Academy Health 2017 Annual Research Meeting. Retrieved from http://www.academyhealth .org/events/site/2017-annual-research-meeting

Case Study

CASE STUDY Advocacy in Action Linda Bradley

Purpose The goal of this case study is to highlight the value of advance disaster planning. This case study will provide a success story of advance disaster planning from the perspective of a lived experience. Planning is relevant to nurses and other health professionals who have knowledge related to disaster planning but may not have taken the step to prepare personally or professionally.

Value-Based Advanced Disaster Planning Since the 1950s, our national disasters and emergency preparedness have transformed and become increasingly more complex, with more oversight by the federal government. The range of monitoring extends from fire and flood prevention and mitigation to addressing terrorism. The federal oversight for disaster preparedness is now directed by the U.S. Department of Health and Human Services (USDHHS) Office of the Assistant Secretary for Preparedness and Response (ASPR). This office “leads the country in preparing for, responding to, and recovering from the adverse health effects of emergencies and disasters.” In the 2017–2022 Health Care Preparedness and Response Capabilities report, the Secretary has set the agenda for alignment and coordination among agencies (ASPR, 2016). The Centers for Medicare & Medicaid Services (CMS), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Agency for Healthcare Quality (AHRQ), and Centers for Disease Control and Prevention (CDC), within each state and their local health departments, institute rules, regulations, and standards for organizations and citizen preparedness (Evans & Baumberger-Henry, 2011). One example is the CMS final rule for implementation of the national Emergency Preparedness Requirements for Medicare

and Medicaid Participating Providers and Suppliers. These regulations will impact healthcare facilities, organizations, their consumers, and employees. Those funded by Medicare and Medicaid must comply and implement all regulations 1 year after the effective date of November 15, 2017 (CMS, 2016). The work of a registered nurse, as many nurses can confess, permeates his or her entire life, even during days off. As healthcare professionals, our responsibilities and expectations are directed by regulations, but also by social expectations. These expectations include those from coworkers, professional organizations, family, and friends. Nurses are expected to be professionals on the job, ready, able, and willing to provide skilled nursing services within our scope of practice and, off the job, to provide our thoughts, opinions, and care. Nursing skills are multidimensional and transferable over many settings. Such skills are priceless during a crisis, whether in hospital units, the home of a client, or the classroom. Included in nursing scope of practice are teaching hydration and staying cool in the summer, keeping warm and dry in the winter, and being prepared for disasters (McMahon, 2014; New York State Department of Health, 2017). During disasters and other related events, the ability to assess, identify, plan, implement, and evaluate are valuable tools in a nurse’s toolkit (Bulson, 2011). The interconnections of nursing knowledge as related to advanced disaster planning, skills, and ability to provide care during a disaster add value to the multidisciplinary efforts of local, state, and national agencies. Value is defined as “a relative worth, utility, or importance,” and “something (such as a principle or quality) intrinsically valuable or desirable” (Merriam-Webster, 2017). The value of the knowledge related to how to prepare is only relevant if it is applied. More than evident was nursing involvement during and after Hurricane Sandy in 2012. Nurses went door to door to people’s homes and apartments, connecting those in need with services that included emotional support, food, and/or emergency care (Leland, 2012) Cathleen Evans and Mary Baumberger-Henry (2014) aptly stated that although nurses have the knowledge and readiness to respond in an emergency, there is a gap in how many nurses make their own disaster preparations. Nurses who

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have been personally affected during a disaster incident, family health issue, or other problem may be ill-equipped to respond appropriately and effectively themselves as a first responder to conditions that may be beyond their control.

Case Study Nurses who have experienced natural and human-made disasters worldwide may have also experienced and realized that some situations are beyond their control. During the aftermath of Hurricane Katrina, as I volunteered and provided care for others at one of the help centers in New York, I realized I needed to institute my own advanced disaster preparations. It is these times that make you pause to re-evaluate yourself, your abilities, and limitations. (Evans & BaumbergerHenry, 2014; La Sastry & Gregory, 2013). This was the case when Hurricane Sandy arrived.

October 26, 2012 A New York Times article described the need for awareness and the city’s preparations for the storm. Television and internet news reports showed a large area of clouds that was headed for the eastern seaboard of the United States. Sandy had the potential to be one of the most massive storms to affect the East Coast, including New York City (Schwartz, 2012).

October 28, 2012 I was in Florida preparing to return to New York City. I kept abreast of the pending storm and potential to cancel flights. My flight was still scheduled and left on time. Back in New York, all traffic in and out of the coastal areas was blocked. The hurricane was upgraded: It was imminent and making landfall. As a nurse I always planned, organized, and scheduled my professional and personal life. All my skills and planning could not prepare me for the days, months, and years ahead.

October 29, 2012–October 30, 2012 The community-based agencies, nursing homes, places of worship, schools, community centers, and more all did their part of preparing for this pending storm. They heeded Mayor Bloomberg’s warnings and moved with dispatch (Santora, 2012). Hurricane Sandy arrived with a vengeance. Due to the practice we had during Hurricane Irene, our family plan to meet in a central location worked.

Everyone arrived safely. Our mood at this time was somber. We had no idea of the devastation occurring outside. Sadly, many people did not take the Mayor’s warning seriously and remained in their homes through the storm. Many indicated the results of Hurricane Irene as the basis for their decision, thinking Sandy would be similarly uneventful.

October 31–November 5, 2012 The news provided reports of the damage to New York, New Jersey, and all other impacted areas. On November 5, I traveled to our home and I could not believe my eyes. The combination of the wind, water, and surge was incredible. The freezer, the refrigerator—these heavy appliances were flat on the ground. The television, electronics, beds, clothing, and other items were scattered about. You could smell the sea, and mud was everywhere. Boats were on the street, and the boardwalk was displaced yards away from the beach. Little did I know how long the recovery would be.

