Health Care Reform

by Paul Govern

Illustration by Diana Duren

Health care reform aims to transform U.S. health care delivery into a more preventive, coordinated posture. While the law is still hotly contested throughout the country, most agree that whatever happens, it will usher in a new era of opportunity for nurses.

Under the provisions of the law, experts believe there will be more nurses practicing at the full scope of their license, the potential for pay equality with comparable providers, more nurse-managed community health services and more nurses involved in disease management.

A focus on outcomes
Based on a survey done early last year, the Centers for Disease Control estimated that 59 million Americans went without health insurance coverage for at least some part of 12 months preceding the survey. Access to coverage understandably dominated the public debate surrounding passage of the Patient Protection and Affordable Care Act, which became law in March 2010.


Major Access Provisions
According to a Congressional Budget Office estimate, under the provisions of the Accountable Care Act some 32 million more Americans will acquire health coverage by 2019. Read more »

Once the dust began to settle, cost and quality provisions in the law began to receive notice. According to Barbara Safriet, JD, a specialist in health law and policy, a visiting professor at Lewis and Clark Law School in Portland, Ore., and retired Associate Dean of Yale Law School, the Accountable Care Act has the potential to have far greater effects on health care delivery than the enactment in 1965 of Medicaid and Medicare.

“What we did [with enactment of Medicare and Medicaid] was say we’re going to have a major new payer but we’re going to bind its hands when it comes to looking at quality and cost issues. The true heart of the Accountable Care Act is a huge focus on quality — something not originally part of Medicare and Medicaid — and a focus on cost. It’s saying we are going to study in every way possible what works, what doesn’t work, we’re going to assess costs, and we’re going to meld those into decision-making and have system reform based on that.

“Well that, in this country, is pretty revolutionary,” Safriet said.

The new law adds support across the board for nurse education and training, especially around primary care, and it allocates $11 billion over five years in new funding for community health centers, including new funds expressly for nurse-managed health centers.

However, the real impact on nursing seems to rest less with these much needed workforce provisions than with the law’s broader implications. In a recent talk at Vanderbilt University School of Nursing, Paul Keckley, PhD, executive director of the Deloitte Center for Health Solutions in Washington, D.C., summed up the implications of the law as a shift from volume-based payment to outcomes-based payment, a shift from health system fragmentation to health system integration, and the bridging of the gap between public health and the commercially insured delivery system.

A work in progress
The Accountable Care Act weighs in at 2,409 pages.

“There are some hanging chads here, some stuff that could blow up and go in opposite directions. … Every law goes through a process of fixing and amending and replacing,” Keckley said in his recent presentation at the School. Experts interviewed for this article say health reform will remain a work in progress for years to come.

In this first round, lawmakers did not order HHS (the Department of Health and Human Services) to pay physicians and nurses equally for primary care and specialty services (with one exception: physicians and nurse-midwives are now paid equally by CMS). They also did not cancel CMS payment rules that preclude nurses from independently certifying federal beneficiaries for long-term care or home health services.

Left to right: Paul Keckley, Bonnie Pilon and Marilyn Dubree. Photos by Daniel Dubois, Dean Dixon and Susan Urmy.

Bonnie Pilon, DSN, RN, senior associate dean for clinical and community partnerships at VUSN, takes these omissions in stride.

“Remember the environment in which this thing got passed. I was holding my breath that anything would get out of Congress at all,” Pilon said.

“Although there are many provisions in the bill that are favorable to nursing, there continue to be some physician organizations that do not agree with an expanded scope of practice for APNs. But there are other groups with some pretty big audiences — the American Association of Retired Persons, the Institute of Medicine — that have different ideas about nurse roles,” Pilon said.

Safriet observed that, at least where Medicare and Medicaid are concerned, lawmakers and regulators appear in a mood to lift impediments for nurses.

“They raised reimbursement for nurse-midwives from 65 percent to 100 percent of physician reimbursement. You can read into that. For me what it says is that we should be moving toward equal payment,” Safriet said.

Scope of practice
Marilyn Dubree, MSN, RN, executive chief nursing officer at Vanderbilt University Medical Center, sees in the law a more open field for nurses.

“The bill will ask every provider – physicians, certified nurse specialists, nurse practitioners, respiratory therapists – to practice at the top of his or her license so that every team that comes into play on behalf of a group of patients can work at the top of its functionality. Regardless of details that may be missing in the law, that’s clearly going to emerge as an important aspect of this reform,” she said.

Dubree also thinks reform is apt to spur new review of state scope of practice provisions.

“As patients go from state to state and as more technologies like telemedicine are placed against the management of patient care, the need for standardization of practice across states is really great. That will ask the states to look at their nurse scope of practice laws really carefully. That’s going to be a big deal.”

New approaches to old problems
Larger providers apparently aren’t sitting on their hands while the details of health reform get worked out.

David Posch, CEO of The Vanderbilt Clinic and executive director of Vanderbilt Medical Group, said Vanderbilt University Medical Center is undergoing “repositioning in light of health reform.” Under its value-based care initiative, VUMC is already testing new disease management solutions, new health promotion measures and new coordination of acute and outpatient services.

“(Health care reform) very well could be a bonanza for integrated health care delivery. And nurses are going to be heavily engaged in making that happen,” he said.


Major Cost and Quality Provisions
This modified “Hippocratic Oath” was composed in 1893 by Lystra E. Gretter and a Committee for the Farrand Training School for Nurses, Detroit. It was called the Florence Nightingale Pledge as a token of esteem for the founder of modern nursing. Read more »

My Health Team at Vanderbilt is a new disease management program, involving robust surveillance, telemedicine, standardized protocols and curbside consults. Nurses serve as care coordinators, tracking, educating and coaching patients, with special attention to eliminating any barriers to physiologic control. They’re starting with hypertension, diabetes and congestive heart failure.

Another group at Vanderbilt is developing a post-discharge “outpatient ICU” for patients newly diagnosed with acute coronary syndrome. Using standardized medication management and health coaching, the program aims for optimum coordination of inpatient and outpatient episodes of care.

“This potentially significantly changes how nurses will focus their time. … Nurses will have to understand more about health coaching,” said Robin Steaban, MSN, RN, administrative director of Cardiovascular Services, who leads the project with Paul Sternberg, MD, assistant vice chancellor for Adult Health Affairs. Once testing is complete Vanderbilt will look to expand the program to other acute patient problems.

Vanderbilt’s employee health plan is piloting intensive lifestyle training for employees with diabetes. Dexter Shurney, MD, MBA, MPH, is medical director of the health plan.

“If providers like Vanderbilt become accountable care organizations and take responsibility for costs across the spectrum, they’re going to have to manage the risk factors for a population better than they have been.

“I think it’s a huge opportunity for nurses,” Shurney said.

Keckley wrapped up his recent talk with a prediction about the Accountable Care Act.

“In 2012 we’re going to see somebody say, from the left, ‘This bill doesn’t really solve problems, let’s just go ahead and talk about a single payer system.’
“And from the right you’re going to have at least three candidates who’ll say, ‘If I’m elected, we’ll repeal this law.’

“And neither will happen,” Keckley said.