The title of this message,
Nursing in the Front Lines of Obama Health Care Reform Era, was the headline for a May 8, 2009 telenews briefing sponsored by the American Academy of Nursing (AAN) “Raise the Voice” campaign. This news briefing featured nurse-managed health centers as a key solution to the healthcare crisis. The main message of this briefing is that advanced practice nurses (nurse practitioners [NPs]) have developed an infrastructure of health centers and convenient care clinics that are already in place and can meet the primary healthcare needs of our citizens if financial and regulatory barriers are removed. University of Miami President Donna E. Shalala, former Secretary of the US Department of Health and Human Services (HHS) and Chair of the National Advisory Council of the Robert Wood Johnson Foundation-funded “Raise the Voice” campaign of the American Academy of Nursing, said, “While increasing access to health insurance will help improve access to health care, our nation's health care crisis cannot be solved by insurance alone. Enhanced nurse practitioner involvement in primary care has the potential to dramatically increase access to health care, improve care for patients with chronic diseases, and improve the efficiency of the health care system, all by maximizing the use of our existing health care resources. One option, Nurse-Managed Health Centers, need additional federal funding. Just as important, nurses need a seat at the table when true reform is being debated.”
1The case for Nurse-Managed Health Centers encompassing a broader range of care was made by Independence Foundation President and nurse, Susan E. Sherman: “Philadelphia may be the future vision of health care reform in the United States. Because we believe in the model's potential, the Independence Foundation has invested millions of dollars in 12 Nurse-Managed Health Centers that provide primary care, health promotion, and disease prevention services. These Nurse-Managed Health Centers help clients manage current health problems, detect potential health problems, and reduce the risk of future health problems. We are proud of our support of this innovative model of care, but our support is not enough to sustain these centers. We need federal funding to bolster private sector support.”1 Pennsylvania Governor Ed Rendell discussed his state's groundbreaking effort to support these centers and care provided by NPs. He pointed out that his state made 49 changes in regulatory and statutory barriers to NPs being able to practice to the full scope of their roles.
At this same news conference, Tine Hansen-Hurton, CEO of the National Nursing Centers Consortium, a non-profit organization comprised of Nurse-Managed Health Centers throughout the country, outlined a 5-point plan of innovative delivery models to increase access to health care, improve care for patients with chronic diseases, and improve the efficiency of the healthcare system:
•Ensure Access to Care for the Underserved by Protecting the Government's Investment in Nurse-Managed Health Centers. Many Nurse-Managed Health Centers are affiliated with academic schools of nursing and received federal start-up funding through the HRSA Division of Nursing. Although these centers serve a high percentage of uninsured patients, they often cannot qualify for the enhanced resources that the government offers Federally Qualified Health Centers (FQHCs). By increasing funding and reimbursement for this innovative model of care, the government can encourage the sustainability of existing primary care access points and help health centers offset the high costs of providing care to uninsured, low-income and vulnerable families.
•Improve Geriatric and Chronic Care by Adopting an Inclusive Definition of the “Medical Home.” Nurse practitioners are currently excluded from participating in a number of “medical home” initiatives—including the Medicare Medical Homes demonstration project administered by the Center for Medicare and Medicaid Services (CMS)—despite the fact that Nurse-Managed Health Centers serve as full-fledged primary care homes for hundreds of thousands of individuals. To ensure that America's increasing population of seniors has access to high-quality, comprehensive primary care models, it is essential that the concept of the “medical home” be expanded to include nurse-led practices.
•Create More Efficient Infrastructure for Health Care Administration. Even though the process of provider credentialing is essentially the same for every insurer, providers must submit multiple credentialing applications to all insurers in his or her market. A unified credentialing clearinghouse for all healthcare providers could reduce or eliminate unnecessary delays and redundancies in the credentialing process. This could reduce administrative costs in health centers by 25%.
•Increase Opportunities for Health Information Technology Implementation. Nurse practitioners and Nurse-Managed Health Centers must have the same opportunities as other providers to take part in initiatives designed to improve primary care outcomes. To achieve this, the government must fund health information technology (IT) initiatives outside of its existing funding frameworks, which tend to focus on physician-led practices and existing FQHCs. Given the nation's growing shortage of primary care physicians, it is critical that the government ensures that Nurse-Managed Health Centers have access to incentives that would allow them to implement new health IT initiatives and improve quality of care for their patients.
•Invite New Players to Join the Health Reform Discussion. Nurse practitioners are the fastest growing group of primary care professionals in the country. Although nurse-managed care models are a relatively new movement in health care, they reach large numbers of patients throughout the country. These providers have new ideas that promise to increase the accessibility and affordability of health care in the United States. Without their voices at the health reform table, we may lose the opportunity to implement a more interdisciplinary, team-based model of health care.2 By the time this message is published, we likely will know what form healthcare reform is taking in this Congress. Nineteen years ago, Janelle Kreuger, Linda Moody and one of us (PHM) wrote in this journal: “Far from being the best in the world, the United States' cure-oriented patchwork of fee-for-service medical care has left 37 million American citizens without access to health care. The new public debate on healthcare reform gives nurses an opportunity to transform this ineffective market-oriented medical model into a universal, true healthcare system.”3 Well, now we have
>45 million uninsured, a market-oriented, fee-for-service patchwork that continues to raise many barriers to the innovative, integrated healthcare delivery that nurses are leading.
So why do we think it might be different this time? First, the public views healthcare reform as one of the top priorities for the Obama administration and for Congress. Second, the rapid movement of such reform in the Congress signifies a renewed energy and prioritization. Third, others such as Karen Ignani, President and CEO of America's Health Insurance Plans (AHIP), are now calling for full utilization of nurse practitioners. At a forum on healthcare reform on May 5th at Hunter College, City University of New York, Ignani suggested that a federal pre-emptive directive to override state laws and regulations that remain as barriers may be in order. At the Academy's news briefing, Governor Rendell noted that insurers were key to moving policymakers to support the policy changes in Pennsylvania.
The public is also clear in polls conducted by the Kaiser Family Foundation that they do not favor reform plans that raise their costs or dictate their choices.4 Each of the interest groups who are at the reform tables have agendas that may or may not be focused on the interests of the public. There is much discussion of patient-centered care, but the details continue to focus on the payment mechanisms and the interests of the various groups providing that care.
Interest group politics notwithstanding, we believe this time there are enough voices from both the public and the health professions seeking to support public policies that will transform the healthcare delivery system in cost-effective ways. Thus, the third reason we feel optimistic this time around is the combined power of those voices, focusing on the public good and calling for a health care system that emphasizes the promotion of health, coordination of chronic illness, primary care, and public health.
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