Post-Hurricane Sandy In consideration of Maslow’s hierarchy of needs (physiological, safety, love and belonging [social], esteem, and self-actualization), until these personal requirements were met I was not able to assist with any other individual’s problems or issues. The basic needs of food, shelter, and clothing became my priorities. Recovery takes time and patience! In retrospect, there were many plans instituted by the city, state, and federal authorities that went right, but plenty went wrong. These issues were well documented in the news through multiple types of media. Based on the postmortem from the impact on the individual families and communities, the idea of planning and preparation should continue and remain in the foreground of our personal and professional lives. It is this preparation that helped to preserve my relevant documents, but more importantly the lives of my family. I took the advice I often gave others and put them into action. I have a newfound respect and value of advance preparedness. I am sure that many who have lived through such events appreciated the efforts of those who could and did respond to and assist in their recovery. As a nurse, which includes all my off-duty roles, I consider the cost of things and look at the value of the lives saved when advanced disaster planning

Case Study is implemented. Property can be replaced and rebuilt, and damage remediated, but not lives. It is with this awareness we can continue to prepare ourselves, our families, and communities for the unexpected, putting knowledge into action. Lessons learned:

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The time spent in careful assessment of your possessions and family needs is valuable. Time spent with family, friends, and community planning and learning how to assist in a disaster is important. Stay connected to your local community organizations and officials. These connections are important for advocacy and advancing meaningful policy changes as gaps and needs are identified. Connect to the elderly and vulnerable near your home, and keep an up-to-date contact list and use it to make a call chain. Each person will call a set number of individuals, who then call those on their list. This will helpful when you need to contact your elderly neighbors and those with special needs. Prepare a go-kit and schedule periodic dates and times to check the contents. Scanned and electronic records will save you time, money, and heartache.

Case Study Questions 1. What possessions do you believe you would not want to part with? 2. When was the last time you considered your role as a first responder or first receiver? 3. How would you continue to maintain your professional responsibilities if you were impacted by a natural or human-made disaster? 4. Do you know where the community emergency response team (CERT) is in your community? 5. If you or a family member are considered a vulnerable population and not able to prepare and advocate for yourself then who are the people who will?

References Assistant Secretary for Preparedness and Response. (2016). 2017–2022 health care preparedness and response capabilities. U.S. Department of Health and Human Services Public Health Emergency website. Retrieved from https:// www.phe.gov/Preparedness/planning/hpp/reports /Documents/2017-2022-healthcare-pr-capablities.pdf Bulson, J. A. (2011). Nursing process and critical thinking linked to disaster preparedness. Emergency Nurses Association, 37(5), 477–483. doi:10.1016/j.jen.2010.07.011 Centers for Medicare & Medicaid Services (CMS). (2016, September 8). Emergency preparedness rule. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment -and-Certification/SurveyCertEmergPrep/Emergency -Prep-Rule.html Evans, C. A., & Baumberger-Henry, M. (2014). Readiness: How prepared are you? Journal of Emergency Nursing, 40(5), 448–452. Retrived from https://doi.org/10.1016/j.jen .2014.03.006 Federal Emergency Management Agency (FEMA). (2017). Community emergency response team. Retrieved from https://www.fema.gov/community-emergency-response -teams Haddow, G. D., Bullock, J. A., & Coppola, D. P. (2011). Introduction to emergency management (4th ed.). Burlington, MA: Elsevier. La Sastry, N., & Gregory, J. (2013). The effect of Hurricane Katrina on the prevalence of health impairments and disability among adults in New Orleans: Differences by age, race, and sex. Social Science & Medicine, 80, 121–129. Leland, J. (2012, November 1). Enduring the storm for homebound patients. The New York Times, A23. McMahon, M. M. (2014, September). Disaster/emergency preparedness resources. Journal of Emergency Nursing, 40(5), 446–447. doi: 10.1016/j.jen.2014.07.012 New York State Department of Health. (2017). New York State disaster preparedness. Retrieved from www.health .ny.gov/environmental/emergency/ Santora, M. (2012, October 27). Urgent warning as hurricane Sandy heads northeast. The New York Times, A22. Schwartz, J. (2012, October 25). Early worries that Hurricane Sandy could be a “perfect storm.” The New York Times. A24. U.S. Department of Homeland Security. (2017). Plan ahead for disasters. Retrieved from https://www.ready.gov/ Value. (2017). Merriam-Webster Online Dictonary. Retrieved from https://www.merriam-webster.com/dictionary/value

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Index Note: Page numbers followed by f or t refer to figures or tables, respectively.

A AALL. See American Association for Labor Legislation ACA. See Affordable Care Act academic medical centers geographic location, 346–347 physicians, 295 in urban areas, 256 accountable care organizations (ACOs), 219, 241, 265 and alignment of services, 303–304 CMS Innovation Center, 282t core functions, 283 evolution of, 281, 283 HMO concept, 280 Innovation Center, 282t in United States, 284t ACS. See American Cancer Society activities of daily living, 72, 259 acute care psychiatry, safety and, 128–133 ADH. See Arkansas Department of Health Adult Protective Service (APS), 84–86 advanced alternative payment models (AAPMs), 244, 319–320 advanced practice registered nurses (APRNs) career choice, 416–419 licensure, 420–421 as primary care coordinator, 220–221, 424 advocacy, and nursing breast cancer and, 16–19 Henry Street Settlement, 6–7 history and political, 9–11

politics, career in, 20–23 in Town & Country, 7–9 Affordable Care Act (ACA), 26, 207–208, 211t, 215–216, 231, 255, 271. See also health reform benefits of insurance, 148–149 breast cancer and, 17 congressional activity and, 153–155 consumer protections under, 217t healthcare costs and, 198–200 and healthcare quality, 177–178 healthcare services delivery, 292 health reform, 66 history of, 143–145 and hospital care rationalization, 303 insurance plan premium rates and, 156 litigation, 156–157 Medicaid and, 146, 265–266 and Medicare, 27, 239–241, 294 overview of, 145–149 PCMH model, 280 policy adoption, 36 prevention initiatives, 150 principles of, 145 private insurance industry, 218–219 private insurance rules, 147 provisions, 343 quality improvement and, 150 team-based care, 342 Trump administration and, 155–156 Agency for Healthcare Research and Quality (AHRQ), 72, 172–173 patient safety indicators, 173

