Health Care Reform
Nurses are ethically bound to engage in efforts of improving health and healthcare delivery and, even more important, nurses recently have been called out as key leaders in the reform of healthcare delivery, including many components of the Patient Protection and Affordable Care Act. The Patient Protection and Affordable Care Act, its history, and what healthcare will look like during and after implementa- tion are addressed in this article. A discussion of the role and value of nurses in healthcare reform accompanies knowledge-building and action-oriented resources available to nurses and clients.
As nurses, we are watching and experiencing healthcare reform as both professionals and citizens. The nursing profession is now placed in a unique position to facilitate development
of patient coordination including identification of key points in client care to manage wellness and illness as well as systematic measurement of health outcomes. In this article, we present a review of the Patient Protection and Affordable Care Act (ACA).
When President Obama signed the Patient Protection and Affordable Care Act on March 23, 2010, a collection of laws was created that, as a whole, put in place com- prehensive healthcare and health insurance reform. The development of these laws began much earlier with legislation and regulation designed to create a patientâ€™s a bill of rights, encourage the use of evidence-based best practices, and increase access to affordable healthcare. The resulting ACA legislation focused on building change into our existing system and is the most signifi- cant reform of how we pay for and deliver healthcare since the 1965 adoption of Medicare and Medicaid (Jost, 2014). This legislation represents a complex series of changes.
The major goals of the ACA are to build on our cur- rent system by (1) expanding Medicaid, (2) preserving
surance they have personally selected and are person- ally paying for (Congressional Budget Office, 2014). It is predicted that new and younger people entering the healthcare market will drive the costs of healthcare down. Recent analysis by the Congressional Budget Office now predicts that the costs of implementing the ACA are even lower than previously reported (Stein & Young, 2014). Still, to date, many of the benefits of the ACA remain largely unseen.
The costs of delivering healthcare in our country have become a major concern, with the overall costs of now at 23% of the federal budget and 20% of most household budgets (Centers for Medicare and Medicaid Services, 2014; Hartman, Martin, Benson, & Catlin, 2013). Healthcare costs have risen to a point that 32% of people with insurance have difficulty paying their medi- cals bills, must pay healthcare over time, or are unable to pay at all (Pollitz & Cox, 2014). The No. 1 cause of personal bankruptcy for middle-class, insured, working
U.S. citizens is healthcare costs (Himmelstein, Thorne, Warren, & Woolhandler, 2009). By addressing the cost of healthcare, as well as issues of access to healthcare, better health and financial stability are possible for indi- viduals, businesses, and government.
Historically, U.S. healthcare has been complicated by the inherent competition set up between systems of payers, providers, users, and regulators. Effective healthcare and good and affordable health for any pop- ulation result from high-quality, affordable, and acces- sible care (Lamb, 2014). These three points are fre- quently represented by disparate and disconnected industries, often industries that are competing with each other rather than working together to maintain good health for their clients. The â€œtriple aimâ€ of health reform, and of the ACA, is to (1) improve the patient experience with higher quality care, (2) increase access to care, and (3) control healthcare costs (Institute of
both employer/job-based coverage and Medicare, and
(3) promoting state control of insurance markets. The ACA has had early success in implementing these re- forms and preserving the structure of care (Jost, 2014). Thirty-four percent of new enrollees are under 34 years of age; during the first enrollment period, more than 8 million people have obtained coverage through the ACA Health Insurance MarketPlace, and even many more private pay nonelderly people are covered with in-
Brenda Luther, PhD, RN, Assistant Professor, Director Care Management Programs, College of Nursing, University of Utah, Salt Lake City.
Sara Hart, PhD, RN, Assistant Professor, College of Nursing, University of Utah, Salt Lake City, and Gold Humanism Scholar from the Harvard Macy Institute.
The authors and planners have disclosed no conflicts of interest, finan- cial or otherwise.
Medicine, 2011). The ACA has attempted to deal with more than just payment and cost of healthcare by im- proving the quality of care delivered and access to pre- ventive care and early intervention.
Competition between disconnected organizations is demonstrated in our traditional fee-for-service health- care system. When more services are provided, more rev- enue is generated. But more care does not necessarily result in higher quality care or better health outcomes. Services must represent appropriate interventions and expected outcome based on the clientâ€™s goals of care. While quality is inherently measured and valued in healthcare, it has not often been paid for or incentivized. The economic risks of healthcare costs have traditionally fallen most heavily on third party payers (insurers and the state and federal governments), not the providers.
