Paula M. Davis-Huffman, DNP, ANP-BC, PPCNP-BC
I
n the United States, the health-care environment is an extensive, rapidly changing, all-encompassing arena. This arena includes personal living spaces, providers’offices and clinics, hospitals, extended or skilled nursing care facilities, nursing homes and hospices, numerous service organizations related to health, private and public health systems, and a plethora of other locations and entities providing support and services. Service providers commonly include the pharmaceutical industry, labora- tory or radiological services, and, more recently, information technology services.
Essentially, health care within the system can transpire at any time or in any location where health-care providers, or their surrogates, interact with persons needing or seeking health care or where their personal health information is accessed.
The status of the health-care system in the United States has changed signifi- cantly since 2010 with the passage of the Patient Protection and Affordable Care
K E Y T E R M S Affordable Care Act (ACA) Emergency Medical Treatment
and Active Labor Act (EMTALA) Government health care Health professional shortage
area (HPSA) Medicaid Medicare
National or universal health care Private health care
Public health care Underinsured Uninsured L E A R N I N G O U T C O M E S
● Explore differences between private and public, including government- provided, health care.
● Identify barriers experienced within the U.S. health-care system.
● Discuss the development of the Patient Protection and Affordable Care Act (ACA).
● Describe the differences between Medicare and Medicaid.
● Highlight the role of nurse leaders and managers, and nurses overall, in the area of health policy.
Act, commonly referred to as the Affordable Care Act (ACA). The number of uninsured is expected to decrease over time; however, access to health care, complicated by a lack of providers and services, is of concern to all health-care providers. The cost of health care and the quality of care provided continue to be of paramount impor- tance to nurse leaders and managers who are faced with the consequences of the rising costs of health care, decreasing reimbursement for health-care services, and limited resources.
Many believe that the ACA will transform the health-care system in the United States and provide safer, higher-quality, more affordable, and more accessible care (Institute of Medicine [IOM], 2011). Strong nursing leadership is necessary to make this vision a reality. Nurses are called to be leaders “from the bedside to the board- room” (IOM, 2011, p. 7). Equally important is that all nurses, students, bedside and community nurses, chief nursing officers, members of nursing organizations, and nursing researchers must develop leadership competencies, especially those related to health policy (IOM, 2011).
Nurse leaders and managers determine policies, procedures, and resources for their staff members and facilities to provide safe and quality care and ensure evidence-based interventions to assist in the control of costs and in improved patient outcomes. Nurse leaders and managers must advocate for society by serv- ing as experts in promoting and implementing health policies. Further, nurses are experts in health and should be at the table where and when policies are developed that affect the populations with which they interact.
This chapter discusses the current status of health care in the United States, the ACA, Medicare and Medicaid, health policy, and the role nurse leaders and managers play in these issues.
Knowledge, skills, and attitudes related to the following core competencies are included in this chapter: patient-centered care; teamwork and collaboration; and evidence-based practice.
SYSTEMS WITHIN THE HEALTH-CARE ENVIRONMENT
Health care in most cases can be broken down into private and public health-care sectors. Private health-care sectors include companies, for profit and nonprofit, not associated directly with government agencies, whereas public health-care sectors are often funded by tax dollars.
Private health careis monetarily compensated health care that is provided to indi- viduals seeking care within the health-care environment. The payment for private health care is usually predetermined and sometimes negotiated with health-care providers. The cost of services can be paid directly to the provider by a monetary payment or rendered through government or commercial (private) health insurers, also known as third-party payers. Private health care is the predominant form of health care for persons residing in the United States. Reporting for the U.S. Depart- ment of Commerce, United States Census Bureau, Smith and Medalia (2014) esti- mated that 64.2% of individuals were covered by private health insurance in 2013, of which 53.9% was employment based (provided through an employer). The total percentage of people with health insurance was estimated at 86.6% in 2013.
The U.S. private health-care system is often referred to as “the greatest health care system in the world” but yet is ranked 37th in the world (Murray & Frank, 2010). Life expectancy is often considered a measure of the adequacy of a health- care system’s influence on its population. According to the World Health Organ- ization (WHO, 2014), combined life expectancy in the United States is 79 years for both males and females (76 for males and 81 for females); however, it does not rank within the 10 top-ranked countries for life expectancy in either male or female categories (WHO, 2014).
Public health care, according to the Centers for Disease Control and Prevention (CDC) Foundation, “is the science of protecting and improving the health of fami- lies and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases” (CDC Foun- dation, 2016, para. 1). All states have public health departments that support this role and must report to U.S. government health agencies such as the CDC, which is a division of the U.S. Department of Health and Human Services. In certain states and communities, public health departments often provide primary care to indigent populations and underserved populations. Vaccination service and sexually trans- mitted disease clinics are frequently operated by state and county health depart- ments. These services usually offer reduced payment options or free care for qualified individuals.
