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To complete this assignment, you will need to access to the following databases: CINAHL, MEDLINE, Cochrane Library, and the Joanna Briggs Institute. I

know you can do this work, so don’t go short cut and mess it up. Research each heading and complete.

See the article I attached. Find more articles to complete to complete this work.

As a writer, you should first write a good introduction for each topic briefly say the story you about to tell, the subjects you going to talk about.

You then tall this story by each subject.

You summarize all the story for conclusion

Don’t do lazy work no beginning , no end. Don’t be repetitive to fill the page

Don’t copy old work

Don’t give me somebody’s work. I will know.

Grammer has got to improve. I end up deleting all work in the process of editing. Most time work below college level. I mean it. And sometimes it can be accepted at masters level.

1: Distinguish selected factors affecting U.S. healthcare delivery systems and organizations

Introduction: Find good article

2: Examine factors affecting healthcare finance and payment systems

Introduction

3: Evaluate selected healthcare policy models and frameworks

Intrduction: Find good article

Suptopics

4: Formulate strategies for coalition building and health advocacy

Intrduction: Find good article

5: Synthesize selected policy analyses affecting advanced practice nursing

Intrduction: Find good article

Inclusion of all story work

Examples

Increased health insurance coverage

Payer pressures to reduce costs

• Medicare physician services payments are based on fee schedule (Resource Based Relative Value Scale, or RBRVS).

Change from “reasonable cost” to prospective payment system based on diagnosis related groups for hospital inpatient services begins under Medicare

Interview conducted and issues highlighted. Find issues in the policy or issues you can associate to the yellow highlighted in box

High staffing turnover

Diabetics patients are noncompliant with medication is more predominant

The facility denies any safety concerns

There is high staff turnover

No diabetics education protocol or policy in

place for the old and newly diagnosed diabetics

Facility denies and sentinel event

Yes

The relationship is good. Staff are not expected to take short cuts

Management is open for suggestions or improvements

Examples:

Staff members are not mistreated

Electronic health Record is not in use, No plans for one. Still using paper medical records

No further issues

Diabetic education for noncompliant diabetics patients

Very good role model

The nurse leader will be good preceptor

Transformational leadership

yes

Category

Points

Description

Introduction

Introduces the interview, purpose of the interview, and provides rationale for engaged interview process.

To determine existing practice problem within the organization

Description of Policy Issue

Please discuss the organizational assessment and how you decided upon this particular policy. Also include any subtopics regarding selected healthcare policy issue. Use examples from the interview that support your assertions and relevant examples from your practice situation.

Presentation of Policy Analysis

Include eight subtopics regarding selected healthcare policy analysis pathway. Summarize your subtopics using examples from the interview that support your assertions as well as relevant examples from your practice situation.

Conclusion

An effective conclusion identifies the main ideas and major conclusions from the body of your report. Minor details are left out. Summarize the benefits of the selected policy analysis to nursing practice.

Clarity of writing

Use of standard English grammar and sentence structure. No spelling errors or typographical errors. Organized around the required components using appropriate headers.

APA format

All information taken from another source, even if summarized, must be appropriately cited in the report (including citation of interview) and listed in the references using APA (6th ed.) format:

1. Document setup

2. Title and reference pages

3. Citations in the text and references.

Total:

250

100%

A quality report will meet or exceed all of the above requirements.

There are more than 9000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.”

Clayton M. Christensen

Health care financing in the United States is fragmented, complex, and the most costly in the world. The Affordable Care Act (ACA) of 2010 takes some steps to reshape how health care is paid for, but its primary purpose is to extend insurance coverage to approximately 30 million uninsured Americans through private insurance regulation, expansion of pubic insurance programs, and creation of health insurance marketplaces to foster competition in the private health insurance market. As the ACA is implemented, making health insurance more affordable and containing the rise in health care costs are significant ongoing policy challenges in system transformation. This chapter will provide an overview of the current system of health care financing in the United States, including the impact of the ACA.

Historical Perspectives on Health Care Financing

Understanding today’s complex and often confusing approaches to financing health care requires an examination of the nation’s values and historical context. Some dominant values underpin the U.S. political and economic systems. The United States has a long history of individualism, an emphasis on freedom to choose alternatives and an aversion to large-scale government intervention into the private realm. Compared with other developed nations with capitalist economies, social programs have been the exception rather than the rule and have been adopted primarily during times of great need or social and political upheaval. Examples of these exceptions include the passage of the Social Security Act of 1935 and the passage of Medicare and Medicaid in 1965.

Because health care in the United States had its origins in the private sector market, not government, and because of the growing political power of physicians, hospitals, and insurance companies, the degree to which government should be involved in health care remains controversial. Other developed capitalist countries, such as Canada, the United Kingdom, France, Germany, and Switzerland, view health care as a social good that should be available to all. In contrast, the United States has viewed health care as a market-based commodity, readily available to those who can pay for it but not available universally to all people. With its capitalist orientation and politically powerful financial stakeholders, the United States has been resistant to significant health care reform, especially as it relates to expanding access to affordable health insurance.

The debate over the role of government in social programs intensified in the decades after the Great Depression. Although the Social Security Act of 1935 brought sweeping social welfare legislation, providing for Social Security payments, workman’s compensation, welfare assistance for the poor, and certain public health, maternal, and child health services, it did not provide for health care insurance coverage for all Americans. Also, during the decade following the Great Depression, nonprofit Blue Cross and Blue Shield (BC/BS) emerged as a private 173insurance plan to cover hospital and physician care. The idea that people should pay for their medical care before they actually got sick, through insurance, ensured some level of security for both providers and consumers of medical services. The creation of insurance plans effectively defused a strong political movement toward legislating a broader, compulsory government-run health insurance plan at the time (Starr, 1982). After a failed attempt by President Truman in the late 1940s to provide Americans with a national health plan, no progress occurred on this issue until the 1960s, when Medicare and Medicaid were enacted.

BC/BS dominated the health insurance industry until the 1950s, when for-profit commercial insurance companies entered the market and were able to compete with BC/BS by holding down costs through their practice of excluding sick (with preexisting conditions) people from insurance coverage. Over time, the distinction between BC/BS and commercial insurance companies became increasingly blurred as BC/BS began to offer competitive for-profit plans (Kovner, Knickman, & Weisfeld, 2011. In the 1960s, the United States enjoyed relative prosperity, along with a burgeoning social conscience, and an appetite for change that led to a heightened concern for the poor and older adults and the impact of catastrophic illness. In response, Medicaid and Medicare, two separate but related programs, were created in 1965 by amendments to the Social Security Act. Medicare is a federal government-administered health insurance program for the disabled and those over 65 years (Kaiser Family Foundation [KFF], 2014c), and Medicaid, until recently, has been a state and federal government-administered health insurance program for low-income people, who are in certain categories, such as pregnant women with children.

Government Programs

Current Public/Federal Funding for Health Care in the United States

In the United States, no single public entity oversees or controls the entire health care system, making the payment for and delivery of health care complex, inefficient, and expensive. Instead, the system is composed of many public and private programs that form interrelated parts at the federal, state, and local levels. The public funding systems, which include Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), the U.S. Department of Veterans Affairs (VA), and the Defense Health Program (TRICARE) for military personnel, their families, military retirees, and some others, continue to represent a larger and larger proportion of health care spending. Other examples of federal programs are the Indian Health Service, which covers American Indians and Alaskan Natives, and the Federal Employees Health Benefits (FEHB) Program, which covers all federal employees unless excluded by law or regulation.

Federal health expenditures for these programs totaled $731.6 billion or 26% of all health care expenditures in 2012 (Martin et al., 2014). Medicare outlays were $572.5 billion in 2012 and accounted for 20% of all national health care expenditures with Medicare Advantage (a Medicare-managed care program provided by insurance plans that can be chosen by beneficiaries instead of the traditional Medicare program) growing most rapidly (Martin et al., 2014). Medicaid outlays in 2012 were $412.2 billion and accounted for 15% of total national health care expenditures, and its spending growth also decelerated that year (Martin et al., 2014).

Medicare

Before the enactment of Medicare in 1965, older adults were more likely to be uninsured and more likely to be impoverished by excessive health care costs. Half of older Americans had no health insurance; but by 2000, 96% of seniors had health care coverage through Medicare (Federal Interagency Forum on Age-Related Statistics, 2000).

Medicare had a beneficial effect on the health of older adults by facilitating access to care and medical technology, and, in 2006, prescription drug coverage helped improve the economic status of older adults. The percentage of persons over age 65 years living below the poverty line decreased from 35% in 1959 (when older adults had the highest poverty rate of the population) to 9% in 2012 (U.S. Census Bureau, 2014).

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Americans are eligible for Medicare Part A at age 65 years, the age for Social Security eligibility, or sooner, if they are determined to be disabled. Medicare Part A accounted for 31% of benefit spending in 2012 and covers 52 million Americans. Medicare Part A covers hospital and related costs and is financed through payroll deduction to the Hospital Insurance Trust Fund at the payroll tax rate of 2.9% of earnings paid by employers and employees (1.45% each) (KFF, 2014a). Medicare Part B, which accounted for approximately one third of benefit spending in 2012, covers 80% of the fees for physician services, outpatient medical services and supplies, home care, durable medical equipment, laboratory services, physical and occupational therapy, and outpatient mental health services. Part B is financed through subscriber premiums and general revenue funding as well as cost-sharing with beneficiaries.

Medicare Part C, or the Medicare Advantage Program, through which beneficiaries can enroll in a private health plan and also receive some extra services such as vision or hearing services, accounted for 23% of benefit spending in 2012 and had more than 14.1 million enrollees, or 28% of all Medicare beneficiaries in 2013 (Medpac, 2013). Medicare Advantage enrollment has been increasing and is up 30% since 2010 (KFF, 2014a). Extra payments that the federal government has made to private Medicare Advantage Plans are due to be phased out by the ACA, raising concerns that insurers will drop their Medicare Advantage Plans as a result.

Medicare Part D is a voluntary, subsidized outpatient prescription drug plan with additional subsidies for low- and modest-income individuals. It accounted for 10% of benefit spending in 2012 and enrolled 39 million beneficiaries in 2013 (KFF, 2014a, 2014b). Figure 18-1 presents Medicare benefit payments by type of service in 2012 (KFF, 2014a). Medicare Part D is financed through general revenues and beneficiary premiums as well as state payments for recipients who get both Medicare and Medicaid, also known as “dual eligibles” (KFF, 2014b). The ACA phases out the Medicare Part D “donut hole,” a period of noncoverage for prescription drugs that left many seniors unable to pay out-of-pocket for their medications.

FIGURE 18-1 Medicare benefit payments by type of service, 2012. (From Kaiser Family Foundation. [2014]. Retrieved from kff.org/medicare/fact-sheet/medicare-spending-and-financing-fact-sheet/.)

The ACA authorized that certified nurse midwives (CNMs) be reimbursed at 100% of the physician payment rate. Other advanced practice registered nurses (APRNs), including nurse practitioners (NPs), are paid 85% of the physician rate 175for the same services. In addition, Medicare will not pay for home care or hospice services unless they are ordered by a physician. And, unfortunately, the ACA required physician orders for durable medical equipment for Medicare beneficiaries.

Medicaid

Medicaid is the public insurance program jointly funded by state and federal governments but administered by individual states under guidelines of the federal government. Medicaid is a means-tested program because eligibility is determined by financial status. Before changes by the ACA, only low-income people within certain categories, such as recipients of Supplemental Social Security Income (SSI), families receiving Temporary Assistance to Needy Families (TANF), and children and pregnant women whose family income is at or below 133% of the poverty level were eligible. To qualify for federal Medicaid matching grants, a state must provide a minimum set of benefits, including hospitalization, physician care, laboratory services, radiology studies, prenatal care, and preventive services; nursing home and home health care; and medically necessary transportation. Medicaid programs are also required to pay the Medicare premiums, deductibles, and copayments for certain low-income persons who are eligible for both programs. Medicaid is increasingly becoming a long-term care financing program of last resort for older adults in nursing homes. Many older adults have to spend down their life savings to become low income and be eligible for Medicaid. Family and pediatric NPs and CNMs are also required to be reimbursed under federal Medicaid rules if, in accordance with state regulations, they are legally authorized to provide Medicaid-covered services.