The ACA and the New Roles for Nurses
The ACA promotes healthcare that is designed within co- ordinated, orchestrated, and value-based care models. Value-based care incentivizes healthcare providers to keep population groups healthy by focusing on outcomes of care rather than volume of service of care. Value-based care incentivizes healthcare organizations to meet benchmark health outcomes for their clients. This also creates healthcare systems that are focused on wellness, prevention, minimizing repetition, and unnecessary costs. Nurses are key players in this component of health- care reform. Uniquely situated on the front lines of pa- tient care, as well as within healthcare payer and supplier agencies, nurses have the expertise and obligation to in- fluence practice and policy (Institute of Medicine, 2011). Nurses promote health, navigate chronic illness, and pre- vent the development of secondary conditions, all of which align with the triple aims of healthcare reform.
As hospitals, insurance providers, and provider groups align to be a part of value-based payment systems, the roles of nurses become integral to promoting these changes. Care managers, care coordinators, and infor- matics expertsâ€”nursesâ€”are vital leadership for directing care process changes, quality and evidence-based inter- ventions, and measurement of care outcomes (Lamb,
2014). Nurses have a demonstrated history of leadership in team-based care processes. Nurses have patient- centered care as a core professional standard and compe- tency. Nurses are pivotal to care quality and patient satis- faction, as well as efficacious use of resources to provide patient-centered and evidence-based care.
What Are the Health Insurance MarketPlaces?
Health Insurance MarketPlaces are centralized sources for state-level information on the options and costs for indi- viduals and small businesses when purchasing affordable healthcare coverage. Individuals use the MarketPlace to determine whether they qualify for insurance premium subsidies (subsidies are cost sharing reductions or govern- ment-sponsored programs based on income). People liv- ing between 130% and 400% of the Federal Poverty Level typically qualify for subsidized policies (Sommers, Graves, Swartz, & Rosenbaum, 2014). States were given the option to develop their own State MarketPlace or to use a state- based but federally developed MarketPlace. In October 2013, the Federal MarketPlace launched with many tech- nical challenges. Yet most stat-developed MarketPlaces were up and functioning with little problems. As of May 2014, more than 8 million new, subsidized enrollees were processed through the MarketPlace and, unexpectedly, more than 12 million private, self-pay clients found afford- able healthcare they could purchase (Stein & Young, 2014). People will continue to access the online MarketPlace individually but in-person navigators are also available to help individuals understand their options and the enrollment process. Open enrollment via the MarketPlaces officially closed March 31, 2014. Until the next open enrollment period, the MarketPlace remains open for enrollment for individuals and families experi- encing qualifying events such as job loss and changes to family composition.
Sources for Educating Ourselves and Our Clients
As nurses, we are always challenged to teach clients about the healthcare delivery system and the ACA has
TABLE 1. D EFINITIONS
Cost-sharing reduction A discount given for insurance through the MarketPlace exchanges based on income and health plan type Deductible The amount the consumer owes for services before the health plan will begin to pay
Federal poverty level Levels of personal income used to determine a clientâ€™s eligibility for Medicaid, Childrenâ€™s Health Insurance Program, and Subsidized Coverage of ACA
Fee-for-service Paying providers for each service they perform rather than the quality of services provided Job-based coverage Insurance coverage offered to employees and often their dependents
MarketPlace A resource to learn about coverage options, compare plans, and enroll. Some are run by the state and others by the federal government
Navigator Trained individual or organization to help consumers and small businesses look for healthcare coverage. Services are free to consumers
Qualified health plan An insurance plan certified to provide the essential benefits and established limits on costs such as deductibles, copay, out-of-pocket
Value-based care Linking provider payments for services to the quality of care they provide
TABLE 2. L INKS FOR C LIENT Q UESTIONS
Need to get ready to enroll?
find alocal navigator?
Why should a client be covered?
What are different types of health insurance?
www.dol.gov Consumer Information on the Affordable Care Act
significantly increased the need for these efforts. Many clients are confused with their options and the pro- cesses for obtaining and accessing health coverage. For example, new users may be surprised that the plans they selected are low cost in monthly premiums and una- ware those will typically translate to higher deductibles, even though the deductibles are typically below policies outside of those offered at the MarketPlace (Jost, 2014). Nurses may find themselves overwhelmed by the educa- tion and information needs of their clients. Below are three tables: a list of definitions (see Table 1) and lists of resources for client questions (see Table 2) and valuable resources for you as a nurse (see Table 3).