The Commissioned Corps of the U.S. Public Health Service, also a branch of the Department of Health and Human Services, is a commissioned corps of health-care providers, including nurses, similar to the military with regard to rank and retirement. Members of this corps work in a number of health-care are- nas, including the CDC, National Institutes of Health, Indian Health Service, Food and Drug Administration, Agency for Healthcare Research and Quality (AHRQ), and many more.
Government health carein the United States is not provided directly by the govern- ment in most cases. The term actually refers to government-provided health insur- ance, such as Medicare and Medicaid (discussed later in this chapter), which is actually provided by the private health-care system.
The Veterans Health Administration and military hospitals and clinics are directly funded by tax dollars and provide care directly to active duty military personnel and former service members of the armed services (Army, Navy, Marine Corps, Air Force, and Coast Guard). These are actual representations of government-provided health care within the Department of Veterans Affairs (VA) and Department of Defense (DOD) system. Both agencies maintain numerous outpatient facilities and hospitals. The VA is primarily staffed by civilians, whereas the DOD has a considerable number of active duty personnel staffing military clinics and hospitals.
In the United States, charity care or reduced-cost care exists for persons who do not have adequate access to the private, public, or government health-care systems as a result of life circumstances (e.g., financial, geographic, lack of transportation).
However, this care is very limited in scope and location.
National or universal health carerefers to health care provided to citizens through the government, usually without the involvement of private health insurers.
Currently, Australia, Canada and the United Kingdom (England, Scotland, Wales, and Northern Ireland), and many other European countries provide this type of health care to their citizens. Although there are many advocates for the implemen- tation of a national or universal health-care system in the United States, politically and culturally it is not likely to occur in the near future.
CURRENT STATUS OF HEALTH CARE IN THE UNITED STATES
Although there have been recent changes to laws intended to improve the health- care system, specifically the ACA, the U.S. health-care system continues to be plagued by barriers stemming from an inability to access the system, cost of care, and quality of care provided (Davidson, 2013) (Fig. 2-1).
Access to Health Care
Accessibility to health care “is particularly hard to disentangle from considerations of health care quality in that it is a prerequisite to receipt of quality health care”
(Docteur & Berenson, 2009, p 2). Health-care quality in the United States appears low in comparison with other countries with regard to prevention and care of chronic conditions. Access barriers experienced by the uninsured(those without health-care insurance coverage) and underinsured(those who have insurance cover- age but lack adequate income to facilitate access to care because of high deductibles and co-payments) likely contribute to decreased health-care quality (Docteur &
Berenson, 2009).
There are primarily two avenues through which health care can be accessed in the United States. The first is through a physician or care provider practice or clinic, and the other is through a hospital emergency department. Provider prac- tices and clinics are generally not required to accept patients with the inability to pay for services provided. Emergency departments, conversely, are subject to the Emergency Medical Treatment and Labor Act (EMTALA)that requires that “all Medicare participating hospitals with emergency departments provide stabilizing emer- gency care for all patients seeking help (including patients in labor), regardless of their insurance status or ability to pay” (La Couture, 2015, p. 1). Often this results in what is considered inappropriate use of the emergency department. In many cases, extended wait times and delays in transfer of patients to inpatient beds result in low patient satisfaction. Developing accurate models of emergency department service completion times is a critical first step in identifying barriers to patient flow and patient wait times (Ding et al., 2010).
US Health-care System
Access Cost Quality
Figure 2-1Barriers within the U.S. health-care system.
Nurses at all levels must understand the implications of ineffective access to the health-care system. This may manifest as a patient who is seen in the emer- gency department, perhaps on numerous occasions secondary to lack of insur- ance. This situation may translate into an inability to access more affordable care by a primary care provider. Traditionally, nurses have not concerned themselves with how a patient pays for services rendered because, in theory, care is provided to each patient in the same manner regardless of ability to pay. Often, however, these patients are labeled as noncompliant, and caring for them in a busy emer- gency department can be stressful when more urgent needs are evident. This situation is grossly unfair to these patients and does affect how they are treated in the emergency department. Further, labeling and treating patients in this manner violate provision one of the American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements (2015), “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person”
(p. 1). The same can be said for patients admitted to the hospital repeatedly for the same condition. Nurses should consider whether this occurs as a consequence of inadequate access or inability to afford medications for their condition.