In keeping with its goal to expand health insurance coverage to more Americans, the ACA expands eligibility for the Medicaid program to any legal resident under the age of 65 years with an income up to 138% of the federal poverty level. The intent of the health reform law was to have one eligibility standard across all states and eliminate eligibility by specific categories (Commonwealth Fund, 2011; Rosenbaum, 2011). The federal government has agreed to pay for nearly all the expansion costs to insure more low-income people. The U.S. Supreme Court, however, struck down the mandate to expand Medicaid and ruled that states could decide whether or not to expand the program. Figure 18-2 indicates that as of April 2014, 27 states had decided to expand Medicaid, 5 are still debating this, and 19 are not moving forward (KFF, 2014d). States that decide to opt out of the expansion can follow old federal guidelines for eligibility, leaving wide disparities in health insurance coverage between states and leaving uninsured large proportions of the population below 138% of the poverty level. Of the states that have opted out of expansion, all have Republican political leaders explicit in their opposition to the ACA, although Republican Governor Jan Brewer of Arizona pushed her state to expand Medicaid in 2013 so that 300,000 more poor and disabled residents of the state would have coverage (Schwartz, 2013). In many of the nonparticipating states, physicians, nurses, hospitals, and other health care organizations and stakeholders are pressuring their state governments to expand Medicaid as a way to improve access to health care for more low-income people.

FIGURE 18-2 State Medicaid expansion, November 2014. (From FamiliesUSA. [2014]. Retrieved fromfamiliesusa.org/product/50-state-look-medicaid-expansion; and Kaiser Family Foundation. [2014]. Retrieved fromkff.org/medicaid/fact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/.)

CHIP was created in 1997 to help cover uninsured children whose families were not eligible for Medicaid. It has been funded through state and federal funds, but states set their own eligibility standards. The ACA commits the federal government to paying most of its costs, beginning in 2015, up to 100%. It also requires states to maintain their eligibility standards for CHIP (Emanuel, 2014). CHIP will be reauthorized in 2015, and, because it is expected that many more children will have gained coverage through family health insurance plans, debate is expected over the role of the program. CHIP is enrolling a record number of children now estimated to be one third of all children in the United States. Advocates want to maintain these high child health insurance rates until the ACA is fully implemented and full coverage for children under the provisions of the ACA is assured.

State Health Care Financing

State governments not only administer and partially fund some public insurance programs such as Medicaid and CHIP but they are also responsible for individual state public health programs. 176The definition of public health as compared with other types of health programs is not always well understood. The mission of public health as defined by the Institute of Medicine (IOM) is to ensure conditions in which people can be healthy (IOM, 1988). Whereas medicine focuses on the individual patient, public health focuses on whole populations. Medical care for the individual patient is associated with payment by health insurance, but population-based public health programs are funded by local, county, state revenues, often combined with grants from the federal government in areas such as maternal and child health, obesity prevention, HIV/AIDS, substance abuse, and environmental health. Even with a greater federal role in health care through the ACA, states will continue to have a major responsibility for the regulation of health insurance, health care providers and professionals, and public health activities.

Reduction of budgets for public health programs during times of fiscal constraint has resulted in the resurgence of infectious diseases such as tuberculosis and sexually transmitted diseases in some communities. A series of natural disasters such as tornados also brought to light gaps in the public health system, especially the ability to respond, for example, to mass casualty events. Although the ACA authorized $15 billion for the creation of a Prevention and Public Health Fund to invest in public health and disease prevention, Congress reduced by one third the amount of funding mandated by the law in 2012 and President Obama signed the legislation to pay for other initiatives (Health Policy Brief, 2012).

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Local/County Level

Similar to state governments, local and county governments in many states also have the responsibility of protecting public health. Some provide indigent care by funding and running public hospitals and clinics, such as New York City’s Health and Hospitals Corporation and Chicago’s Cook County Hospital. Although receiving a subsidy from their local government, these hospitals, which have served primarily poor patients and those without health insurance, have gotten significant special payments, especially from Medicare to serve these populations. These disproportionate share hospital (DSH) payments are being gradually reduced under the ACA because it is presumed that eventually, under the ACA, many more people will gain health insurance coverage. Because public hospitals and clinics are so dependent on public funds, their budgets are historically squeezed during times of fiscal restraint by local, state, and federal governments, making them vulnerable to long-term sustainability. In fact, many public health hospitals have closed, and in many parts of the country, the populations they have served have been absorbed by other types of hospital providers (KFF, 2013).

The Private Health Insurance and Delivery Systems

The U.S. health care system has been predominantly a private one that operates more like a business and, more or less, according to free market principles. Private health insurance has been the dominant payer and, for most Americans, it is obtained as a benefit of employment in the form of group health insurance. However, until the passage of the ACA employers have had no obligation to provide employee health insurance, leaving many Americans uninsured or underinsured, especially those working in lower-wage jobs. As private health insurance premiums have risen, employers asked employees to pay for a greater percentage of their insurance premium, and to enroll in plans that required more cost-sharing in the form of copayment, deductibles, and coinsurance. Approximately 15% of insured Americans have purchased their health insurance from the nongroup individual insurance market. Typically, these plans were more expensive and insurers in all but a few states had been able to deny insurance to applicants with preexisting medical conditions, until the practice of discrimination based on medical history was outlawed by the ACA in 2010. Because private insurers are regulated by individual states, there are wide disparities in coverage from state to state, as private insurers are powerful political stakeholders who resist attempts at state or federal regulations to make insurance more accessible and affordable. Whereas private health insurance will continue to be a cornerstone of the U.S. health care financing system, public insurers such as Medicare and Medicaid are paying for an increasing percentage of health care costs.

It should be noted that health insurance is regulated by the states. Some states now mandate that NPs be considered primary care providers and eligible for credentialing and payment by private insurers. But there is wide variation in the extent to which APRNs are included in insurers’ provider panels. This variation can be seen among states, among insurers within a given state, and among the plans offered by an insurer (Brassard, 2014).

Most care in the United States is provided by nonprofit or for-profit hospitals and health care systems and private insurance plans (Truffer et al., 2010). Pharmaceutical companies, suppliers of health care technology, and the various service industries that support the health care system in the United States are part of what has been called the medical industrial complex (Meyers, 1970), and there is little government regulation of these industries. Although the private delivery system is dependent on payment from private insurers as well as government insurers, it has usually been resistant to government-directed efforts to expand access to care or cost-containment measures. Well-financed special interest groups representing industry stakeholders have had a great deal of influence over the political process at both the state and federal levels. For example, the medical device industry is lobbying Congress hard to repeal or reduce the medical device tax that the ACA levied to help pay 178for the expansion of insurance coverage under the health care law and has gained significant support in Congress (Kramer & Kasselheim, 2013).

The Problem of Continually Rising Health Care Costs

From the 1970s to the present, continually rising insurance premiums and health care delivery costs have strained government budgets, become a costly expense to businesses that offer health insurance to their employees, and put health care increasingly out of reach for individuals and families. Figure 18-3 depicts the annual percentage change in national health expenditures by selected sources of funds, 1960 to 2012 (KFF, 2014e).

FIGURE 18-3 Annual percentage change in national health expenditures, by selected sources of funds, 1960 to 2012. (From Kaiser Family Foundation. [2014]. Retrieved fromkaiserfamilyfoundation.files.wordpress.com/2014/02/annual-percent-change-in-national-health-expenditures-by-selected-sources-of-funds-1960-2012-healthcosts.png.)

Stakeholders in small and large businesses, government, organized labor, health care providers, and consumer groups have convened over the years to tackle the problem of rising health care costs, with little lasting success. Although a range of strategies was employed to curb rising health care costs over those 40 years, health care expenditures as a percentage of the gross domestic product (GDP) increased steadily over that time. Although multiple factors are responsible for rising health care costs as a percentage of GDP, the key one is that, unlike other capitalist democracies, the federal and state governments have little, if any, role in regulating what can be charged for health care services and supplies. Prices are largely negotiated between health insurances and providers, resulting in wide variances in prices for similar or exact services, largely based on the market clout of providers to negotiate higher prices. Other contributing factors to high health care costs include the complex administrative systems of insurers and providers, the use of expensive medical technology and medical specialists, and 179the incentive in fee-for-service reimbursement for providers to increase their volume of services and provide unnecessary health care. Consumers have also lacked knowledge of the actual cost of their care, leading to an inability of the market to accurately respond to cost and differential health care prices by region, type of hospital, or health care facility.

Future costs will also be impacted by the aging of the population and increasing number of people with complex chronic illness who use a disproportionately high percentage of the health care dollars. For example, from 1977 to 2007, a very stable 5% of the population who had complex chronic illness accounted for nearly 50% of the health care expenditures (KFF, 2010; Stanton, 2006), despite efforts to control costs among this population. In 2009, the costliest 5% of beneficiaries accounted for 39% of all Medicare fee-for-service spending. The least costly 50% of beneficiaries accounted for 5% of all spending (Medpac, 2013). The majority of those in the high-expenditure group are not older adults but rather those with complex chronic illnesses (Stanton, 2006).

All other industrialized countries spend significantly less on health care but have better health outcomes and a longer life expectancy. For example, the United States ranks among the worst of industrialized nations on important health indicators such as infant mortality, maternal mortality, and life expectancy at birth (Squires, 2014). Yet, in 2012, it ranked first in health care costs per capita at approximately $8915 per person (Organization for Economic Co-operation and Development [OECD], 2013b). This amounted to close to 18% of its GDP, compared with The Netherlands, which ranked second at 12% of its GDP (OECD, 2013a).

Cost-Containment Efforts

Over time, several approaches have been used to contain costs, including the following.

Regulation Versus Competition.

During the 1970s, modest government regulation attempted to contain health care costs through state rate-setting agencies and health planning mechanisms, such as Certificate of Need (CON) programs and regional Health Systems Agencies (HSAs), which evaluated and approved applications for the construction of new facilities, beds, and new technology. During the 1980s and early 1990s, when proponents of competition and free market health care became politically more influential, rate setting and CON programs were weakened and HSAs were eliminated. While free-market principles, as they apply to health care, have few similarities to a fully competitive market in economic terms, the rise of managed care programs and competition among health insurance plans in the 1980s may have temporarily slowed the growth of health costs before they began to rise again. As health insurers expanded the use of copayments, deductibles, and coinsurance as economic incentives to discourage care, the onus of cost-containment fell more heavily on the consumer/patient. However, ample research shows that low-income people may avoid necessary care because of copayments and deductibles. Chapter 17 more fully describes the mechanisms underlying the market system in health care.

Managed Care.

The origins of today’s managed care plans were in early prepaid health plans of the 1920s, which evolved into Health Maintenance Organizations (HMOs) in the 1970s, and into a variety of models in the subsequent 30 years, including Preferred Provider Organizations (PPOs). A managed care system shifts health care delivery and payment from open-ended access to providers, paid for through fee-for-service reimbursement, toward one in which the provider is a gatekeeper or manager of the patient’s health care and assumes some degree of financial responsibility for the care that is given through a capitated budget in which to pay for the patient’s care. Managed care implies not only that spending will be controlled but also that other aspects of care will be managed, such as quality and accessibility. In managed care, the primary care provider has traditionally been the gatekeeper, deciding what specialty services are appropriate and where these services can be obtained at the lowest cost. In the 1990s, negative media attention concerning the incentives to restrict care in the managed care model fueled a political backlash. Consumer and provider demands for 180greater choice for services and access to providers caused managed care plans to loosen gatekeeper requirements and provide more direct access to specialists. As a result, managed care became less effective in holding down expenditures and fueled a rise in health insurance premiums.

