Karen S. Cox, PhD, RN, FACHE, FAAN
In March of 2019, the Board of Directors approved the American Academy of Nursing's Policy Priorities for 2019-2020. The process began by seeking insights from the organization's Expert Panels (EPs). With 24 EPs, the organization has a wealth of knowledge that is broadly defined, but also includes specific bodies of research and practice that help inform policy at the institutional, state, and federal levels. Last year, in an attempt to narrow the organization's focus, the Board selected particular policy priorities that were key drivers in only a few select areas. This year, we elected to take a different approach.
Through a process of theme analysis and robust discussions at our monthly Board meetings, the decision was made to expand our priorities so that they are broad and nimble enough to respond to current and emerging debates. The end result includes the Academy's commitment to:
Advance Health Equity & Champion Wellness
The Academy advances policies that closely consider the social determinants of health. Where individuals were born, live, work, attend school, or travel, all impact their wellness. Moreover, the need grows to reduce the impact of violence, toxic stress, and other environmental factors, on the individual, the family, and the community. The Academy believes to truly improve health, policies must expand access to quality care through innovative approaches, aimed at eliminating health disparities. To safeguard our future, the Academy champions the wellness and safety of not only children and vulnerable populations, but of every individual in any location during all health stages.
Promote Innovation & Sustainability
The Academy advances policies that adopt modernizations which are sustainable and effective over time. This includes technologies, treatments, and models of care. Policies that recognize providers for their expertise, education, and clinical training amplify patient choice. Competition in the healthcare provider market increases access and reduces cost while improving quality. Moreover, innovation in the health care industry, as well as emerging practices, must be tested and advanced for heightened impact and outcomes. This includes necessary investments in research and scientific careers.
Reduce Patient, Provider, & System Burden
The Academy advances policies that provide patients, providers, and systems, the ability to give and receive optimal care. This requires efforts to reduce regulatory burden on daily practice while balancing patient privacy protections. In order to achieve the goal of placing the patient at the center of care delivery, policies must equally support providers and systems.
These policy priorities will guide our work over the next two years and will be threaded across our EP work, policy conference, and signature initiatives (Institute for Nursing Leadership, Edge Runners, and the Council for the Advancement of Nursing Science). This is to keep pace with the national election cycle so that we can ensure we are aligned with the pressing issues of the day and be thoughtful contributors. The goal of this work was to be intentional actors instead of being reactors. There is great opportunity for collaboration, partnership, and advancement using this strategy. Below are a few prime examples of how the Academy envisions this alignment moving forward.
On March 20, 2019, the National Academies of Science, Engineering, and Medicine held their first public session for the Committee on The Future of Nursing 2020-2030.
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This consensus study, led by the National Academy of Medicine, “will chart a path for the nursing profession to help our nation create a culture of health, reduce health disparities, and improve the health and wellbeing of the U.S. population in the 21st century.”(¶3)National Academy of Medicine (2019, March). Public Session for the Committee on the Future of Nursing 2020-2030. Retrieved from: http://www.nationalacademies.org/hmd/Activities/Workforce/futureofnursing2030/2019-MAR-20.aspx
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Reading this goal, it is clear to see the direct synergy with the Academy's first policy priority, Advance Health Equity & Champion Wellness. The work of the new Future of Nursing consensus study also draws on one of the Academy's signature initiatives, the Edge Runners. As the committee looks to advance recommendations related to the anticipated health and social care needs in the next decade, the work of the Academy's Edge Runner models are prime exemplars of nurses transforming care in the community for local and global impact.National Academy of Medicine (n.d.) Activity: The Future of Nursing 2020-2030. Retrieved from: http://www.nationalacademies.org/hmd/Activities/Workforce/futureofnursing2030.aspx
Promote Innovation and Sustainability, the Academy's second policy priority, looks at the impact of technology, team-based care, and science as essential elements to improve quality, cost, efficiency, and effectiveness. To that end, a number of national initiatives are pursuing policy change and developing new programs to achieve this goal. One significant body of work is the National Institutes of Health's precision medicine/health initiatives. Precision medicine is focused on personalized treatment by investigating an individual's genetics, environment, and lifestyle.
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At its most recent State of the Science (2018), the Council for the Advancement of Nursing Science highlighted nursing's unique contribution to advance this work. The entire conference focused on demonstrating where nurses are leading research portfolios in genetics/genomics as well as personalized care.National Institutes of Health, National Library of Medicine (n.d.) What is the Precision Medicine Initiative? Retrieved from: https://ghr.nlm.nih.gov/primer/precisionmedicine/initiative
Core to the priority of promoting innovation and sustainability is patient choice as it relates to providers. Here again federal officials are examining options for better policy. In December of 2018, the Trump Administration released the report Reforming America's Healthcare through Choice and Competition.