AHA. See American Hospital Association AHCA. See American Health Care Act AHRQ. See Agency for Healthcare Research and Quality AIDS/HIV, 89–90 ALS. See amyotrophic lateral sclerosis alternative payment models (APM), 285 AMA. See American Medical Association American Association for Labor Legislation (AALL), 139–140 American Association for the History of Nursing (AAHN), 9 American Association of Critical-Care Nurses (AACN), 222 American Cancer Society (ACS), 16 American Health Care Act (AHCA), 153 American Hospital Association (AHA), 208 American Medical Association (AMA) policy-making process, 33 American Medical Informatics Association (AMIA), 373 American Nurses Association (ANA), 373, 375 advocacy network, 48 Nursing’s Social Policy Statement, 406 Social Policy Statement, 3 stakeholder power, 56 American Nurses Credentialing Center (ANCC), 373

449

450

Index

American Public Health Association (APHA), 16, 324 American Recovery and Reinvestment Act (ARRA), 173, 375 American Red Cross, 8 American Red Cross Town & Country, 6–9 AMIA. See American Medical Informatics Association amyotrophic lateral sclerosis (ALS), 234 ANA. See American Nurses Association ANCC. See American Nurses Credentialing Center Anderson, R., 171 APHA. See American Public Health Association APM. See alternative payment models APRNs. See advanced practice registered nurses (APRNs) APS. See Adult Protective Service Arkansas, newborn screening in, 57–59 Arkansas Department of Health (ADH), 57–58 Arkansas Genetics Health Advisory Committee, 57 Arkansas Nurses Association (ArNA) collaboration with medicine, 55 primary healthcare needs, 55 process for success, 55–56 strategic plan, 56 study bill, 55 Arkansas State Board of Nursing Update magazine, 58 ArNA. See Arkansas Nurses Association ARRA. See American Recovery and Reinvestment Act

B bachelor of science in nursing (BSN), 416 Baer, Ellen, 4 Balanced Budget Act, 234 Balanced Budget Refinement Act (BBRA), 235 BARDA. See Biomedical Advanced Research and Development Authority

Baumann, Steven L., 59–62 Benatar, S. R., 77 Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCCQIOs) Program, 243 Benefits Improvement and Protection Act (BIPA), 235 Berkowitz, B., 10 Beverly, Claudia J., 55–56 biology, vulnerability of, 76 Biomedical Advanced Research and Development Authority (BARDA), 89 Bipartisan approach, primary care and, 317–318 Bipartisan Budget Act, 237 birth control, 53–54 Bishop, T., 112 black nurses, 8 Blue Cross, 209, 210t Blue Cross Commission of AHA (1938), 209 Blue Shield, 209, 210t Bozeman, Faye, 58–59 BPCI. See bundled-payment care improvement Braden Scales, 182 Bradley, Linda, 445–447 brain death, 342 Branden, Pennie Sessler, 16–19 Braslow, J. T., 111 Breast and Cervical Cancer Prevention and Treatment Act of 2000, 259 breast cancer, 16–19 broad care, coordination, 285t bundled-payment care improvement (BPCI), 196, 282t, 285, 286t bundled payment model, 285 Buresh, B., 49 Bush, G. W., 373, 375

C capitation, and risk contracting, 303 care coordination, 220–222 AHRQ and, 285t physicians and, 350–351 care delivery system, nursing and, 415–416 Caress, Barbara, 310–311 Carter, Jimmy, 142 Casey, M., 152 causation, policy framework, 32

CBO. See Congressional Budget Office C3 Collaborating for Health, 101–103 CDHP. See consumer-driven health plan CDHS. See County Department of Health Services CDRs. See clinical data repositories Centers for Medicare & Medicaid Services (CMS), 193, 196–197, 376–377, 379, 384 preventable complications, 177–178 Reporting Hospital Quality Data for Annual Payment Update program, 177 CER. See comparative effectiveness research certification, nursing, 416–418 Chapman, Tom, 275–276 Chesler, Ellen, 52–54 children hospital for, 48 legislative initiatives, 6 Medicaid, 259, 260t children and youth with disabilities and special healthcare needs (CYSHCN), 271 Children’s Health Act of 2000 (Public Law 106-310), 107 Children’s Health Insurance Program (CHIP), 73 CHIP. See Children’s Health Insurance Program chronic disease, management of, 283 Clement, Fannie, 66 clinical data repositories (CDRs), 382 CMS. See Centers for Medicare & Medicaid Services CMS Innovation Center, 282t, 286t coalition building, 16–19 COBRA. See Consolidated Omnibus Budget Reconciliation Act Code of Ethics for Nurses with Interpretive Statements (2015), 10 COGME. See Council on Graduate Medical Education cognitive status, of older surgical patients, 250 case study Harris’ postoperative course, 251 routine preoperative assessment and care, 250–251

Index individual practice change recommendations, 252–253 postoperative cognitive decline, 249–250 South Shore University Hospital, 251–252 Combating Autism Act of 2006 (Public Law 109-416), 107 commercial insurance, NP and, 225–225 Committee on Global Health and the Future of the United States (CGH), 90–91 Commonwealth Fund scorecard, 257 communication HCAHPS survey, 176–177 nurse coordinators, 219 telephone/electronic, 283 communities construction of hospitals, 300–301 handguns and drugs in, 60 inner city, 347 natural disaster, 34 racial and ethnic minorities, 356 rural, 7, 301, 347 urban, 256 vulnerable, 68 Community Care Networks, 265 community hospitals, 294–295, 295t challenges competitive financial environment, 300–301 excess capacity, 298–299 vulnerable populations, 301 length of stay, 294, 298–299 nonprofit hospitals, 297 by ownership type, 297t source of payment, 297 comparative effectiveness research (CER), 173 Comprehensive Addiction and Recovery Act of 2016 (CARA), 116 Comstock, Anthony, 53 Comstock law, 53 condoms, 54 Congressional Budget Office (CBO), 116, 241 Consolidated Omnibus Budget Reconciliation Act (COBRA), 210t Consumer Assessment of Healthcare Providers and Systems (CAHPS), 276 consumer-driven health plan (CDHP), 208, 212

contraception, 53, 54 Cook, Wesley, 225–228 costs, healthcare. See healthcare costs Council on Graduate Medical Education (COGME), 347 County Department of Health Services (CDHS), 79 Culture of Health, 11