In addition, concerns of consumers and providers challenging the quality of care provided by some Managed Care Organizations (MCOs) resulted in state and federal laws to further regulate managed care plans (Kongstvedt, 2001). These laws included provisions related to grievance procedures, confidentiality of health information, requirements for informing patients of the benefits they will receive, antidiscrimination clauses, and assurances that various quality mechanisms were in place so that patient satisfaction was measured and efforts to control costs did not curtail needed care. In addition, most states adopted policies giving health plan enrollees a right to appeal plan determinations involving a denial of coverage to an independent medical review entity, which is often a private organization approved by the state (American Association of Health Plans, 2001). Efforts to pass into law the federal Patient’s Bill of Rights, which contained many consumer protections related to managed care, were not successful.

Medicaid and Medicare also promoted managed care plans to control their expenditures for health care by using capitated payment and managing patient care. All 50 states offer some type of Medicaid-managed care plans, and states can decide if participation is voluntary or mandatory. Some states have created state-run Medicaid-only plans, but others enroll Medicaid recipients in private MCOs. By 2010, 70% of the Medicaid population received some or all of their services through Medicaid-managed plans (Kaiser Health News, 2010).

Financing Mechanisms

Fee-for-Service Reimbursement.

Until the 1980s, Medicare and private health insurers paid providers through fee-for-service (FFS) reimbursement. In FFS, providers charge a fee for each service, and then providers or patients submit claims to insurers for payment. There is a strong incentive under the FFS payment for providers to increase the volume of services and raise prices to increase their revenue. In addition, through the reimbursement mechanisms of their patients who are on Medicare, the federal government has paid hospitals according to the percentage of Medicare recipients, which has been inherently inflationary. Both health care organizations (such as hospitals) and individual providers (such as physicians) were historically paid through FFS reimbursement. By contrast, nursing services in hospitals continue to be grouped into an aggregate hospital fee or as part of the room fee, rendering nursing care to be in effect a cost center rather than a revenue generator. This mechanism makes it difficult to measure quality of nursing care in hospital situations.

Physician/Clinician Reimbursement Under Fee-for-Service.

Payment for physician services is approximately 20% of total national health expenditures (Emanuel, 2014), a significant cost-driver in health care. FFS is still the predominant way of reimbursing for physician and clinician services. Public and private health insurers pay physicians through a complicated formula related to medical coding and medical billing to determine the final payment (Emanuel, 2014).

The American Medical Association (AMA) created Current Procedural Terminology (CPT), a coding system for visits to physicians and other providers. There are codes for evaluation and management, office visits, emergency room visits, prevention services, anesthesia, radiology, pathology, laboratory codes, and medicine codes, such as for dialysis (Emanuel, 2014). These codes are then linked to a specific diagnosis as outlined in the International Classification of Diseases IDC-9 (soon to be IDC-10) and then assigned payment levels.

Prospective Payment Systems.

In the 1980s, the federal government replaced the old FFS system for Medicare Part A with a prospective payment system (PPS) for hospital care, establishing payment based on diagnosis-related groups (DRGs). DRGs set a payment level for each of the approximately 500 diagnostic groups typically used in inpatient care. The prospective payment approach helped to 181slow the rate of growth of payment for hospital care, shortening average length of stay, and increasing patient acuity in hospitals (Heffler et al., 2001).

In the past, insurers paid whatever physicians billed. But in 1992, under Medicare Part B physician payment reform, payment was linked to a Resource-Based Relative Value Scale (RBRVS). In this physician reimbursement system under Medicare, the relative value unit (RVU) for each service is based on the degree of physician work (time, skill, training, intensity), practice expertise (nonphysician labor and practice expenses), and the cost of malpractice for the specialty, as well as the geographic cost of living (Emmanuel, 2014). Its goal was not only cost savings but also to redistribute physician services to increase primary care services and decrease the use of highly specialized physicians. However, the RVU system has been criticized for still favoring specialist care and hospital-based care. The Centers for Medicare and Medicaid Services (CMS) adopts over 80% of the recommendations of the AMA’s recommendations for RVUs for each service. This mechanism has been criticized as a conflict of interest, especially as specialists and surgeons comprise a significant proportion of the AMA committee making the recommendations (Emanuel, 2014). In addition, the same procedure done in a hospital is reimbursed at a higher rate than if done in a physician’s office. Hence, the incentive is to do more procedures in hospital-owned facilities. The Medicare RVUs per service ratings have been adopted by private insurers, but they use different conversion factors, enabling them to pay more for each service.

Since 1997, the Medicare program has also attempted to contain costs by limiting how much physician payments can increase through the Sustainable Growth Rate (SGR), a target based on physician costs, Medicare enrollment, and the GDP (Emanuel, 2014). There is no incentive in the SGR for individual physicians to contain costs because the SGR is calculated for physician services for the entire country. The intent of the original law was to reduce Medicare payments to physicians if the SGR was exceeded. However, Congress regularly passes a so-called “doc-fix” bill to prevent SGR cuts from going into effect, enabling higher Medicare payment rates for physicians, APRNs, and other providers (Lowrey, 2014). The SGR continues to be a controversial issue, and Congress has been unable to address the problem, except on an episodic basis.

Bundled Payments/Global Payments.

An estimated 85% of payment to providers is still through an FFS payment system, creating an inherent incentive to increase volume and costs (Emanuel, 2014). More recently, policymakers are promoting bundled and global payments as a way to not only contain costs but to also provide an incentive for providers to better coordinate and manage patient care.

Under payment bundling, hospitals, doctors, and providers are paid a flat rate for an episode of care, rather than by individual service. Bundled payment is a form of prospective payment that is being tested by Medicare, private insurers, and provider systems, such as Accountable Care Organizations (ACOs). Global payment is a form of capitation in which the insurer is usually paid per member per month. Proponents of both argue that these payment models differ from traditional capitation in that payment is risk-adjusted and providers can share in savings if care is coordinated and managed and patients are kept healthy. Massachusetts is an example of a state that has provided incentives to insurers and providers to move to bundled and global payment reform.

The ACA and Health Care Costs

Although improving access to care by enabling more Americans to gain health insurance coverage is the main objective of the ACA, the law is also expected to have a significant impact on containing health care costs. According to the Congressional Budget Office (2014), the ACA will reduce projected federal spending on health care by $109 billion between 2014 and 2024 (Jost, 2014). The ACA does this through reducing prices and controlling the use of services while maintaining quality (Emanuel, 2014). As of December 2014, there was evidence that spending was indeed decreasing. CMS reported that health care spending for 2013 increased by only 3.5%, the lowest rate of growth 182since 1960. This has been attributed at least in part to the ACA (Carey, 2014).

The ACA seeks to contain Medicare costs and pay for coverage expansion through:

• Medicare will phase out the extra payments it was making to insurers who offered Medicare Advantage Plans, the managed care private plans that older adults can choose instead of traditional FFS Medicare.

• Medicare will pay a lower annual increase in hospital, home, skilled nursing, and hospice care.

• Medicare will pay less for durable medical equipment such as wheelchairs, walkers, and oxygen equipment because of a mandated competitive bidding process for these supplies (Emanuel, 2014).

Additional provisions to control costs include:

• Reduction of special payments the federal government has historically made to hospitals serving disproportionate numbers of uninsured, with the expectation that more people will have health insurance under the ACA

• Taxing employers who offer high-cost private insurance plans to employees, encouraging them to redesign their health benefits and provide more affordable choices for their employees, scheduled to go into effect in 2018

• Encouraging the development of ACOs for Medicare recipients, integrated networks of providers responsible for managing and coordinating care of patients, especially those with costly chronic conditions

• Penalizing hospitals if they have excessive 30-day readmissions and hospital-acquired infections, by reducing their Medicare reimbursement and providing an incentive for them to improve the quality of care (Centers for Medicare and Medicaid Services, 2013)

• Implementing aggressive Medicare/Medicaid fraud and abuse prevention measures, which are projected to save the federal budget $7 billion over 10 years (McDonough, 2011)

• Establishing an Independent Payment Advisory Board (IPAB), which will recommend how to reduce the per capita growth of Medicare and reduce health care spending when health care inflation reaches a certain point

• Implementing administrative simplification measures that are aimed at the entire health sector and could save more than $11.6 billion in federal budget spending (McDonough, 2011)

• Conducting comparative effectiveness research, which will help physicians, other providers, and patients to determine which treatments work

Other provisions that have a major impact on nurses in primary care include some of the points that have been mentioned such as increases for reimbursement for primary care services, a strong focus on preventative health care (which is best delivered by nurses), and promotion of Patient-Centered Medical or Health Care Homes (PCMHs). As more and more Americans gain access to primary care services, nurses will be on the front lines of care. In addition, the Graduate Nursing Education (GNE) demonstration at five hospitals was part of the ACA. The demonstration is testing the use of Medicare funds to support clinical training of graduate nursing students, as is done with physicians (Graduate Medical Education, or GME). The outcomes of this demonstration may provide the evidence to move nursing’s share of these funds from diploma nursing programs to graduate education. In another example, the Health Resources and Services Administration (HRSA) provided $250 million for nursing workforce demonstrations projects as well as ways to enlarge and refinance APRN workforce education.

Discussion Questions

1. What forces have had an effect on increasing health care costs over the past 30 years?

2. What components of the ACA do you think will have a positive effect on improving health care outcomes and decreasing costs?

3. How has nursing fared in health care cost containment and what are the implications of the ACA on nursing?

References

American Association of Health Plans. Independent medical review of health plan coverage decisions: Empowering consumers with solutions. Author: Washington, DC; 2001.

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Brassard A. Making the case for NPs as primary care providers. The American Nurse. 2014 [Retrieved from] www.theamericannurse.org/index.php/2013/07/01/making-the-case-for-nps-as-primary-care-providers/.

Carey MA. Growth in U.S. health spending is lowest since 1960. Kaiser Health News. [Retrieved from] kaiserhealthnews.org/news/growth-in-u-s-health-spending-in-2013-is-lowest-since-1960/; 2014, December 4.

Centers for Medicare and Medicaid Services. Fact sheets: CMS final rule to improve quality of care during hospital inpatient stays. [Retrieved from] www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2013-fact-sheets-items/2013-08-02-3.html; 2013.

Commonwealth Fund. Realizing health reform’s potential. [Retrieved from] www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jan/1466_Abrams_how_ACA_will_strengthen_primary_care_reform_brief_v3.pdf; 2011.

Congressional Budget Office. Updated estimates of the effects of the insurance coverage provisions of the Affordable Care Act, April 2014. [Retrieved from] www.cbo.gov/publication/45231; 2014.

Emanuel E. Reinventing American health care. Public Affairs: New York; 2014.

Federal Interagency Forum on Age-Related Statistics. Older Americans 2000: Key indicators of well-being. Hyattsville, MD: Federal Interagency Forum on Age-Related Statistics; 2000.

Health Policy Brief. Health policy brief: The prevention and public health fund. Health Affairs. 2012 [Retrieved from] healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_63.pdf.

Heffler S, Levit K, Smith S, Smith C, Cowan C, Lazenby H, et al. Health care spending growth up in 1999: Faster growth expected in the future. Health Affairs. 2001;20(2):193–203.

Institute of Medicine. The future of public health. National Academy Press: Washington, DC; 1988.

Jost T. Implementing health reform: CBO projects lower ACA costs, greater coverage. Health Affairs Blog. 2014 [Retrieved from] healthaffairs.org/blog/2014/04/15/implementing-health-reform-cbo-projects-lower-aca-costs-greater-coverage/.

Kaiser Family Foundation. National health expenditures per capita and their share of gross domestic product, 1960–2008. [Retrieved from] facts.kff.org/chart.aspx?ch=1344; 2010.

Kaiser Family Foundation. Issue brief: How do disproportionate share hospital (DSH) payments change under the ACA?. [Retrieved from] kaiserfamilyfoundation.files.wordpress.com/2013/11/8513-how-do-medicaid-dsh-payments-change-under-the-aca.pdf; 2013.

Kaiser Family Foundation. Medicare spending and financing fact sheet. [Retrieved from] kff.org/medicare/fact-sheet/medicare-spending-and-financing-fact-sheet/; 2014.

Kaiser Family Foundation. The Medicare prescription drug benefit fact sheet. [Retrieved from] kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/; 2014.

