Optimism as a Political Act

I want to rise to the challenge of being a policy columnist, and write what I believe is the truth about APNs, and be original, independent and free of artifice, so I need to pay attention to the larger context—what’s happening in Washington, how are the pockets of innovation across the country playing out, how are APNs experiencing practice across the United States. I have been reporting on APNs and health policy for years, and then “IT HAPPENED” on March 23, 2010. President Obama signed the  transformational  ‘Patient Protection and Affordable Care Act’ into law…an international news event that made the front pages of the New Delhi newspapers. I know this because I was in India and missed the whole thing. Although getting news in an international context is interesting, it lacked the detail I craved.

A Quick Look at the New Legislation
At the first opportunity, I dove into the details of the bill, while still battling “Delhi belly” and disorienting jet lag. I could not help but be overcome by a sense of wonder at what actually got passed. Essentially this new law of the land is the necessary spark that will shift the power dynamic in healthcare from profit-driven insurers to patients. It begins to re-incentivize health systems to focus on quality of care and patient-centeredness. For example, the legislation directs the Secretary of Health and Human Services (HHS) to test models that bundle payment to health systems, so that the cost risk is shifted to the delivery system and away from the payor. Delivery systems will be given one predetermined payment for all of the care for an episode of illness, such as a payment of $30,000 for open heart surgery, which would include all pre-op care, 3-months’ post-op care, and any and all complications.  It builds in deep incentives for systems to improve their care processes and presents a number of possibilities for APNs.

The new legislation has remarkable patient protections, many of which will be in place by September of this year; others will be phased in over several years. The laws that will be in place this year will have immediate impacts that may result in a surge in demand for APNs based on the provisions effective in the coming months (for a listing of changes, see Immediate Patient Protections Expected by September 2010). 

The legislation is chock full of provider-neutral language, but there are two exciting provisions that are highly specific to APNs. There are true opportunities for APNs to reframe what excellent care looks like; in a way, the legislation is providing public funds we can use to prove ourselves.

Graduate Nursing Education
The reform law includes a demonstration project to create a Graduate Nursing Education program. Medicare funding for workforce development has historically been almost entirely directed at physicians (at a cost of around $8 billion dollars annually).  This demonstration would take Medicare dollars and direct them to APN education, an open acknowledgement of and significant investment in the value of APNs by the federal government. This provision limits the scope of the demonstration to only five hospitals. However, if the study is methodologically congruent with health services research standards, it should answer policy questions such as, “do we get greater value for our Medicare dollar—such as lowered cost, reduced readmissions, and other favorable outcomes—by investing in the education of APNs?” While some in the nursing community are disappointed at the small number of hospitals in the demonstration, there is no reason for us to not include behemoth hospitals across the states so that the results are significant and scalable to national policy. Moreover, we can sharpen our distinction from that of physicians, highlighting and demonstrating what a beautiful solution APNs are to many of the most perennial problems in health care. We can create this care-transition role that is fun to work in, avoiding one with a narrow focus on a medical model. that only just allows for our survival, or worse. This is not frivolous. Avoiding mind-numbing work that does not keep our patients alive and whole will be key to success and sustainability.

Opportunities always look bigger going than coming. If the study is carried out with the highest caliber of science and with our best nursing and health services researchers carefully planning the design, this demonstration opportunity could position APNs as integral to the care of Medicare patients for generations to come. APN education funding would no longer be an annual Title VIII appropriations fight, subject to irrational political circumstances. Rather, this study could be the beginning of APNs being viewed as integral to the care of Medicare patients and worthy of funding through the Medicare program. It could represent a sea of change by way of a formal and steady funding mechanism for APN education.

Demonstration to Reduce Rehospitalization
This demonstration will build on the important work of Dr. Mary Naylor’s care transitions by assigning funding to APNs or physicians to assist patients through care transitions and to test home-based primary care models. Our chance to shine! This is another opportunity for APNs to develop robust science to showcase how the holistic and caring APN approach to care coordination can measurably improve patient outcomes and decrease costs.