D Daniels, N., 315 D’Antonio, P., 5, 13 data security, HIT and, 383–391 administrative safeguards, levels of, 386t–388t physical safeguards, levels of, 389t privacy violations, 385–386 protective mechanisms, 386, 388–390 standards for protection of PHI, 390–391 technical safeguards, levels of, 389t Davis, Frances Elliot, 8 death, prevention of overdose, 363–370 decision-making process policy adoption, 36–37 politics of, 34 delirium, 249 delivery models, healthcare services and, 281–287 demonstration projects, 281 dental health, primary care and, 331–332 diagnosis-related groups (DRG), 234, 299 diagnostic error, 354 Directly Observed Therapy (DOT), 80 direct marketing, of pharmaceuticals, 28 discrimination gays and lesbians, 70 social factors, 75 disparity, vulnerability and, 72, 81 District Nursing Association of Northern Westchester (DNA), 66 Ellen Wood, 66–67, 69 and Henry Street Settlement, 68 Doan-Johnson, S., 168 Dock, Lavinia, 5, 66, 67

451

documentation, EHR and, 382–383 Don’t Ask, Don’t Tell Repeal Act of 2010 (Public Law No: 111-321), 114 donut hole, 239 Dorsen, C., 78 DOT. See Directly Observed Therapy DRG. See diagnosis-related groups dual federalism, 29 Dupree, E., 171

E Eckardt, Patricia, 363–370 economic policy, 27 Edge Runners models of care, 408t–412t EHB. See essential health benefits EHR. See electronic health records elder abuse, vulnerability and, 84–86 electronic health records (EHR), 371, 373–376, 378–383 electronic medical records (EMR), 371, 372, 380 Emergency Medical Treatment and Labor Act (EMTALA), 234 Employee Retirement Income Security Act (ERISA), 215 employer-based private healthcare insurance model, 207 employer-sponsored health insurance, 214–215 EMR. See electronic medical records end-stage renal disease (ESRD), 232, 234, 299 epilepsy, case study, 342–343 ERISA. See Employee Retirement Income Security Act error management, 169–170 in healthcare settings, 170–171 strategies for, 171 error theory, 168–169 ESRD. See end-stage renal disease essential health benefits (EHB), 217 Executive Order 13335, 373–374 expert power internal, newborn screening, 57–59 in organization, 48–51 external stakeholder power Margaret Sanger, 52–54 nurse legislation, 55–56

452

Index

F Faed, P., 70–71, 75 Fairman, J., 5, 13 Family Health and Childbirthing Center, 221 family planning, 53–54 FDA. See U.S. Food and Drug Administration Federal Government, mental and behavioral health, 107–109 Federal Hospital Insurance, 241 federal hospitals, 294 federalism, 29–30 policy-making process, 31–32 Federal Security Agency, 233 Federal Supplementary Medical Insurance Trust, 241 fee-for-service medicine, 352 Feeg, Veronica D., 20–23, 363–370 Ferguson, S., 10 Flaskerud, J., 71, 77 flexible spending account (FSA), 214 Flexner, Abraham, 329–331 foreign policy, 27 for-profit hospitals, 297 Fortin, M., 70, 72 fragmentation, 30 Friedman, E. H., 61 FSA. See flexible spending account Future of Nursing, The (IOM, 2010), 10, 413, 417, 421 Future of Nursing: Leading Change, Advancing Health, The (IOM, 2011), 49

G GDP. See gross domestic product genetics, vulnerability, 76 Gibson, Mary, 7 Girouard, Shirley, 441–444 global healthcare professionals CGH’s recommendations, 93t–97t politics of, in US, 89–98 priority areas, 91–92 Goodman-Bacon, Andrew, 264 Gordon, S., 49 government federalism, 29–30 framework for, 26–28 intervention, 30–31 markets vs., 28–29

Grabovschi, C., 70, 72 Great Depression, 27, 29 Griswold v. Connecticut, 53–54 gross domestic product (GDP) healthcare costs and, 194 expenditures, 35 Group Health Cooperative in Puget Sound, 209 group plans and insurers, 217–218 Gruhn, Valerie, 99 Guide to Patient and Family Engagement in Hospital Quality and Safety (AHRQ, 2013a), 173

H Hall-Long, Bethany, 20–23 Hancock, Christine, 101–103 HCA. See Hospital Corporation of America HCAHPS. See Hospital Consumer Assessment of Healthcare Providers and Systems HCERA. See Health Care and Education Reconciliation Act HDHP. See high-deductible health plan healthcare costs ACA and, 198–200 demand for health, 190–191 insurance, 191–192 market role, 189–190 problems, 193–198 resource allocation, 189–190 supply of health care, 191 understanding of, 188–189 U.S. market and, 188–189 error management in, 170–171 expenditures, 35 labor force, 38 policy, 306–307 private. See private health insurance market professionals behavior and dress, 50 communication failure, 50 expert power, 48–51 interdisciplinary approach, 44 Magnet designation, 50 political process role, 44 power pyramid, 45–46, 46f

stakeholder power, 46–48 toolkit/working model, 44 quality AHRQ, 172–173 documentation errors, 168 error management, 169–170 error settings, 167 error theory, 168–169 human error, 167–171 IHI, 171–172 lack of attentiveness, 168 moral agency, 168 nursing errors, 168 patient-centered care, 171–172 quality care and public policy, 166–167 Health Care and Education Reconciliation Act (HCERA), 216 healthcare disparity. See disparity, vulnerability and healthcare field, interest groups and, 32–33 Health Care Financing Administration (HCFA), 234 Healthcare Information Management and Systems Society (HIMSS), 373, 381, 390 healthcare services delivery models, 281–287 Health Effectiveness Data and Information Set (HEDIS), 276 health equity, and political advocacy, 77–79 Health Information Technology for Economic and Clinical Health Act (HITECH Act), 304, 317, 375–378 health information technology (HIT) data security and, 383–391 levels of administrative safeguards, 386t–388t levels of physical safeguards, 389t levels of technical safeguards, 389t privacy violations, 385–386 protective mechanisms, 386, 388–390 standards for protection of PHI, 390–391 development of, Federal origin and influence in, 373–378