Kaiser Family Foundation. Medicare. [Retrieved from] kff.org/medicare/; 2014.

Kaiser Family Foundation. A closer look at the impact of state decisions not to expand Medicaid on coverage for uninsured adults. [Retrieved from] kff.org/medicaid/fact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/; 2014.

Kaiser Family Foundation. Annual percent change in National Health Expenditures, by selected sources of funds, 1960–2012. [Retrieved from] kaiserfamilyfoundation.files.wordpress.com/2014/02/annual-percent-change-in-national-health-expenditures-by-selected-sources-of-funds-1960-2012-healthcosts.png; 2014.

Kaiser Health News. Research roundup: Medicare spending, community health centers, children’s dental services. [Retrieved from] www.kaiserhealthnews.org/Daily-Reports/2010/February/05/Research-Roundup.aspx; 2010.

Kongstvedt P. The managed health care handbook. 4th ed. Aspen: Gaithersburg, MD; 2001.

Kovner A, Knickman J, Weisfeld V. Jonas and Kovner’s health care delivery in the United States. 10th ed. Springer: New York; 2011.

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Lowrey W. For 17th time in 11 years, Congress delays Medicare reimbursement cuts as Senate passes ‘doc fix’. Washington Post. 2014 [Retrieved from] www.washingtonpost.com/blogs/post-politics/wp/2014/03/31/for-17th-time-in-11-years-congress-delays-medicare-reimbursement-cuts-as-senate-passes-doc-fix/.

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Online Resources

Kaiser Family Foundation.

www.kff.org.

Agency for Health Care Research and Quality.

www.ahrq.gov.

Commonwealth Fund.

www.commonwealthfund.org.

Introduction

Excellent introduction of interview process. Rationale is well-presented and purpose fully developed.

Basic understanding and/or limited use of interview application and/or inappropriate emphasis on an area.

Little or very general introduction of interview process. Little to no explanation; inappropriate emphasis on an area.

Description of Policy Issue

Excellent discussion of organizational assessment and why the selected healthcare policy issue was selected. Interview subtopics are supported with examples.

Basic discussion of organizational assessment and/or why the selected healthcare policy issue was selected. Interview process and/or issue not supported with examples.

Little or very general discussion of organizational assessment and why the selected healthcare policy issue was selected. Little or no interview process application or issue not supported with examples.

Presentation of Policy Analysis

Excellent discussion of all eight required subtopics. Presentation of policy analysis is supported with examples.

Basic discussion of all eight required subtopics and/or presentation of policy analysis not supported with examples.

Little or very general discussion of all eight required subtopics, or missing one or more of required subtopics. Little or no application to interview and/or practice examples.

Conclusion

Excellent understanding of policy analysis. Conclusions are well-evidenced and fully developed.

Basic understanding and/or limited use of policy analysis and/or inappropriate emphasis on an area.

Little understanding of policy analysis. Little to no explanation; inappropriate emphasis on an area.

Clarity of writing

Excellent use of standard English showing original thought. No spelling or grammar errors. Well-organized with proper flow of meaning.

Some evidence of own expression and competent use of language. No more than three spelling or grammar errors. Well-organized thoughts and concepts.

Language needs development. Four or more spelling and/or grammar errors. Poorly organized thoughts and concepts.

APA format

APA format correct with no more than one or two minor errors.

Three to five errors in APA format and/or one to two citations are missing.

APA formatting contains multiple errors and/or several citations are missing.

Evaluating the Work of the Nurses Serving in Congress

The performance of members of Congress has been in the limelight during the 113th Congress. Major partisan differences centering on the ACA and economic policies are blamed for increasing dissatisfaction with members of Congress. Overall approval ratings are reported to be very low by many organizations conducting polls. PollingReport.com provides a compilation of polls related to politics and current political events and is useful in getting an overall picture of how Congress is doing.

The public is increasingly involved in evaluative political dialogue through the steady adoption of new technology. Social media, including Facebook and Twitter, have provided constituents with immediate, up-to-the-moment, unfiltered communication from politicians and are arguably changing the face of political media strategy. Congressmen post to their Twitter accounts, engaging directly with their followers providing direct access to personal thoughts and opinions (Peterson, 2012). Within minutes of a statement being made by a political leader, the public can, and does, begin discussing and analyzing. Regardless of the results of polls, opinions of analysts, or social media judgments, the ultimate evaluation of a Congressman’s success is measured by their reelection.

Political Perspective

There are several tools available for evaluating political perspective. PolitiFact.com is a Pulitzer Prize winning Tampa Bay Times fact-checking project designed to find the truth in American politics. Reporters and editors of The Times evaluate and rate the factuality of comments made by politicians (PolitiFact.com, 2014). A search of PolitiFact can rapidly confirm or debunk statements and helps constituents evaluate their Representatives. Every year, the nonpartisan National Journal uses voting records to compare lawmakers on an ideologic, liberal/conservative scale based on controversial economic, foreign, or social issues (National Journal, 2013). The most recent National Journal ratings of the six nurses in Congress are listed in Table 42-1.

TABLE 42-1

National Journal’s Ratings of the Nurses in the 112th U.S. Congress (2013)

LIBERAL RATINGS

CONSERVATIVE RATINGS

COMPOSITE SCORE

Liberal

Conservative

Eddie Bernice Johnson, D-TX

78.0

22.0

Carolyn McCarthy, D-NY

66.5

33.5

Lois Capps, D-CA

81.5

18.5

Karen Bass, D-CA

90.5

9.5

Diane Black, R-TN

6.0

94.0

Renee Ellmers, R-TN

8.8

91.2

How to read the ratings: A score of 68 on economic issues in the liberal column, for example, means that the Representative was more liberal than 68% of her House colleagues on key economic votes in 2011. The designations E, S, and F refer to the economic, social, and foreign policy votes used to determine overall ratings (National Journal, 2013).

375

Interest Group Ratings

Some interest groups grade, rate, or rank members of Congress on issues of interest to the group. For example, the Cato Institute, a libertarian public policy research organization, evaluates the support that members of Congress provide for open trade. They host an interactive website that allows the user to see how individual Congressmen have voted on legislation affecting free trade (Cato Institute, 2014). The National Rifle Association (2014) graded the 113th Congress on their voting record on gun rights, and The New York Times mapped their ratings in an interactive website (New York Times, 2012). Project Vote Smart is a political website devoted to providing the public with factual, timely, accurate information on politics in the United States. In addition to keeping a searchable database on performance evaluations of politicians from an extensive list of special interest groups, they provide interactive tools that allow comparing elected officials and potential candidates according to issue areas (Project Vote Smart, 2014).

Campaign Financing

There is big money in politics. In 2012, the cost of winning the office of U.S. Representative averaged $1,689,580, and the average cost of a Senate seat was $10,476,451 (Costa, 2013). Candidate’s campaign funds come from a variety of sources, including interest groups, lobbyists, political action committees, organizations, and individuals. The Center for Responsive Politics is a nonpartisan organization dedicated to tracking money and analyzing the effects of money on U.S. politics and public policy. Their website, OpenSecrets.org, houses unbiased information on campaign contributions and lobbying that anyone interested can easily access (Center for Responsive Politics, 2014). Table 42-2 demonstrates overall fund-raising and expenditures of each nurse in Congress during the 2012 congressional election cycle.

TABLE 42-2

Nurses in the 113th Congress: 2012 Election Cycle Fund-Raising

Raised

Spent

Karen Bass, D-CA

$812,448

$933,375

Diane Black, R-TN

$2,497,751

$2,207,350

Lois Capps, D-CA

$3,325,296

$3,289,188

Renee Ellmers, R-NC

$1,136,890

$1,238,946

Eddie Bernice
Johnson, D-TX

$779,237

$882,303

Carolyn McCarthy D-NY

$2,278,000

$1,860,331

Small Individual

Large Individual

Political Action Committees

Candidate Self-Financing

Other

Karen Bass, D-CA

$21,423 (3%)

$215,672 (31%)

$442,998 (64%)

$12,896 (2%)

Diane Black, R-TN

$50,410 (2%)

$862,880 (35%)

$1,178,331 (48%)

$304,523 (12%)

$41,086 (2%)

Lois Capps, D-CA

$419,388 (13%)

$1,697,422 (51%)

$1,132,703 (34%)

$70,557 (2%)

Renee Ellmers, R-NC

$106,653 (10%)

$349,274 (32%)

$597,024 (55%)

$33,919 (3%)

Eddie Bernice
Johnson, D-TX

$23,390 (3%)

$236,340 (30%)

$518,496 (67%)

$1000 (0%)

$12 (0%)

Carolyn McCarthy, D-NY

$718,316 (32%)

$730,072 (32%)

$823,663 (36%)

$0 (0%)

$5950 (0%)

From Center for Responsive Politics (www.OpenSecrets.org).

Sources of Campaign Funds

As of 2014, for the first time in history, more than half of the elected Representatives in Congress 376were millionaires (Center for Responsive Politics, 2014). This has sparked increased public discussion about how well Congress represents the actual population and the increasing wealth inequality. In the United States, 75.4% of all wealth is held by the richest 10% of the people. This is among the highest in the developed nations and has been steadily increasing (Credit Suisse Research Institute, 2013). Two nurses in Congress are in the multimillionaire category: Diane Black with an average net worth of $69.6 million, and Carolyn McCarthy with $4.3 million. With campaigns becoming increasingly expensive, the field of prospective legislators has narrowed. Table 42-2 outlines the campaign financing for the nurses serving in the 113th Congress.

Evaluating members of Congress is difficult. The reader may recall the Hindu fable where six sightless men touching an elephant came to six different conclusions about what an elephant was like. The six men touched six different parts and came to six different conclusions about the elephant. Although each man may have been telling a truth, each man was wrong about his conclusion. This also applies in Congress. A true picture of a Congressperson’s effectiveness will necessarily include a variety of measures from a variety of perspectives.

References

American Nurses Association. Fact sheet: Registered nurses in the U.S. [Retrieved from] nursingworld.org/NursingbytheNumbersFactSheet; 2011.

Bass K. About me: Full biography. [Retrieved from] bass.house.gov/about-me/full-biography; 2014.

Bass K. Issues. [Retrieved from] bass.house.gov/issues; 2014.

Black D. About me: Biography. [Retrieved from] black.house.gov/about-me/full-biography; 2014.

Black D. Legislative work. [Retrieved from] black.house.gov/legislative-work; 2014.

Capps L. About me: Full biography. [Retrieved from] capps.house.gov/about-me/full-biography; 2014.

Capps L. Legislative work: Issues. [Retrieved from] capps.house.gov/issues; 2014.

Cato Institute. Free trade, free markets: Rating the Congress. [Retrieved from] www.cato.org/research/trade-immigration/congress; 2014.

Center for Responsive Politics. About us. [Retrieved from] www.opensecrets.org/pfds/; 2014.