Are There New Services Offered Under the ACA?
There are new requirements for the healthcare benefits offered in any Qualified Health Plan. Enrollment in a Qualified Health Plan is required by the Individual Mandate of the ACA. No longer can policies be offered that do not provide â€œEssential Benefitsâ€ such as preven- tive care or comprehensive care or maternity benefits, for example (see Table 4). Previous to the ACA individ- ual insurance policies often lacked these basic levels of coverage. Coverage of the essential health benefits, as mandated under the ACA laws and regulations, ex- panded effective and affordable, quality healthcare cov- erage for millions of Americans, but some have pre- dicted this may also drive up costs of insurance premiums. This controversy continues to play out in the reform debate, but what is also being discovered is how
many people were purchasing ineffective, low-cost/low- benefit policies that actually did not save them money when they needed coverage for essential services.
Interesting components of these essential services are worthy of discussion. For instance, the additional requirement of mental health and behavioral health, in- cluding counseling and psychotherapy, has resulted in many primary care organizations developing integrated physical and mental health services for their clients. Those with chronic illness now have access to ongoing therapy services to help them achieve optimal function. New wellness and prevention and behavioral health ser- vices are quickly being expanded into the traditional service lines of primary care, medical homes, family practice, and outpatient services.
Key Elements of an Accountability Care Organization
Accountable care organizations (ACOs), a Medicare Pilot Program under the ACA, is a way of organizing care delivery that establishes a system of value-based payment contracts for large populations of the insured. The ACO model allows Medicare, and other payors of healthcare, to contract with providers for services based upon benchmark health outcomes for their clients. Though still a fee-for-service model, the ACO payment structure is based on financial incentives to improve benchmarks. For example, an ACO may negotiate that a majority of their clients will have controlled blood pres- sure levels. If the ACO attains the agreed-upon bench- mark for their population of their clients, the ACO will share in the savings achieved rather than the insurer keeping all those savings. Incentivized, benchmarked, value-based outcomes system is the heart of creating an ACO framework as a method of healthcare reform.
To set and measure benchmarks for quality and cost, we must first reach agreement on accurate measures of quality. This requires available informatics systems ca- pable of tracking and reporting outcomes data in an ACO. This highlights the importance of new health in- formation technology requirements rolled out in the ACA. Many clinical groups and providers did not have
T ABLE 3. V ALUABLE L INKS FOR H EALTHCARE R EFORM R ESOURCES
American Nurses Association: â€œprofessional organization representing the interests of the nationâ€™s 3.1 million registered nursesâ€
Centers for Medicare and Medicaid Services: governmental website with client and provider Medicare and Medicaid information
Institute of Medicine: â€œan independent, non-profit organization working outside of government to provide unbiased and authoritative advice ftor decision makers and the publicâ€ Kaiser Family Foundation: an independent, non-profit foundation focusing on providing research and knowledge about major healthcare issues
National Council of Nonprofits: a resource and advocate for nonprofit agencies
U.S. Department of Labor: information related to employment-based health plan coverage related to the ACA
TABLE 4. E SSENTIAL H EALTH P LANS B ENEFITS M UST I NCLUDE
Ambulatory services Emergency services Hospitalizations Maternity and newborn care Mental health and substance use disorder services including behavioral health treatment Prescription drugs Rehabilitation and habilitation services Laboratory services Preventative and wellness services adequate systems for ACO participation; thus, the ACA also offered provider networks funding to upgrade and implement information systems.
An ideal model for healthcare delivery reform ad- dresses four key concepts integral to the sustainability:
(1) access, (2) care coordination, (3) healthcare infor- mation technology, and (4) payment reform (Patient- Centered Primary Care Collaborative, 2011). Table 5 briefly presents these concepts based on what we know from trends, data, and evidence (Patient-Centered Primary Care Collaborative, 2011).
Nursing and Integrated Care Teams and ACOs
Identify the problems associated with the current manufacturing system, particularly comment upon shop floor operations and manufacturing planning and control systems.
November 26, 2022
November 26, 2022