Index health policy, intersection of data security and, 383–391 introduction, 372–373 national action plan on, 381–382 nursing, 378–380 data of nursing care, 380–381 and electronic health record, 382–383 terminology, 380–381 Office of the National Coordinator, 373–375 rules to control spending, 377 to enforce against breaches, 377–378 to enhance protections, 377–378 to improve quality, 377 to maintaining access, 377 to penalize violations, 377–378 Stimulus Bill and, 375–377 health insurance breast cancer and, 16 Clinton’s plan, 36 fragmentation, 30 governmental action, 27 impact on cost of, 218 laws and regulations of, 215–216 NP and, 225–228 payment reform, 352 reimbursement, 222, 225–228 Health Insurance for the Aged (Medicare) Act, 233 health insurance plan (HIP), 209–214 Health Insurance Portability and Accountability Act (HIPAA), 211t, 215–216, 234, 377 evolution of, 395–404 nurses and, 403–404 penalty of violations, HIT, 377–378 rules for security, 377–378 Health Maintenance Organization (HMO), 209, 210, 210t, 234, 280 Health Manpower Act of 1968, 406 health outcomes in United States, 257–258 health policy, 27 education about, nursing and, 441–444 in HIT, intersection of data security and, 383–391

levels of administrative safeguards, 386t–388t levels of physical safeguards, 389t levels of technical safeguards, 389t privacy violations, 385–386 protective mechanisms, 386, 388–390 standards for protection of PHI, 390–391 health reform, 306–307. See also Affordable Care Act ACA and, 143–145 financing and, 149–150 historical attempts and failures, 139–143 in United States, 138–145 health reimbursement arrangement (HRA), 213 health savings account (HSA), 213 Health Security Act (1993), 210t health services, vulnerability, 75–76 Health Services for Children (HSC) Health Care System, 272 under leadership of Tom Chapman, 275–276 Health Services for Children with Special Needs (HSCSN), 272–274 versus Medicaid FFS, 274t Healthy People 2020, 71, 75, 77 Henderson, Virginia, 406 Henry Street Settlement, 66, 68–69 high-deductible health plan (HDHP), 212–213 HIMSS. See Healthcare Information Management and Systems Society HIP. See health insurance plan HIPAA. See Health Insurance Portability and Accountability Act Hippocratic oath, 166–167 HITECH Act. See Health Information Technology for Economic and Clinical Health Act HMO. See Health Maintenance Organization Hopkins, Johns, 66–67 hospital care rationalization, ACA and, 303 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), 176–177

453

Hospital Corporation of America (HCA), 306 hospital nursing school programs, 405 hospitals baseline information, 294–298 beds per 1,000 populations, 299f Blue Cross, 300 as business, 293 centralizing care, 293 community, 294–295, 295t costs, 295–296 expenditures, federal share, 297 for-profit sector, 297 healthcare policy, health reform, 306–307 in historic context, 292–294 hospital-physician integration, 302–303 managed care, 294 market-based, 292 networks and systems, 301–302 noncommunity, 294 nonprofit, 297 number of beds, 294–295, 295t rating systems Best Hospitals rankings, 178 regulation-free approach, 292 role in delivery system, 292 rural areas, 301 source of payment, 297 House on Henry Street, The (Wald), 7 HRA. See health reimbursement arrangement HSA. See health savings account Hubert, H., 268 human error, healthcare quality, 167–171 humanity, case study, 99–101

I IHI. See Institute for Healthcare Improvement IMGs. See international medical graduates impaired providers, 354 incentive payment approaches, 202–205 indemnity insurance plans, 210 independent practice association, 284t individual plans and insurers, 217–218

454

Index

Infant mortality rate (IMR), 194–195 Innovation Center, 280–281 inpatient prospective payment system (IPPS), 234 Institute for Healthcare Improvement (IHI), 171–172, 415 Institute for Safe Medical Practices, 175 Institute of Medicine (IOM), 10, 74, 89–91, 374 defining medical error, 354 To Err is Human: Building a Safer Health System (Corrigan & Donaldson, 2000), 166 medical errors, 166–167, 176 insurance companies, policy-making process, 33, 35 healthcare costs and, 191–192 hidden action and, 193 hidden information and, 192–193 NP and, 225–228 integrated delivery system, 284t interest groups, policy-making process, 32–33 internal expertise power, newborn screening in Arkansas, 57–59 international medical graduates (IMGs), 343 demand, 343–344 IOM. See Institute of Medicine

J job embeddedness, 320t Johnson, Lyndon, 27, 54, 231, 233, 260 Joint Commission, The NPSGs, 175, 177 policy-making process, 33 SPEAK UP campaign, 175 workplace violence, 60

K Kaiser, Henry, 209 Kaiser Permanente, 306 Keeling, A., 7 Kindig, D., 324 Koppelman, J., 332 Kumar, S., 318

L Lebrun, L. A., 70 legislation, policy adoption, 36–37 Levy, Eileen, 59–62 Lewenson, S. B., 7, 66, 75, 78 LGBT-Q community, political protection in, 112–113 licensure nursing, 420–421 of physicians, 31 Lieber, James, 171 Loignon, C., 70, 72 long-term care federalism, 30 Medicaid, 259 long-term general hospitals, 294 Love, C. C., 59