Other Exciting Provisions for Patients
While the patient protections will help patients gain access to the system, we all agree the system they will be accessing is broken. There are sound wellness and prevention measures for patients, such as food labeling, report cards, and tracking the epidemiology of chronicity. More than $11billion dollars is allocated to access issues including boosting the education of nurses and increasing primary care, community health, and nurse-managed health centers. The legislation contains language supporting the development of medical-home and chronic-disease management programs. The new law infuses support and infrastructure for our nation’s health workforce and explicitly addresses programs to promote wellness and public health. There are loads of title VIII (Nursing Workforce Development) provisions, which are succinctly described on AACNs outstanding website: www.aacn.nche.edu/Government/pdf/AACNChartHCReform.pdf

Individual APN Tasks
We must continuously acknowledge the inequitable and dysfunctional nature of pre-reform health care and the role of the stakeholders who perpetuate that system. We must remember our professional responsibility as patient advocates in the broadest sense. We have all adapted to working in a system that often doesn’t work, arguing with insurers, and going around barriers to secure services or medications for patients. Some of us, I am sure, have even used deceit to get patients the care they need. These burdensome acts must be more effectively challenged by APNs as we move through dramatic reform. It is our role to not participate in the “games” inherent in the current system but rather to expose them.

There are immediate and highly concrete steps every APN can take to facilitate and work towards a system built on social justice, reduced disparities and discrimination, increased access to care, decreased waste, and lowered costs. First, every APN must be in a practice that measures the quality of the care he/she provides. Second, every APN must be in a practice that is actively reducing costs, which can include such things as having comparative pricing for different treatments and diagnostics so that informed decisions are made with an eye to cost. Third, APNs should develop relationships with state policymakers. The new legislation leaves a lot of room for interpretation, and there are short-term fixes and phase-ins over years. One thing is clear—since many of the reform measures will be worked out at the state level, we will need a cadre of APNs to be active in statewide and local planning. Step up efforts to energize and engage APNs at the state level, especially in the design of the health exchanges and in getting the requirements in the Licensure, Accreditation, Certification, Education (LACE) document in place. As the surge for APNs unfolds and 32 million more people gain coverage, we must increase our resolve to remove barriers to APN practice and push for the LACE framework. Fourth, APNs need to talk to patients about health reform and rally the public around a far better way of receiving health care. Mercifully, the talk of death panels has abated; however, a great deal of misinformation about government interference has instilled misguided fear in many Americans. Talk with patients about why change is needed and how it may affect them.

Optimism is a political act. Those who prefer the status quo are perfectly happy for us to think nothing is going to improve. To me, cynicism is obedience. The pervasive cynicism we saw in the health reform debate is self-destructive and plays into the hands of those who resist change and want to preserve the old ways of doing things because of the money to be made. Imagine the degree of cynicism we endured when insurers were allowed to drop cancer patients in the middle of chemotherapy. What does this say about our humanity and tolerance for profit at any cost? What is so ground-breaking about healthcare reform 2010 was President Obama’s leadership and his ability to stare directly and without interruption at the massive problems with the health insurance industry while insisting that these problems could be solved. This stubborn commitment to addressing these enormous problems that create social injustices was not naïve but spoke to a larger truth that there is a better way of doing things.

Resilience and Adaptability: Let’s Not Forget
Let’s not forget the task before us is to focus on imaginative solutions and design demonstrations that are sustainable, scalable, and make a huge difference in the lives of patients. Let’s not squander this opportunity to showcase what APNs at the center of healthcare could do to improve quality and lower cost. By focusing on creative solutions, we can transcend political barriers that separate us.

There are many ways for us to unleash our NP creative and entrepreneurial spirit, and it starts with remembering the vows we made as nurses to serve as patient advocates. My favorite recent example of creative solutions and widening our circle is an assignment I gave to doctoral NP students in which they are required to write op-eds on a health policy topic that they care deeply about. A number of them, with titles such as “Childhood Obesity,” “Smoking Cessation,” and “Palliative Care,” have been published. These op-eds are an act of political competence since these NPs now know they are knowledgeable and go directly to the public to educate them on innovative policy solutions. These op-eds overcome powerlessness when APNs look at hard problems and see imaginative solutions. They tell the story in way that gets people to care about it. It is heartening to see the next generation of ANPs, armed with doctorates and coming from a place of power, making sure their voices are heard by writing directly and unapologetically about their concerns and ideas for solutions.

Let’s not let these reform opportunities for APNs be taken down by thugs in a dark alley. We might even expect a backlash from those people who traditionally have opposed our practice or new factions dedicated to misinformation. A posture of “optimistic fighter” is in order because the services we provide and what we can do is so self-evidently real and effective.

We owe a debt of gratitude and respect to those nursing lobbyists who helped get these forward-thinking provisions in the final legislation. While the APN debate was not made public, creative solutions were being offered and heard quietly and behind the scenes. We create our opportunities by asking for them—in this reform process, we asked! This reform must be seen as a tremendous victory for those committed to a system in which caring for the whole person is a high priority and a sign of true prosperity in our country.