Costa J. What’s the cost of a seat

Frameworks for Action in Policy and Politics Eileen T. O’Grady, Diana J. Mason, Freida Hopkins Outlaw, Deborah B. Gardner “The most common way people give up their power is by thinking they don’t have any.” Alice Walker March 31, 2013 marked an important deadline in the implementation of landmark legislation, the Affordable Care Act (ACA)1, also known as Obamacare. By that date those eligible to enroll for insurance coverage through the marketplace had to purchase a plan if they were to avoid a 2015 tax penalty of $95 or 1% of their annual income (whichever was higher). Amid a frenzy of media attention, an estimated 8 million people signed on for coverage during open enrollment—the period between October 2012 and the deadline—exceeding the revised target of 6.5 million (Kennedy, 2014). And the numbers kept increasing, as millions more enrolled in Medicaid or the Children’s Health Insurance Program (known as CHIP) (Centers for Medicare and Medicaid Services [CMS], 2014). Nurses were essential to these enrollments. For example, Adriana Perez, PhD, ANP, RN, an assistant professor at Arizona State University College of Nursing, used her role as president of the Phoenix Chapter of the National Association of Hispanic Nurses to organize town hall meetings with Spanish-speaking state residents to explain the ACA and encourage enrollment among those with a high rate of un- or under-insurance. She also developed a training model in partnership with AARP-Arizona and used it to empower Arizona nurses to educate multicultural communities on the basic provisions of the ACA. Through many such initiatives, the United States reduced the number of uninsured people by over 10 million in 2014; the number is projected to be 20 million by 2016 (Congressional Budget Office [CBO], 2014). However, access to coverage does not necessarily mean access to care, nor does it ensure a healthy population. Health care access means having the ability to receive the right type of care when needed at an affordable price. The U.S. health care system is grounded in expensive, high-tech acute care that does not produce the desired outcomes we ought to have and too often damages instead of heals (National Research Council, 2013). Despite spending more per person on health care than any other nation, a comparative report on health indicators by the Organisation for Economic Co-operation and Development (2013) shows that the United States performs worse than other nations on life 2expectancy at birth for both men and women, infant mortality rate, mortality rates for suicide and cardiovascular disease, the prevalence of diabetes and obesity in children, and other indicators. In 1999, the Institute of Medicine (IOM) issued a report, To Err is Human: Building a Safer Health System, which estimated that health care errors in hospitals were the fifth leading cause of death in the U.S. (IOM, 1999). By 2011, preventable health care errors were estimated to be the third-leading cause of death (Allen, 2013; James, 2013). The ACA includes elements that can begin to create a high-performing health care system, one accountable for the provision of safe care, as well as improved clinical and financial outcomes. It aims to move the health care system in the direction of keeping people out of hospitals, in their own homes and communities, with an emphasis on wellness, health promotion, and better management of chronic illnesses. For example, the ACA uses financial penalties to prod hospitals to reduce 30-day readmission rates. It also provides funding for demonstration projects that improve “transitional care,” services that help patients and their family caregivers to make a smoother transition from hospital or nursing home to their own homes to help reduce preventable hospital readmissions. Based, in part, on research by Mary Naylor, PhD, RN, FAAN, professor of nursing at the University of Pennsylvania School of Nursing, these demonstrations are stimulating creative methods of accountability across health care settings, with most using nurses for care coordination and transitional care providers (CMS, n.d.; Coalition for Evidence-Based Policy, n.d.; Naylor et al., 2011). Upstream Factors Promoting health requires more than a high-performing health care system. First and foremost, health is created where people live, work, and play. It is becoming clear that one’s health status may be more dependent on one’s zip code than on one’s genetic code (Marks, 2009). Geographic analyses of race and ethnicity, income, and health status repeatedly show that financial, racial, and ethnic disparities persist (Braveman et al., 2010). Individual health and family health are severely compromised in communities where good education, nutritious foods, safe places to exercise, and well-paying jobs are scarce (Halpin, Morales-Suárez-Varela, & Martin-Moreno, 2010). Creating a healthier nation requires that we address “upstream factors”; the broad range of issues, other than health care, that can undermine or promote health (also known as “social determinants of health” or “core determinants of health”) (World Health Organization [WHO], n.d.). Upstream factors promoting health include safe environments, adequate housing, and economically thriving communities with employment opportunities, access to affordable and healthful foods, and models for addressing conflict through dialogue rather than violence. According to Williams and colleagues (2008), the key to reducing and eliminating health disparities, which disproportionately affect racial and ethnic minorities, is to provide effective interventions that address upstream factors both in and outside of health care systems. Upstream factors have a large influence on the development and progression of illnesses (Williams et al., 2008). The core determinants of health will be used to further elucidate and make concrete the wider, more comprehensive set of upstream factors that can improve the health of the nation by reducing disparities. Figure 1-1 depicts the core determinants of health developed by the Canadian Forces Health Services Group. FIGURE 1-1 Surgeon General’s Mental Health Strategy: Canadian Forces Health Services Group—An Evolution of Excellence. (From www.forces.gc.ca/en/about-reports-pubs-health/surg-gen-mental-health-strategy-ch-2.page.) A focus on such factors is essential for economic and moral reasons. Even in the most affluent nations, those living in poverty have substantially shorter life expectancies and experience more illness than those who are wealthy, with high costs in human and financial terms (Wilkinson & Marmot, 2003). To date however, most of the focus on reducing disparities has been on health policy that addresses access, coverage, cost, and quality of care once the individual has entered the health care system–despite the fact that for more than a decade research has established that most health care problems begin long before people seek medical care (Williams et al., 2008). Thus, changing the paradigm requires knowledge about the political aspects of the social determinates of health and the broader 3core determinants. Political aspects of the social determinants of health appear in Box 1-1. Box 1-1 Political Aspects of the Social Determinants of Health • The health of individuals and populations is determined significantly by social factors. • The social determinants of health produce great inequities in health within and between societies. • The poor and disadvantaged experience worse health than the rich, have less access to care, and die younger in all societies. • The social determinants of health can be measured and described. • The measurement of the social determinants provides evidence that can serve as the basis for political action. • Evidence is generated and used in a continuous cycle of evidence production, policy development, implementation, and evaluation. • Evidence of the effects of policies and programs on inequities can be measured and can provide data on the effectiveness of interventions. • Evidence regarding the social determinants of health is insufficient to bring about change on its own; political will combined with evidence offers the most powerful strategy to address the negative effects of the social determinants. Adapted from National Institute for Health and Clinical Excellence. (2007). The Social Determinants of Health: Developing an Evidence Base for Political Action. Final report to the World Health Organization Commission on the Social Determinants of Health. Lead authors: J. Mackenbach, M. Exworthy, J. Popay, P. Tugwell, V. Robinson, S. Simpson, T. Narayan, L. Myer, T. Houweling, L. Jadue, and F. Florenza. The ACA begins to carve out a role for the health care system in addressing upstream factors. For example, the law requires that nonprofit hospitals demonstrate a “community benefit” to receive federal tax breaks. Hospitals must conduct a community health assessment, develop a community health improvement plan, and partner with others to implement it. This aligns with a growing emphasis on population health: the health of a group, whether defined by a common disease or health problem or by geographic or demographic characteristics (Felt-Lisk & Higgins, 2011). Consider the 11th Street Family Health Services. Located in an underserved neighborhood in North Philadelphia, this federally qualified, nurse-managed health center (NMHC) was the brainchild of public health nurse Patricia Gerrity, PhD, RN, FAAN, a faculty member at Drexel University School of Nursing. She recognized that the leading health problems in the community were diabetes, obesity, heart failure, and depression. Working with a community advisory group, Gerrity realized that the health center had to address nutrition as an “upstream factor” that could improve the health of those living in the community. With no supermarket in the neighborhood until 2011, she invited area farmers to come to the neighborhood as part of a farmers’ market. She also created a community vegetable garden maintained by the local youth. And area residents were invited to attend nutrition classes on culturally relevant, healthful cooking. 11th Street Family Health Services is one of over 200 NMHCs in the United States that have improved clinical and financial outcomes by addressing the needs of individuals, families, and communities 4(American Academy of Nursing, n.d., b). The ACA authorizes continued support for these centers, although the law does not mandate they be funded. Congress would have to appropriate funding for NMHCs but has not done so. (See Chapter 34 for a more detailed discussion of NMHCs.) The ACA may not go far enough in shifting attention to the health of communities and populations. One approach gaining notice is that of “health in all policies,” the idea that policymakers consider the health implications of social and economic policies that focus on other sectors, such as education, community development, tax codes, and housing (Leppo et al., 2013; Rudolph et al., 2013). As health professionals who focus on the family and community context of the patients they serve, nurses can help to raise questions about the potential health impact of public policies. Nursing and Health Policy Health policy affects every nurse’s daily practice. Indeed, health policy determines who gets what type of health care, when, how, from whom, and at what cost. The study of health policy is an indispensable component of professional development in nursing, whether it is undertaken to advance a healthier society, promote a safer health care system, or support nursing’s ability to care for people with equity and skill. Just as Florence Nightingale understood that health policy held the key to improving the health of poor Londoners and the British military, so are today’s nurses needed to create compelling cases and actively influence better health policies at every level of governance. With national attention focused on how to transform health care in ways that produce better outcomes and reduce health care costs, nursing has an unprecedented opportunity to provide proactive and visionary leadership. Indeed, the Institute of Medicine’s landmark report, The Future of Nursing: Leading Change, Advancing Health (2011), calls for nurses to be leaders in redesigning health care. But will nurses rise to this occasion? Health care opinion leaders in a 2010 poll identified two reasons nurses would fall short of influencing health care reform: too many nurses do not want to lead, and with over 120 national organizations, nursing often fails to present a united front (Gallup, 2010). As the largest health care profession, nursing has great potential power. Yet, similar to many professions, it has struggled to collaborate within its ranks or with other groups on pressing issues of health policy. The IOM report has provided a rallying point for nursing organizations to work together and engage other stakeholders to advance its recommendations. Reforming Health Care The Triple Aim In 2008, Don Berwick, MD, and his colleagues at the Institute for Healthcare Improvement (IHI) first described the Triple Aim of a value-based health care system (Berwick, Nolan, & Whittington, 2008): (1) improving population health, (2) improving the patient experience of care, and (3) reducing per capita costs. This framework aligns with the aims of the Affordable Care Act. The Triple Aim represents a balanced approach: by examining a health care delivery problem from all three dimensions, health care organizations and society can identify system problems and direct resources to activities that can have the greatest impact. Looking at each of these dimensions in isolation prevents organizations from discovering how a new objective, decreasing readmission rates to improve quality and reduce costs, for instance, could negatively impact the third goal of population health, as scarce community resources are directed to acute care transitions and unintentionally shifted away from prevention activities. Solutions must also be evaluated from these three interdependent dimensions. The Triple Aim compels delivery systems and payors to broaden their focus on acute and highly specialized care toward more integrated care, including primary and preventive care (McCarthy & Klein, 2010). The IHI (n.d.) identified these components of any approach seeking to achieve the Triple Aim: • A focus on individuals and families • A redesign of primary care services • Population health management 5 • A cost-control platform • System integration and execution Note that these possess the goal of creating a high-performing health care system but do not focus on geographic communities or social determinants per se. However, these two concepts can be incorporated into the Triple Aim of improving the health of populations and reducing health care costs. The Triple Aim is easy to understand but challenging to implement because it requires all providers, including nurses, to broaden their focus from individuals to populations. The success of the nursing profession’s continued evolution will hinge on its ability to take on new roles, more cogently and creatively engaging with patients and stepping into executive and leadership roles in every sector of heath care. But it must do so within an interprofessional context, leading efforts to break down health professions’ silos and hierarchies and keeping the patient and family at the center of care. The ACA and Nursing The ACA is arguably the most significant piece of social legislation passed in the United States since the enactment of Medicare and Medicaid in 1965. Implementation continues to be a vexing process and a political flashpoint. It has defined the ideologies of U.S. political parties, and yet the public remains largely uninformed and misinformed about the legislation; 3 years after its passage, 4 out of 10 Americans were still unaware of many of its provisions and unsure that the ACA had become law (The Henry J. Kaiser Family Foundation, 2013). (Chapter 19 provides a thorough description of the ACA.) The ACA is over 2000 pages long, which reflects the complexity of creating a new health care infrastructure that addresses a wide array of issues including patient protections, health insurance industry reforms, and workforce development, to name a few. Newer systems of care are emphasized in the ACA that link patient outcomes to costs incurred in treatment and to high-value health systems. The legislation can be categorized into four main cornerstones (Figure 1-2). FIGURE 1-2 Four cornerstones of reform. (From O’Grady, E. T., & Johnson, J. [2013]. Health policy issues in changing environments. In A. Hamric, C. Hanson, D. Way, & E. O’Grady [Eds.], Advanced practice nursing: An integrative approach [5th ed.]