M MACRA. See Medicare Access and CHIP Reauthorization Act Macy Foundation, 313 MAGI. See Modified Adjusted Gross Income Malaria, 89 Male Caregivers Advocacy Support group (MCAS), 272–273 mammogram, 16–19. See also breast cancer managed care (MC) plans, shift to Medicaid, 271–272 Managing Chronicity Across Care Settings, 330 Manchanda, R., 324 March of Dimes List of 29, 57–58 markets, 292 health insurance, 215 hospitals and, 292 vs. government, 28–29 Marmot, Sir Michael, 102 Massachusetts Health Insurance of Boston (1847), 208 Maternal and Child Health Services, 29 MCCA. See Medicare Catastrophic Coverage Act McCaran-Ferguson Act (1945), 215 MDR-TB. See multi-drug-resistant tuberculosis Mechanic, D., 71, 77, 78

Medicaid, 27–28, 148, 151–155, 256, 260–261 costs, variation by state and, 261–265 employer-based health insurance, 343 enrollment and distribution of payment by enrollment, 260t expansion of, 151–152 governmental intervention, 31 health outcomes in United States, 257–258 history of, 141 income eligibility for, 262t overview of, 255–256 policy adoption, 37 implementation, 37 populations served by, 259, 260t medical care, 71 national health spending, 241 medical errors causes, 354–356 defining, 354 frequency, 354 and malpractice, 356 and quality care, 356–357 root causes of, AHRQ, 170 medical home movement, 5 physicians, 350 medical professionalism, 342–343 medical supply industry, role of, 33 Medicare, 27–28, 149, 232 costs, 241–242 current structure, 236 Affordable Care Act and, 239–241 four components of, 236–239 employer-based health insurance, 343 evolution of passage, 233–236 future outlook, 243–247 governmental intervention, 31 history of, 141 hospital insurance revenue sources, 242 landscape, changed, 241 national health insurance, 233 overview of, 231 Part A, 31 payments, 294 policy adoption, 36 implementation, 36

Index preventable complications, 178 Prospective Payment System, 300 quality improvement organizations, 242–243 supplementary medical insurance revenue sources, 242 Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA), 236, 246 Medicare Access and CHIP Reauthorization Act (MACRA), 202–205, 377 Medicare Advantage plans, 241, 242 Medicare Advantage program, 242 Medicare Catastrophic Coverage Act (MCCA), 234 Medicare Prescription Drug, Improvement, and Modernization Act (MMA), 235 Medicare Shared Savings Program (MSSP), 304 medication errors aircraft accidents, 170 and aviation, 170 documentation errors, 168 error theory, 168–169 management, 170–171 measurement tools, 172 report, 166–167 reporting systems, 172 types of, 168 Medigap, 234, 244 Med-Surg Nursing, 330 mental and behavioral health challenges, 112 city services, 110–111 community-based services, 111 community-directed mental health care efforts, 110–111 defined, 106–107 Federal Government efforts to, 107–109 future of policy making, 116–118 introduction, 106–107 LGBT-Q community, political protection in, 112–113 policy innovations, 115–116 political protection, 112–113 presidential efforts to, 107–109 primary care and, 331 recovery movement, 111–112 socioeconomic disparities, 113–114

state-related policies, 109–110 veterans, policy issues and, 114 Mental Health Study Act of 1955 (Public Law 84-182), 107 Mental Retardation Facilities and Community Mental Health Centers Construction Act (Public Law 88-164), 107 merit-based incentive payment system (MIPS), 202–205, 244 Mertz, E., 332 MIPS. See merit-based incentive payment system Modern Nursing Movement, 4 Modified Adjusted Gross Income (MAGI), 260–261 Moore, Geraldine, 363–370 Morrison, E., 59 Morse Fall Scale, 182–183 Moylan, Lois B., 128–133 multi-drug-resistant tuberculosis (MDR-TB), 80 multispecialty group practice, 284t

N NAHQ. See National Association for Healthcare Quality NAMI. See National Alliance on Mental Illness narrow network, 256 Nash, D., 318 Nash, I. S., 171 National Academies of Sciences, Engineering, and Medicine (NAS), 89–92, 93t–97t National Alliance on Mental Illness (NAMI), 109, 129 National Association for Healthcare Quality (NAHQ), 175 National Committee for Quality Assurance (NCQA), 276, 280 National Database of Nursing Quality Indicators (NDNQI), 173–174, 182–183 national error reduction efforts code of silence, 174 national patient safety goals, 175 patient safety, 175 professional codes, 174 safety culture, 175

455

SPEAK UP campaign, 175 Sorry Works! coalition, 174–175 National Federation of Independent Business v. Sebelius, 150–152, 216 National Healthcare Disparities Report (2011), 72 National Healthcare Quality and Disparities Report, The (AHRQ), 72 national health insurance, 233 National Health Service Corps, 265, 347 National Institute for Occupational Safety and Health (NIOSH), 59–60 National Institute of Mental Health (NIMH), 107–109 National Institute of Nursing Research (NINR), 422 National Institutes of Health (NIH) trials, 221 National Patient Safety Goals (NPSGs), 175, 177 National Quality Forum, 170 natural disaster, policy framework, 34 NCDs. See noncommunicable diseases NDNQI. See National Database of Nursing Quality Indicators newborn screening in Arkansas, 57–59 New Deal, 28 new federalism, 30 Newly Eligible Transition (NET) Plan, 239 Nickitas, D. M., 10 Nightingale, F., 4, 326, 405 NIMH. See National Institute of Mental Health NIOSH. See National Institute for Occupational Safety and Health Nixon, Richard, 30, 141–142 Nixon, W. R., 170 NLC. See Nurse Licensure Compact noncommunicable diseases (NCDs), 101–103 noncommunity hospitals, 294 North American Free Trade Agreement, 27 North Shore-LIJ Health System, rebranding of, 310–311 Northwell Health System, New York, 307