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In the report it states,U.S. Department of Health and Human Services (2018, December). Reforming America's Healthcare System through Choice and Competition. Retrieved from: https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf
When state regulators impose excessive entry barriers and undue restrictions on SOP [Scope of Practice] for particular types of providers, they often are not responding to legitimate consumer protection concerns. There is a risk that healthcare professionals with overlapping skill sets will seek these restrictions; they view SOP restrictions as an easy, state-sanctioned opportunity to insulate themselves from competition (p. 32).
For example, advanced practice registered nurses (APRNs), physician assistants (PAs) pharmacists, optometrists, and other highly trained professionals can safely and effectively provide some of the same healthcare services as physicians, in addition to providing complementary services (p. 33).
This report cites evidence from publications such as the Future of Nursing: Leading Change, Advancing Health, National Governors Association, and Federal Trade Commission. Moreover, the Medicare Payment Advisory Commission (MedPAC, an independent congressional agency, established by the Balanced Budget Act of 1997 [P.L. 105-33]) recently evaluated the payment policies for APRNs and recommended:
1. The Congress require APRNs and PAs to bill the Medicare program directly, eliminating “incident to” billing for services they provide; and
2. The Secretary refine Medicare's specialty designations for APRNs and PAs.5MedPAC blog (2019, February 15). Improving Medicare's payment policies for Advanced Practice Registered Nurses and Physician Assistants. Retrieved from: http://www.medpac.gov/-blog-/the-commission-recommends-aprns-and-pas-bill-medicare-directly-/2019/02/15/improving-medicare's-payment-policies-for-aprns-and-pas5MedPAC blog (2019, February 15). Improving Medicare's payment policies for Advanced Practice Registered Nurses and Physician Assistants. Retrieved from: http://www.medpac.gov/-blog-/the-commission-recommends-aprns-and-pas-bill-medicare-directly-/2019/02/15/improving-medicare's-payment-policies-for-aprns-and-pas
In these two recommendations, reimbursement should be based upon the level of care provided by the individual (physician, APRN, or PA) providing it. The opportunity to help advance these recommendations at the federal level speaks directly to the Academy's interest to promote innovation and sustainability.
Finally, the Centers for Medicare and Medicaid Services’ (CMS) central initiative is Patients over Paperwork.
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The goal of this work is to “reduce unnecessary burden, increase efficiencies, and improve beneficiary experience.” The Academy's third priority to Reduce Patient, Provider, and System Burden directly speaks to this timely initiative. While currently under the purview of CMS, the interest to reduce burden is system-wide throughout the U.S. Department of Health and Human Services.Centers for Medicare and Medicaid Services (n.d.) Patients over Paperwork. Retrieved from: https://www.cms.gov/About-CMS/story-page/patients-over-paperwork.html
Great opportunity lies ahead based on these three priorities to help the Academy's goal of transforming health policy through nursing practice. Therefore, the Board of Directors is seeking to further hone and synthesize policy recommendations that have already come out of the American Academy of Nursing. In this issue, there are no policy pages. This was not due to a lack of scholarship on behalf of our Expert Panels, but a strategic decision by the Board of Directors to focus on creating a structure for future work.
In recent years, the Board was purposeful in our request to increase the number of Academy policy documents. The EPs took on this call to action with great fervor. In fact, over the last four years, the Academy has advanced 53 policy documents published in Nursing Outlook, which included 316 policy recommendations. In 2018 alone, there were 22 publications that offered the public 155 policy recommendations, with 20 EPs contributing to the content. The organization has already established a body of knowledge to engage further in the 2019-2020 Policy Priorities. It is time to be impactful.
The Academy is launching this new strategy at a time of great opportunity as the organization is moving through multiple transitions (i.e. new CEO, new staff, new Board members). This is a prime time to reorganize, realign, and chart a path forward based on an incredible foundation the Academy has built. This is our call to collective action. The Academy champions the innovative, compassionate, and evidence driven practice of a profession that is four million strong and highly trusted. Nurses are leaders in every community, whether they have a formal or informal title. To leverage this strength, we must partner, consider uncharted territory, and not rely on the premise of “this is how it has always been done.” Now is the time to be leaders among leaders.
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