. St. Louis, MO: Elsevier-Saunders.) The ACA was born out of national macroeconomic concerns. The United States spent $2.7 trillion in 2011, or $8680 per person, on health care; a rate higher than inflation that is expected to consume nearly 20% of the gross domestic product by 2020 (CMS, 2013). With businesses having to spend such large amounts on health care for employees, the United States cannot compete in the global economy. Furthermore, such high health care expenses divert funds away from addressing the upstream factors that could prevent the need for costly acute care. Although previous presidents in the past 50 years tried unsuccessfully to pass health care reform legislation, President Obama was elected at a time when many Americans agreed that the United States could no longer afford to maintain a health care system that had neither spending controls nor accountability for improving clinical outcomes. The ACA was an outgrowth, in part, to “bend the cost curve,” or reduce the rate of increase in health care spending (Cutler, 2010). To improve the health of the public and reduce health care costs, health promotion and wellness, disease prevention, and chronic care management must be built into the foundation of the health care system (Katz, 2009; Wagner, 1998; Woolf, 2009). At 6the same time, acute care must use fewer resources, be made safer, and produce better outcomes (Conway, Mostashari, & Clancy, 2013). Nurses are important players in shifting the focus of health care to one that prevents illnesses, promotes health, and coordinates care. Nurses have been performing in such roles without naming or measuring their activities for decades. But there are exceptions. The American Academy of Nursing’s Raise the Voice Campaign (American Academy of Nursing, n.d., a) has identified nurses who have developed innovative models of care for which there are good clinical and financial outcome data. Known as “Edge Runners,” these nurses have demonstrated that nursing’s emphasis on care coordination, health promotion, patient- and family-centeredness, and the community context of care provides evidence-based models that can help to transform the health care system. The ACA presents many opportunities for nurses to test new models of care that have already shown promise for improving health outcomes and the experience of health care, while lowering costs. The Center for Medicare and Medicaid Innovation (CMMI) was authorized to spend $10 billion over a decade to pilot-test programs that may improve the safety and quality of care. For example, under the Bundled Payments for Care Improvement Initiative, health systems will enter into payment arrangements that include financial and performance accountability for episodes of care. Currently being studied, an episode of care includes the inpatient stay and all related services during the episode up to 90 days after hospital discharge. These models may lead to higher quality, more coordinated care at a lower cost to Medicare. If the program is successful in achieving these outcomes, they are authorized to launch the program nation-wide. If these can be shown to achieve the Triple Aim, the ACA authorizes the Secretary of the U.S. Department of Health and Human Services to put these programs in place permanently. The CMMI provides opportunities for nurse leaders and nurse researchers to demonstrate new methods of improving care in cost-effective ways. In addition, the ACA created the Patient-Centered Outcomes Research Institute (PCORI) with $3.5 billion to support comparative-effectiveness research that examines the outcomes that matter to consumers. Nurses serve on the governing board and review panels of PCORI. It provides nurses with opportunities to compare nursing interventions, head-to-head or with medications or other treatments that have sufficient evidence. The following examples illustrate how nursing is embedded in the four cornerstones of reform. Some of these examples address only one cornerstone; others address all four. 1. Create Value. NMHCs are operated by advanced practice registered nurses (APRNs), primarily nurse practitioners (NPs). These clinics are often associated with a school, college, university, department of nursing, federally qualified health center, or an independent nonprofit health care agency. Managed by APRNs, NMHCs are staffed by an interprofessional team that may include physicians, social workers, public health nurses, psychiatric mental health nurses at the generic and advanced levels, and behavioral therapists. Barkauskas and colleagues (2011) found that quality measures for NMHCs compared positively with national benchmarks, particularly in chronic disease management. The founders of several NMHCs have been designated Edge Runners, including Patricia Gerrity of the 11th Street Family Health Service, as described earlier. NMHCs serve as critical access points for keeping patients out of the emergency room and hospitals, saving millions of dollars annually (Hansen-Turton et al., 2010). 2. Coordinate Care. The patient-centered “medical home” or “health home”2 (PCMH) model was designed to satisfy patients’ needs and to improve care access (e.g., through extended office hours and increased communication between providers and patients via e-mail and telephone), 7increase care coordination, and enhance overall quality, while simultaneously reducing costs. The medical home relies on a one-stop-shopping approach by a team of providers, such as physicians, nurses, nutritionists, pharmacists, and social workers, to meet a patient’s health care needs. Peikes and colleagues (2012) found that the PCMH model’s attention to the whole person across care settings (such as from hospital to home) may improve physical and behavioral health, access to community-based social services, and management of chronic conditions. A number of NMHCs have achieved PCMH designation by the National Committee on Quality Assurance. 3. Payment Reform. Bundling payments and paying for care coordination, including through “accountable care organizations” (ACOs), are examples of payment reform. ACOs are similar to integrated delivery systems that combine services across health care settings and focus on ways to improve care delivery and outcomes under a bundled payment plan. Bundling payments allows for reimbursement of multiple services provided during an episode of care, rather than the traditional fee-for-service payments for each service or procedure for a single illness. ACOs differ from health maintenance organizations (HMOs) in that they are not incentivized to cut services but rather to keep people healthy. Indeed, one of the major differences between HMOs in the 1990s and ACOs today is that the latter are held to a higher standard of measuring, reporting, and making transparent the process and outcome indicators of quality. Each ACO has to have a minimum of 5000 Medicare patients (population health); if the ACO demonstrates that it keeps people healthy and saves Medicare money, those savings are “shared” with the ACO. Nurses are central to preventing complications in hospitalized patients, ensuring smooth transitions to home, and coaching the patient and family caregivers in self-care and health-promoting behavioral changes. As such, they are a vital component of ACO success. But payment reform is proving to be challenging. The CMMI, authorized under the ACA, initially funded 31 “pioneer” ACOs. By mid-2014, only 22 remained, mostly because of difficulty in managing payment to the various entities in the ACO’s network. Nonetheless, there is some consensus that the fee-for-service payment system encourages overtreatment (unnecessary and costly care) and must be replaced (Cutler, 2010; Gibson & Singh, 2012). 4. Improve Access to Coverage. The ACA does not guarantee health insurance coverage for all, including undocumented immigrants, but, by 2017, it will cover up to 30 million of the 45 million who were uninsured when the bill was signed in 2010 (89% of the total nonolder adult population; 92% of nonolder adult American citizens) (Congressional Budget Office [CBO], 2014). It makes it illegal for insurance companies to deny coverage to people with preexisting conditions, to drop people once they acquire a costly illness, or to apply annual and lifetime caps on coverage. As the demand for health care surges, it is expected that APRNs will be positioned to provide much of the needed primary care, creating the need for APRNs to practice to the full extent of their education and training. Barriers preventing such practice include mandated physician supervision or collaboration in two thirds of states, insurers refusing to credential or impanel APRNs, Medicare requirements for physicians—rather than NPs—to order referrals to home care and hospice, and other local, state, and national policies that limit APRN practice. Access to coverage does not ensure that people will have access to care. There is a lack of primary care physicians (PCPs) serving the poor, in both rural and urban regions; approximately 210,000 PCPs currently practice, and it has been estimated that another 52,000 will be needed by 2025 (Petterson et al., 2012). This shortfall has led to the development of the APRN role. A workforce analysis center at the Health Resources and Services Administration reported that if primary care NPs and physician assistants (PAs) are fully integrated into a health care delivery system that emphasizes team-based care, the projected shortage of PCPs would be “somewhat alleviated” by 2020 (U.S. Department of Health and Human Services, 2013). Community-based health care centers will be expanded in areas where there are health care 8provider shortages. Expansion of the National Health Service Corps is expected to ensure that providers, including registered nurses (RNs) and APRNs, will be available to staff these centers. An emphasis on primary care will increase the demand for NPs and RNs, and the ACA authorizes additional support for primary care workforce development (loans, scholarships, new educational program development, and expansion of existing programs). (See Chapter 60 for more on the nursing workforce.) Nurses as Leaders in Health Care Reform Coinciding with the passage of the ACA was the timely publication of The Future of Nursing: Leading Change, Advancing Health (IOM, 2011). It makes four recommendations, one of which is “Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States” (Figure 1-3). FIGURE 1-3 Four key messages: The IOM report. (From Institute of Medicine. [2011]. The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from www.iom.edu/nursing.) This presents a challenge to nurses: to identify opportunities to participate in policy decision making at all levels of society, the health care system, and health care organizations. Although nursing is well positioned to contribute to a reformed health care system, we cannot assume that those making the decisions about reform will automatically seek nurses’ input. And, if invited to policy tables, will nurses show up and participate fully? The IOM report calls for the profession to develop its leadership capacity, while encouraging policymakers and others to appreciate nurses’ perspectives on policy. Whether developing new models of care, sharing ideas for regulations with policymakers, developing demonstration projects that the new health care law seeks to test, or advocating new legislation to amend and improve upon the law (or preventing it from being dismantled), nurses must strengthen their social covenant with the public and more forcefully engage in shaping policy at all levels within government, workplaces, health-related organizations, and communities. Policy and the Policy Process What do we mean by policy? Policy has been defined as the authoritative decisions made in the legislative, executive, or judicial branches of government intended to influence the actions, behaviors, or decisions of citizens (Longest, 2010). But that definition limits its application to sectors outside of government. For example, health care organizations set policy that affects employees, patients, and even surrounding communities (for example, by closing a neighborhood clinic or buying property for hospital expansion). Thus, a broader definition of policy is “a relatively stable, purposive course of action or inaction followed by an actor or set of actors in dealing with a problem or matter of concern” (Anderson, 2015, p. 6). Public policy is policy crafted by governments. When the intent of a public policy is to influence health or health care, it is a health policy. Social policies identify courses of action to deal with social problems. All are made within a dynamic environment and a complex policymaking process. Private policies are those made by nongovernmental entities, whether health care organizations, insurers, or 9others. Indeed, there is growing recognition that policies set by health care organizations and insurers, for example, can limit APRN practice even in states that have removed laws requiring physician supervision or collaboration. A hospital can limit what APRNs do as long as the organization does not call for APRNs to practice beyond the state’s scope-of-practice policy. Policies are crafted everywhere, from small towns to Capitol Hill. States use policies to specify requirements for health professions’ licensure, to set criteria for Medicaid eligibility, and to require immunization for public university students, for example. Hospitals use policies to direct when visitors may visit patients, to manage staffing, and to respond to disasters. Public schools employ state policies to specify who may administer medications to schoolchildren and what may be sold from a school vending machine. Towns, cities, and other municipalities use policies to manage public water, to define who may run for office, and to decide if residents may keep exotic pets. In a capitalist economy such as that of the United States, private markets can control the production and consumption of goods and services, including health care. The government often “intervenes” with policies when private markets have failed to achieve desired public objectives. But when is it necessary for the government to intercede? Broadly speaking, in the current U.S. political system, the divide between liberal and conservative political parties is a fundamental disagreement about the degree to which government can and should solve problems (Kelly, 2004) in education, national security, the environment, and nearly every other aspect of public life. The American political landscape is continuously shifting, as public mood shifts with new Representatives being elected and senior Representatives desiring to stay in office. Longest (2010) describes two types of public policies the government develops: • Allocative policies provide benefits to a distinct group of individuals or organizations, at the expense of others, to achieve a public objective (this is also referred to as the redistribution of wealth). The enactment of Medicare in 1965 was an allocative policy that provided health benefits to older adults using federal funds (largely from middle- and high-income taxpayers). • Regulatory policies influence the actions, behavior, and decisions of individuals or groups to ensure that a public objective is met. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 regulates how individually identifiable health information is managed by users, as well as other aspects of health records. Policymaking is an often unpredictable dance that requires a high degree of political competence. Our system is based on continuous policy modification—incremental change is exceedingly more likely than revolutionary change. But there are exceptions; once in a generation a large social program is passed such as Medicare and Medicaid in the 1960s and the ACA in 2010. Forces That Shape Health Policy Some of the most prominent forces that shape health policy appear in Figure 1-4. FIGURE 1-4 The forces that shape policy. Values Values undergird proposed and adopted policies and influence all political and policymaking activities. Public policies reflect a society’s values and also its conflicts in values. A policy reflects which values are given priority in a specific decision (Kraft & Furlong, 2010). Once framed, a policy reveals the underlying values that shaped it. Different people value different things, and when resources are finite, policy choices ultimately bring a disadvantage to some groups; some will gain something from the policy, and some will lose (Bankowski, 1996). To support or oppose a policy requires value judgments (Majone, 1989). Conflicts between values were apparent throughout the debates on the ACA; for example, despite a strong contingent of advocates for a government-run, nonprofit insurance option that would compete with private insurers, the insurance industry opposed it, as did others who saw it as an increase in government control, and it was not included in the law. 10 Politics Politics is the use of relationships and power to gain ascendancy among competing stakeholders to influence policy and the allocation of scarce resources. Because inevitably there are competing interests for scarce resources, policymaking is done within a political context. The definition of politics contains several important concepts. Influencing indicates that there are opportunities to shape the outcome of a process. Allocation means that decisions are being made about how to distribute resources. Scarce implies the limits to available resources and that all parties probably cannot have all they want. Finally, resources are usually considered to be financial but could also include human resources (personnel), time, or physical space such as offices (Mason, Leavitt, & Chaffee, 2012). Engaging in the political context of policymaking includes knowing the positions of key stakeholders and political parties, as well as the electoral process, public opinion, the influence of media coverage, and more (see Chapter 9 for an in-depth discussion of political analysis and strategies). Understanding politics is an invitation not to misuse power, people, or information but rather to align the health of the public with the interest of the policymaker. For example, a Congresswoman may have run her campaign focused on improving the economy. She may not have linked the rising obesity epidemic as a threat to the larger macroeconomy and American productivity. Nurses could link obesity to the economy by describing the catastrophic direct and indirect costs of the obesity epidemic and how it is making the United States less competitive in a global market. This is a way for nurses to use their power to create more urgency about the most pressing public health issues. Policy Analysis and Analysts Analysis is the examination of an object or a process to understand it better. Policy analysis uses various methods to assess a problem and determine possible solutions. This encourages deliberate critical thinking about the causes of problems, identifies the ways a government or other groups could respond, evaluates alternatives, and determines the most desirable policy choice. (See Chapter 7.) Policy analysts are individuals who, with professional training and experience, analyze problems and weigh potential solutions. Citizens can also use policy analysis to better understand a problem, 11alternatives, and potential implications of policy choices (Kraft & Furlong, 2010). Advocacy and Activism Advocacy of one patient at a time has long been a central role for nurses. But nurses can be advocates on a larger scale by working in policy and politics, which is endorsed in “nursing’s social policy statement” (American Nurses Association [ANA], 2003), a document that defines nursing and its social context. Political activism may be associated with protests but has grown to include additional diverse and effective strategies such as blogging, using evidence to support policy choices, and garnering media attention in sophisticated ways. Interest Groups and Lobbyists Interest groups advocate for policies that are advantageous to their membership. Groups often employ lobbyists to advocate on their behalf and their power cannot be underestimated. In 2009, 1814 U.S. businesses and organizations spent $554,566,269 on lobbying and employed 3527 lobbyists to advocate for their interests in the health care reform debate and other issues (Center for Responsive Politics, n.d., a). This was a peak year that coincided with interest groups’ attempts to influence the ACA. In 2013, 1299 organizations spent $483,078,712 on lobbying and used 2918 lobbyists to advance their interests, including over $1.6 million by the ANA and $940,000 by the American Association of Nurse Anesthetists (Center for Responsive Politics, n.d., b). The Media The power of media is demonstrated in political and issue campaigns, whether through paid political advertisements or the “talking heads” on “news” programs that present polarized views. The aim is to deliver messages that resonate with the values and emotions of a target audience to support or oppose a candidate or proposed policy. The strategic use of media is imperative in today’s cacophony of information. Gaining the attention of a target audience is power. Persuading that audience to behave the way you want is ultimate power. In this information age, nurses must proactively use media to influence policy and make themselves available to speak with journalists about policy matters. However, nurses have not always been eager to enter the media spotlight (see Chapter 14 on using media as a policy and political tool), particularly when it comes to talking with journalists. Social media is a tool for influencing policymakers (Grande et al., 2014) and provides nurses with an opportunity to control their message. Nurse bloggers such as Barbara Glickstein are getting visibility as “media makers.” Theresa Brown writes for the Opinionator column for The New York Times. Both are bringing nursing perspectives on policy matters to the public’s attention. Science and Research The information age has created an emphasis on evidence-based practice and policies. Scientific findings play a powerful role in the first step of the policy process: getting attention to particular problems and moving them to the policy agenda. Research can also be valuable in defining the size and scope of a problem and substantiating policy recommendations. This can help to obtain support for a proposed policy and in lobbying for support of it. Evidence should be used to inform policy debates and shape policy choices to help ensure that the solution will be effective. That said, evidence is essential but may not be sufficient to advance policies. Values and politics can trump evidence, as has been apparent in recent debates over two issues: climate change and decreasing rates of vaccinations. Despite the evidence showing that humans are contributing to potentially devastating changes in the earth’s climate or that childhood vaccinations do not cause autism, debates about these issues continue and affect whether policies are or are not adopted to address the problems. The Power of Presidents and Other Leaders The president embodies the power of the executive branch of government and is the only person elected to represent the entire nation. As the most visible government official, the president is able to propel issues to the top of the nation’s policy agenda. Although the president cannot introduce legislation, he or she can provide draft legislation 12and legislative guidance. The president can also issue executive orders when he or she cannot get support for policy change from Congress. President Obama has done so in the face of a paralyzed Congress, as did his Republican and Democratic predecessors. This force also applies to the leaders of many public and private entities. Never underestimate the power of the official leader or of those who seek to remove or thwart the leader. The Framework for Action Nursing has a covenant with the public. The profession’s practice laws, standards, and ethics have roots in its history of activism for social justice. A social contract with society demands professional responsibility. Thus, every nurse must continuously consider the policy context of daily practice in any setting. The solutions to today’s most intractable health care problems, including perverse payment mechanisms, deeply disturbing social injustice, and shocking ethnic and racial disparities, are not simple to solve. But, according to the annual Gallup poll (Gallup, 2013), the public regards nurses’ “honesty and ethical standards” more highly than those of any other profession. This public trust places a moral imperative on nurses to vigorously engage in influencing policy. Nurses see close up how policies get played out in patient care and can report on unintended consequences. This imperative requires nurses to expand their involvement in policy decisions at the institutional, community, state, federal, or international realm and need not be restricted to any one setting. The Framework for Action (Figure 1-5) illustrates that nurses operate in four spheres: government, workplace, interest groups (including professional organizations), and community to influence policies that affect health and health care and core/social determinants of health. FIGURE 1-5 A framework: Spheres of influence for action. Nurses need to work in multiple spheres of influence to shape health and social policy. Policies are designed to remedy problems in the health system and to address social determinants of health; both of which aim to improve health. Spheres of Influence The four spheres of influence provide a visual medium for understanding the policy arena. These spheres are not discrete silos. Policy can be shaped in more than one sphere at a time, and action in one sphere can influence others. To achieve greater 13access to care for the uninsured, for example, nurses may work in their own organization to alter policy to increase access to services. They may also use political strategies in the media, such as blogging or being interviewed on television, to express their support for better access to care. They may work with a professional association or an interest group to communicate their views to policymakers. Additional context (the who, what, where, when, and why of nursing’s policy influence) is provided in Figure 1-6. FIGURE 1-6 The who, what, where, when, and why of nursing’s policy influence. The Government Government action and policy affect lives from birth until death. It funds prenatal care, inspects food, controls the safety of toys and cars, operates schools, builds highways, and regulates what is transmitted on airwaves. It provides for the common defense; supplies fire and police protection; and gives financial assistance to the poor, aged, and others who cannot maintain a minimal standard of living. The government responds to disaster, subsidizes agriculture, and licenses funeral homes. Although most U.S. health care is provided in the private sector, much is paid for and regulated by the government. So, how the government crafts health policy is extremely important (Weissert & Weissert, 2012). Government plays a significant role in influencing nursing and nursing practice. States determine the scope of professional activities considered to be nursing, with notable exceptions of the military, veterans’ administration, and Indian health service. Federal and state governments determine who is eligible for care under specific benefit programs and who can be reimbursed 14for providing care. Sometimes government provides leadership in defining problems for both the public and private sectors to address. There are more than a dozen House and Senate committees and subcommittees that shape policy on health, and many more committees address social problems that affect health. In the House of Representatives, the Congressional Nursing Caucus, an informal, bipartisan group of legislators who have declared their interest in helping nurses, lobbies for federal funding for nursing education (Walker, 2009). Abraham Lincoln’s description of a “government of the people, by the people, for the people” (Lincoln, 1863) captures the intricate nature of the relationship of government and its people. There are many ways nurses can influence policymaking in the government sphere, at local, state, and federal levels of government. Examples include: • Obtaining appointment to influential government positions • Serving in federal, state, and local agencies • Serving as elected officials • Working as paid lobbyists • Communicating positions to policymakers • Providing testimony at government hearings • Participating in grassroots efforts, such as rallies, to draw attention to problems The Workforce and Workplace Nurses work in a variety of settings: hospitals, clinics, schools, private sector firms, government agencies, military services, research centers, nursing homes, and home health agencies. All of these environments are political ones; resources are finite, and nurses must work in each to influence the allocation of organizational resources. Policies guide many activities in the health care workplaces where nurses are employed. Many that affect nursing and patient care are internal organizational policies such as staffing policies, clinical procedures, and patient care guidelines. External policies are operative in the health care workplace also; for example, state laws regulating nursing licensure. Federal laws and regulations are evident in the nursing workplace such as Occupational Health and Safety Administration regulations regarding worker protection from bloodborne pathogens. Policy influences the size and composition of the nursing workforce. The ACA authorizes increased funding for scholarships and loans for nursing education, potentially augmenting existing workforce programs funded under Title VII and Title VIII of the Public Health Service Act. The nongovernmental Commission on Graduates of Foreign Nursing Schools is authorized by the federal government to protect the public by ensuring that nurses and other health care professionals educated outside the United States are eligible and qualified to meet U.S. licensure, immigration, and other practice requirements (Commission on Graduates of Foreign Nursing Schools, 2009). The National Council of State Boards of Nursing is a not-for-profit organization that brings together state boards of nursing to act on matters of common interest affecting the public’s health, safety, and welfare, including the development of licensing examinations in nursing (National Council of State Boards of Nursing, 2009). These are just a few examples of the external forces that shape workforce and workplace policy. Associations and Interest Groups Professional nursing associations have played a significant role in influencing practice. Many associations have legislative or policy committees that advocate policies supporting their members’ practice and advance the interests of their patient populations. Working with a group increases the effectiveness of advocacy, provides for the sharing of resources, and enhances networking and learning. In fact, these associations can be excellent training grounds for novice nurses to learn about policy and political action (see Chapter 4). Nurses can be effective in association policy activities by serving on public policy or legislative work groups, providing testimony, and preparing position statements. When nursing organizations join forces through coalitions, their influence can be multiplied. For example, The Nursing Community (www.thenursingcommunity.org) is an informal coalition of national nursing organizations that formed to speak with one voice on matters important to national policy and political appointments (see 15Chapter 75). The Coalition for Patients’ Rights (www.patientsrightscoalition.org) is a group of more than 35 national organizations representing health care professionals that is working to fight the American Medical Association’s attempts to limit patients’ access to nonphysician providers. Twenty members are nursing organizations. Nurses can be influential, not just in nursing associations, but by working with other interest groups such as the American Public Health Association or the Sierra Club. Some interest groups have a broad portfolio of policy interests, whereas others focus on one disease (e.g., National Breast Cancer Coalition) or one issue (e.g., driving while intoxicated, the primary focus of Mothers Against Drunk Driving). Interest groups have become powerful players in policy debates; those with large funding streams are able to shape public opinion with media advertisements. The Community A limited number of nurses will have the opportunity to influence policy at the