456

Index

NPSGs. See National Patient Safety Goals Nurse Licensure Compact (NLC), 421 Nurse Practice Act (NPA), 420 nurse practitioner (NP) commercial insurance, 225–228 regulations of, 335–338 nurses advocates diversity and, 11–12 history, 4–5 history counts, 5–6 Margaret Sanger as, 52–54 medical home movement, 5 black, 8 breast cancer and, 16–19 coalitions and, 16–19 coordinators, 220t data security and, 403–404 employment opportunities, 220t health promotion, 329 humanity, 99–101 influencing policy, 424t–425t information specialists, 220t interests and, 33 navigators, 220t noncommunicable diseases and, 101–103 policy and, 407, 412–413 politics, career in, 20–23 primary care education, 329–331 skills, 321t–323t, 324–329 reimbursement and, 222, 225–228 stake for, 37–38 toxic emotional environments, 61 trade-offs, 38 Nurse Training Act, 406 nursing advocacy developing competencies, 13 Henry Street Settlement, 6–7 history and political, 9–11 in Town & Country, 7–9 APRN, 416–419 care, 11–12 certification, 416–418 data infrastructure, workforce, 435–439 definition, 405, 406 demand, 413, 422 educational remedies, 422–423 education programs, 4, 8

health policy, education about, 441–444 history on political advocacy, 66 HIT and, 378–380 data of nursing care, 380–381 and electronic health record, 382–383 terminology, 380–381 licensure, 420–421 opportunities for, 219 origins, 405–406 patient satisfaction, 419 policy as tool, 425–427 professional remedies, 423–425 professional status demand for RNs, 413 recognition, 408 registration, 5 regulation, 419–420 RNs, 416 shortage, 423 specialization and evolution, 419 strong, 11–12 training programs, 8 workforce, 413–415 World War I, 405 World War II, 406 Nursing History Review (AAHN), 9

O Obama, Barack, 34, 36–37, 89, 108–109, 113, 235, 375 Obamacare. See Affordable Care Act Office of the National Coordinator (ONC), 373–375 ONC. See Office of the National Coordinator opioid overdose prevention, 363–370 organizational power, focus and locus, 46f organizations, expert power, 48–51 original Medicare, 236

P patient care, delivery, ACOs and PCMHs, 280 patient-centered care, 171–172

patient-centered medical homes (PCMHs) CMS Innovation Center, 282t evolution of, 283–285 Innovation Center, 282t model, 280 Patient Protection and Affordable Care Act (PPACA), 116, 145–149. See also Affordable Care Act patient risk assessment tools, 182–183 patient safety indicators, 173–174 red flag alerts for, 179 patient satisfaction, 419 patient skin assessment tools, 182–183 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343, 122 Stat.5765), 112 payment reform to improve quality, 304–306 primary care and, 318–324 PCCT. See Protect Our Care CT PDAC. See Plan-Do-Act Cycle peer review organizations (PROs), 234 Peplau, Hildegard, 406 pharmaceutical industry, policymaking process, 33 Pharmaceutical Research and Manufacturers of America (PhRMA), 33 physician-hospital organization, 284t physicians accountability, 353–356 care coordination, 350–351 case study, epilepsy, 342–343 demand for medical services, 343 employer-based health insurance, 343 equipment owner, 352 financial arrangements, 352 geographic location, 346–347 government regulation, 353 group practices, 348–350 income, 347 international medical graduates, 343–344 loan forgiveness program, 347 medical errors. See medical errors medical home, 350 meeting health care needs, 343

Index minority physicians, 344 payment, 347–349 payment reform, 352 population ratios, 343 practice characteristics, specialization, 346–347 primary care demand, 346–347 public health activities, 349 quality care, 356–357 race, ethnicity, and gender, 344, 346 rural and inner city practices, 347 self-regulation, 353 supply and number of medical schools, 343, 344t in United States, 343 women’s participation, 346 workforce, 344 Plan-Do-Act Cycle (PDAC), 172 Planned Parenthood, 16 Planned Parenthood Federation, 54 point of service (POS) plan, 210 policy. See also specific categories adoption, 36–37 definition, 26–27 implementation, 36–37 policy innovations, 115–116 policy makers, 265 policy-making future of, 116–118 interest groups, 32–33 process, 31–32 political advocacy, 9–11 Ellen Wood, 66–69 health equity and, 77–79 Ponemon Institute, 384 POS plan. See point of service plan postoperative cognitive decline or dysfunction (POCD), 249–253 postoperative delirium (POD), 249–250 PPACA. See Patient Protection and Affordable Care Act PPO. See preferred provider organization PPS. See prospective payment system Practice Breakdown Research Advisory Panel, The, 168 preferred provider organization (PPO), 210 Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States (2017), 118

Presidential Memorandum for the Secretary of Defense and the Secretary of Homeland Security (2017), 114 President’s Commission on Mental Health, 107 Preston, Ann, 405 pretax savings plans, comparison of, 213t primary care Bipartisan approach and, 317–318 dental health and, 331–332 healthcare harm and, 315–317 importance of, 315 mental health and, 331 nurses education, 329–331 skills, 321t–323t, 324–329 overtreatment, 315–317 overuse, 315–317 payment reform and, 318–324 value-based care, 317–318 waste and, 315–317 private health insurance market ACA and, 218–219 employer-sponsored health insurance, 214–215 health insurance laws and regulations of, 215–216 plans, 209–214 health reform changes, private insurers, 216 nursing, opportunities for, 219 overview of, 207–208 private insurance industry, ACA, 218–219 private plans, 215 quality patient care and care coordination strategies, 220–222 U.S. health insurance reform, history of, 208–209 prospective payment system (PPS), 235 Protect Our Care CT (PCCT), 18 public health advocate, Margaret Sanger as, 52–54 defined, 324 vulnerability and, 74–75 public policy, 26–27 quality care and, 166–167 public quality reporting systems, 176–177

457

Q quality-based vs. quantity-based incentive payment approaches, 202–205 quality care medical errors and, 356–357 and public policy, 166–167 Quality Improvement Organizations (QIOs) Program, 242–243 quality patient care, 220–222 Quality Payment Program (QPP), 202–205, 244

R Rainbow Heights Club, 112 Rawls, J., 315 RBRVS. See resource-based relative value scale Reagan, Ronald, 30, 347 Reason, James, 168–169 recognition, nursing, 408 registered nurses (RNs) career choice, 416 demand for, 413 roles on 21st century, 421–422 top areas of employment, 414t work force, 11 regulations, 31 nursing, 419–420 Relative Value Scales, 352 reproductive rights, 53–54 resource-based relative value scale (RBRVS), 234 Rieckmann, T., 110 risk-bearing care delivery process, 319, 320t Rivera, G., 111 Rivers, R. M., 170 RNs. See registered nurses Robert Wood Johnson Foundation (RWJF), 11, 413 Roe v. Wade, 53 Rogers, A. C., 77 Roosevelt, Eleanor, 54 Roosevelt, Franklin D., 54, 140–141 Roosevelt, Theodore, 233 Rosenstock, Yael, 122–124 Rudner, Nancy, 335–338

458

Index

S Saloner, B., 315 SAMSHA. See Substance Abuse and Mental Health Services Administration Sanger, Margaret, 52–54 SCHIP. See State Children’s Health Insurance Program Selekman, Janice, 125–127 Shi, L., 70 Singleton, J., 78 6-sulfatoxymelatonin (6-SMT) fluctuating, 253 skilled nursing facility (SNF), 236 Small Business Health Options Program, 216 SNAP. See Supplemental Nutrition Assistance Program social factors, vulnerability, 75 social justice, and responsibility, 77–79 social policy, 27 Social Security Act, 27, 30, 84, 210t, 267 Title XVIII of, 233 Social Security Administration (SSA), 233 Social Security Disability Insurance (SSDI), 234 Social Security in 1965, 233 specific care coordination, 285t SSI. See Supplemental Security Income stakeholder power, 46–48 close/distant issue, 47 external Margaret Sanger, 52–54 nurse legislation, 55–56 police department, 47 simplified map, 47f Starr, Paul, 306 State Children’s Health Insurance Program (SCHIP), 211t, 261, 268 state health insurance marketplaces, 218 Stevens, G., 70 Stimulus Bill, 375–377 Stoddard, G., 324 Stone, Hannah, 53 Substance Abuse and Mental Health Services Administration (SAMSHA), 107–109 Sundean, Lisa J., 435–439

Supplemental Nutrition Assistance Program (SNAP), 76 Supplemental Security Income (SSI), 260 alternative managed Medicaid for, 271 health services for children with special needs, 272–274 HSC health care system, 275–276 shift to Medicaid managed care, 271–272 Sustainable Growth Rate (SGR) methodology, 236 Swain, D., 170 Swiss Cheese Model, 169

T Tanner, J., 71 taxation, 31 Tax Equity and Fiscal Responsibility Act of 1982, 234 TCM. See Transitional Care Model TCN. See transitional care nurse team-based care, 342 Teitelbaum, Joel B., 161–164 telehealth, 377–378 Temporary Assistance to Needy Families (TANF), 261 Thibault, George, 313 Ticket to Work and Work Incentives Improvements Act (TWWIIA), 235 Title XIX of the Social Security ActMedicaid (1965), 210t Title XVIII of the Social Security Act-Medicare (1965), 210t To Err is Human: Building a Safer Health System (Corrigan & Donaldson, 2000), 167 toolkit, case studies, 52 transgender, policy issues, 125–127 Transitional Care Model (TCM), 221 transitional care nurse (TCN), 221 transitions coach, 220t Triple Aim, 171–172, 415 Truglio-Londrigan, M., 78 Truman, Harry, 141, 233 Tsai, J., 70 tuberculosis, 79, 80, 87, 89, 94 type 2 diabetes, case study of, 319

U United States adult access and affordability of care in, 258t health outcomes in, 257–258 U.S. Department of Health and Human Services and Healthy People 2020, 12 U.S. Department of Health and Human Services Omnibus Rule, 377, 384, 391 U.S. Department of Health and Human Services report, 12 U.S. Department of Health and Human Services (USDHHS), 106, 242, 268, 381, 384, 386, 388 U.S. federalism system, 215 U.S. Food and Drug Administration (FDA), 89 medication errors and, 166 U.S. health insurance reform, history of, 208–209 U.S. News and World Report, 178 USDHHS. See U.S. Department of Health and Human Services USDHHS Omnibus Rule. See U.S. Department of Health and Human Services Omnibus Rule

V value-based advanced disaster planning, 445–447 veterans, 47 Veterans Health Administration (VHA), 31 virtual physician organization, 284t Vogel, Ralph, 57–59 vulnerability aging changes, 71–72 biology and genetics, 76 and disparity, 72–77 elder abuse, case study, 84–86 factors and precipitators leading, 72–77 genetics, 76 health services, 75–76 individual behavior, 76 policy making, 76–77 political advocacy, 77–79 population at risk, 79

Index poverty and, 70 public health framework, 74–75 public health nurse, case study, 79–80 social factors, 75 social justice and responsibility, 77–79 stroke, case study, 71 vulnerable, 68 people, health insurance and health of, 267–268 populations, 255–276

W Wald, Lillian, 6–8, 66, 81 warm handoff, 320t Weiner, Keith, 395–404 Werner, Helen, 182–183 WHO. See World Health Organization Wilensky, Sara E., 161–164 Wilson, James Q., 47 Winslow, B. W., 77

459

women equality, 53–54 healthcare reform, 67–68 rights, 53–54 Wood, Ellen, 66–69 Woods, A., 168 workplace violence, 59–62, 128–133 World Health Organization (WHO), 90–91, 107 World War II, health insurance and, 141