highest levels of government, but extensive opportunities exist for nurses to influence health and social policy in communities. Nursing has a rich history of community activism with remarkable examples provided by leaders such as Lillian Wald, Harriet Tubman, and Ruth Lubic. This legacy continues today with the community advocacy efforts of nurses such as Cora Tomalinas, Mary Behrens, Ellie Lopez-Bowlan, the Nightingales who took on Big Tobacco, and the nurses who are a part of the Canary Coalition for Clean Air (their stories appear in this book). A community is a group of people who share something in common and interact with one another, who may exhibit a commitment to one another or share a geographic boundary (Lundy & Janes, 2001). A community may be a neighborhood, a city, an online group with a common interest, or a faith-based network. Nurses can be influential in communities by identifying problems, strategizing with others, mobilizing support, and advocating change. In residential communities (such as towns, villages, and urban districts), there are opportunities to serve in positions that influence policy. Many groups, such as planning boards, civic organizations, and parent-teacher associations, offer opportunities for involvement. Health The Framework for Action includes health as an element of the model to represent that optimal health is viewed as the goal of nursing’s policy efforts. Optimal health (whether for the individual patient, family, a population, or community) is the central focus of the political and policy activity described in this book. This focus makes it clear that the ultimate goal for advancing nursing’s interests must be to promote the public’s health. Nursing embraces a broad definition of health that aligns with the World Health Organization (1948): “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It incorporates the concept of positive health, not just ill health (Greene et al., 2014). This definition requires a focus on creating communities that thrive economically, have safe environments, and use resources to ensure that their members have access to good nutrition and other elements that can promote health. Health and Social Policy This definition of health leads to the focus on health and social policy as key elements in the Framework for Action. Many factors that affect health are social ones, such as income, education, and housing. Although nurses involved in policy often focus on health policies, the emphasis on upstream factors requires a broader focus on the socioeconomic factors that affect health, including labor policy, laws that can stimulate job creation, or local ordinances on smoking bans. Health Systems and Social Determinants of Health The health care system is the focus of most discussions of health policy to date. Much of this book focuses on understanding the complex and sometimes chaotic U.S. health care system, the ACA’s role in augmenting the system’s performance, and other 16policies needed to achieve the Triple Aim. It also addresses the powerful impact that upstream factors have on the health of populations. A singular focus on the health care system is limited in the extent to which it can lead to higher levels of health for individuals, families, and communities. Nursing Essentials Nursing has also developed a competency-based educational curriculum supporting future nurses’ involvement in policy. The American Association of Colleges of Nursing (AACN) publishes the necessary curriculum content and expected competencies of all nursing school graduates from baccalaureate, master’s, doctor of nursing practice, and research doctorate (PhD) programs. These documents serve as a framework for twenty-first-century nursing and ground the profession in the direct and indirect care of individuals, families, communities, and populations. The content builds on nursing knowledge, theory, and research and derives knowledge from a wide array of fields and professions. A study by Byrd and colleagues (2012) found that undergraduate nursing students for the most part are largely unaware of the importance of political activity for nurses. After participating in a robust and active public policy learning activity, students measured high on a political astuteness scale. This study suggests that political skills can be learned when presented with relevance to nursing and used to hone skills such as inquiry, critical thinking, and complex problem solving. These results highlight the importance of increasing students’ awareness of how to participate in the political process, as well as encouraging their participation in student and professional organizations. For each level of nursing education—BSN, MSN, DNP, and PhD—there is a clear expectation that graduates will have policy competency, with increasing emphasis on policy leadership as nursing students progress academically, although this is less well defined for PhD graduates (AACN, 2006; AACN Task Force, n.d.). These essentials make it clear that health policy directly influences nursing practice and every aspect of the health care system. It is understood that patient safety and quality cannot be addressed outside of the context of policy. The broader policy context is emphasized throughout nursing degree programs. It is expected that DNP graduates are able to design, implement, and advocate health policies that improve the health of populations. The powerful practice experiences of nurses can become potent influencers in policy formation. Additionally, a DNP graduate integrates these practice experiences with two additional skill sets: the ability to analyze the policy process and the ability to engage in politically competent action (AACN, 2006). See Table 1-1 for a summary of the policy competencies in successive nursing education programs. TABLE 1-1 AACN’s Nursing Essentials Series: Policy Competencies for Nurses Nursing Program Policy Essential: All Nurses at This Level Must Have Expertise in: Description BSN Policy Essential VI1 (2008) Health care policy, finance, and regulatory environments Health care policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the health care system and thereby are important considerations in professional nursing practice. MSN Policy Essential VI1 (1996) Health policy and advocacy Recognizes that the master’s-prepared nurse is able to intervene at the system level through the policy development process and to employ advocacy strategies to influence health and health care. DNP Policy Essential V1 (2011) Health care policy for advocacy in health care The DNP graduate has the capacity to engage proactively in the development and implementation of health policy at all levels, including institutional, local, state, regional, federal, and international levels. DNP graduates, as leaders in the practice arena, provide a critical interface among practice, research, and policy. Preparing graduates with the essential competencies to assume a leadership role in the development of health policy requires that students have opportunities to contrast the major contextual factors and policy triggers that influence health policymaking at various levels. Research-Focused Doctorate in Nursing (PhD)2 (2010) Curricular elements include: Communicate research findings to lay and professional audiences and identify implications for policy, nursing practice, and the profession Strategies to influence health policy. Leadership related to health policy and professional issues. 1The American Association of Colleges of Nursing. Essentials Series. Baccalaureate (2008); Masters (1996); DNP (2011). Retrieved from www.aacn.nche.edu/education-resources/essential-series. 2The American Association of Colleges of Nursing. (2010). The Research-Focused Doctoral Program in Nursing: Pathways to excellence. Report from the AACN Task Force on the Research-Focused Doctorate in Nursing. Retrieved from www.aacn.nche.edu/education-resources/phdposition.pdf. Sources: Policy and Political Competence Competence is being adequately prepared or qualified to perform a specific role. It encompasses a combination of knowledge, skills, and behaviors that improve performance. Nurses are often reluctant to become involved in policy because of the “politics.” Political skill has a bad reputation; for some, it conjures up thoughts of manipulation, self-interested behavior, and favoritism (Ferris, Davidson, & Perrewe, 2005). “She plays politics” is not generally considered to be a compliment, but true political skill is critical in health care leadership, advocating for others, and shaping policy. It is simply not possible to succeed in any decision-making arena by ignoring the political realm. Ferris, Davidson, and Perrewe (2005) consider political skill to be the ability to understand others and to use that knowledge to influence others to act in a way that supports one’s objectives. They identify political skill in four components: 1. Social astuteness: Skill at being attuned to others and social situations; ability to interpret one’s own behaviors and the behavior of others. 2. Interpersonal influence: Convincing personal style that influences others featuring the ability to adapt behavior to situations and be pleasant and productive to work with. 3. Networking ability: The ability to develop and use diverse networks of people, and the ability 17to position oneself to create and take advantage of opportunities. 4. Apparent sincerity: The display of high levels of integrity, authenticity, sincerity, and genuineness (pp. 9-12). In most cases, policymakers are generalists who make decisions on a broad range of issues. Nurses can have a profound impact on policymaking by using their knowledge to frame and define health policy alternatives. Influencing policy at all levels requires a strong set of interpersonal skills, integrity, and knowledge. According to O’Grady and Johnson (2013), political competency, at either the individual or the organizational level, can be defined by three main elements: deep knowledge, political antennae, and power (Figure 1-7). FIGURE 1-7 Political competencies. (From O’Grady, E. T., & Johnson, J. [2013]. Health policy issues in changing environments. In A. Hamric, C. Hanson, D. Way, & E. O’Grady [Eds.], Advanced practice nursing: An integrative approach [5th ed.]. St. Louis, MO: Elsevier-Saunders.) Deep Knowledge Deep knowledge requires freely sharing expertise and gaining the knowledge you need from others. Subject-matter expertise without knowledge of policy and its processes is a doomed strategy. Deep knowledge involves knowing the viewpoints of others, including the opposition, and having a clear message and data at the ready to support your position and neutralize opposition. For example, many physicians’ organizations oppose expansion of practice for APRNs, citing patient safety as a primary concern. Politically competent nurses can arm themselves with a summary of decades of evidence citing no such concerns (Newhouse et al., 2011; O’Grady, 2008). 18 Political Antennae Developing political competence requires a continuous scanning of the environment, and it is critical that nurses offer solutions to policy problems that are not solely nursing focused but also address the Triple Aim. Agendas cannot be advanced without the formation of coalitions and networks. Influencers of policy must consider alternative scenario development to use if opposition develops. For example, the 2008 recession had an impact on the nursing shortage: many nurses chose not to retire during that uncertain economic period. The nursing community was able to maintain nursing education funding despite the lessening of the nursing shortage using scenario development. For example, during the economic downturn and slashing of many federal programs, nurses were able to create a scenario in which the aging population explodes, the nursing workforce nears retirement age, and there is a dire nursing faculty shortage. Projections were made predicting catastrophic hospital vacancy rates and unmet health care needs. This scenario was highly effective in preventing cuts in federal funding to nursing education. Having political antennae requires active listening with policymakers to understand their motives and to develop strategies that fit their political objectives. So if policymakers promised constituents they would not raise taxes, the politically competent nurse would work in a coalition to help find a budget-neutral solution. Finally, having political antennae requires the avoidance of bridge-burning. Ruptured relationships can cause lasting damage, not only to the nurse involved but also to the profession. Many wounds can develop during policymaking, and it may be crucial that one exercises restraint. Political and policy disagreements require a response of genuine warmth, a quality that can go a long way in building trust. Learning how to navigate differences and agreeing to disagree without being disagreeable are important political skills. Use of Power Power is the ability to act so as to achieve a goal. In the policy process, power is knowing who has it, who is on what committee, and who are the thought leaders in the community. A coalition is one important way nurses can augment their policymaking power. But an individual nurse can claim it by being articulate and having an elevator speech that can spark interest. 19 Application of power requires raising one’s awareness about what is true and what is false. Being grounded in truth, such as knowing the value of human caring and the role that nursing can have on individuals and populations, is a form of personal integrity that leads to power. Using power is a choice that requires a noncondemnatory and helpful attitude. By freely giving expertise away and approaching “difficult” people with a benign attitude (they are doing the best they can), we hold onto our integrity, build trust, and keep emotions in check. To be effective in the policy arena, nurses must have a sharp focus on the evidence, not emotion. Advancing nursing’s policy agenda through such a use of power demands that we drop narcissism and nursing parochialism and focus on problem solving. Nursing narcissism is when a nurse shows an inordinate fascination with oneself, self-centeredness, and a high degree of smugness. This can include taking sole responsibility for some action or project in which a team was responsible. Nursing parochialism is when a nurse is in a problem-solving context (policy meeting) and only offers up the solution of “nurses” as the remedy to every problem. Parochialism is an approach that narrows options and interests and appears self-serving. Both of these destructive approaches do not deploy the cost-quality-access triad framework to problem solving and therefore severely constricts nursing power. They are to be avoided at all costs and nurses exhibiting these attitudes must be removed from decision-making tables. Effective use of power avoids polarization, egotism, and self-serving postures at all costs. Bringing nurses’ stories to the policy arena is, however, a powerful way to pair the human story to the scientific evidence. Corralling the political power of the 3.1 million registered nurses in the U.S. can only occur if individual nurses join, support, and fully engage with professional nursing organizations. More than any other effort to date, The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) has brought disparate nurses together to engage across associations and educational institutions, and with new community partners, to change policy. Many of the recommendations direct policy changes resonant with nurses. This effort is increasing nursing’s political competence, but more could be done: printed op-eds, blog posts, and interviews with nurses in major media outlets could capitalize on the high regard the public has for nursing. Nurses who effectively use power are a sought-after and a valued asset. They get invited to the table, but they are asked back and often invited to more tables with ever-expanding influence. This requires a great degree of knowledge, along with humility, a problem-solving attitude, and a patient-centered lens. Such activities and attitudes strengthen an individual’s interpersonal power and integrity, which can inspire others. 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In practice, facilities are designated as “medical homes” if they meet criteria set by the National Committee on Quality Assurance. This book will use that language, while recognizing that “health hom

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