Nurse leaders and managers set the vision for nursing practice in the delivery of safe and quality nursing care. To that end, nurse leaders and managers must have effective communication and relationship-building skills, according to the American Organization of Nurse Executives (AONE, 2015a & AONE, 2015b). These skills would manifest in nurses’ ability to influence behavior by asserting their views in a nonthreatening, nonjudgmental way and inspiring desired behaviors, while also managing undesired behaviors.
Nurse leaders and managers must also fully investigate barriers within the sys- tem that increase wait times and decrease patient flow in the emergency depart- ment and transfer to an inpatient bed. Considerations should include acceptable time frames for patients’ discharge, staffing barriers preventing notification of housekeeping staff to prepare the room once the patient is discharged, admission timing from the emergency department to the inpatient bed, and adequate staffing of all personnel to facilitate these processes. Nurse leaders and managers must work to eliminate these barriers to ensure that care is safe, timely, efficient, equi- table, evidence-based, and patient centered.
The Cost of Health Care
In the year 2000, the United States was estimated to have spent $4,703 per person for health care. By 2010, that figure had increased to $8,233 per person, an increase of $3,530 per person. Considering all countries within the Region of the Americas, which includes the United States, Canada, and all Central and South American countries, combined spending in all of these countries including the United States was $1,985 per person in 2000 and $3,454 per person in 2010 (WHO, 2013). The combined totals for the remaining five WHO regions (African, South-East Asia, European, Eastern Mediterranean, and Western Pacific regions) surpass the per capita total expenditure of the United States on health care per person by $2,873 and $4,696, respectively, for 2000 and 2010.
If one views the U.S. health-care system from the health-care provider perspec- tive, the revelation that “insurers do not cover provider costs” can be surmised (Davidson, 2013, p. 9). Davidson estimates that individuals without insurance pay amounts closest to actual charges, or approximately 90% of actual costs. Those with private insurance pay approximately 65% to 75% of actual charges, depending on the insurer, and those with Medicare pay approximately 65% of actual provider costs. Medicaid has historically paid an even smaller percentage of actual provider costs; this applies to services at individual health-care practices as well as hospitals and other larger facilities. These unpaid costs are commonly referred to as uncom- pensated care (Fig. 2-2).
Many advocate for charity care or reduced-cost care for the uninsured or under- insured. In the United States, charity care or reduced cost care exists for persons who do not have adequate access to the private, public, or government health-care systems or insurance as a result of life circumstances. As mentioned earlier, this type of health care is very limited in scope and location and, for the most part, is also uncompensated care.
Secondary to EMTALA, hospitals with emergency departments accepting Medicare are required to stabilize all patients regardless of their ability to pay. In- conveniently, persons unable to access the health-care system through a provider’s office or clinic often use the emergency department for care that could easily be provided in a primary care setting and at a substantial cost reduction. This results in uncompensated excessive costs for services that normally would cost much less if care had been provided by a primary care provider.
Inherent in this untenable situation is that inefficiency permeates the system, and individual service costs increase yearly, commonly in response to increased costs for supplies, medications, and professionals’ compensation (Davidson, 2013). Despite the increasing costs of the system, in 2013 the Commonwealth Fund Commission on a High Performance Health System noted, “There is broad evidence . . . that much of the excess spending is wasteful” (2013, p. 7).
Nurses at all levels must be aware of the limitations under which health-care systems operate. Labor is the largest component of total costs, with nursing being
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5%
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35%
Uninsured 10%
Private Insurers
25%
Medicare 35%
Figure 2-2Percentage of uncompensated health-care costs.
the largest of that component. In hospitals, labor correlates closely with total expenses. Hospital operating margins, the comparison of the operating budget compared with total income, vary per system, but usually operations leave less than 5% to 6% of total income available for profit (Health Leaders Media, 2015).
Nurses must be cognizant of their contribution to increasing costs to the system and make a concerted effort to be good stewards of available resources in the delivery of safe and quality nursing care.
Nurse leaders and managers must be accountable for nursing expenditures, budgets, and outcomes. Skills required, according to the AONE (2015a), include financial management, human resources management, strategic planning, and in- formation management and technology. Financial management includes manage- ment of annual operating budgets and long-term expenditures and education of patient care team members in relation to financial implications of patient care decisions. Human resources management includes the development of educational programs, workforce planning or employment decisions, corrective discipline, em- ployee satisfaction, reward and recognition programs, promotion of healthy work environments, and compliance with legal and regulatory guidelines. Strategic man- agement includes defending the business component of nursing, the analysis of market data in relation to supply and demand, and promotion of the image of nurs- ing and the organization through effective media. Information technology and man- agement consist of using technology to support clinical and financial improvements;
collaborating to establish information technology resources, evaluate technology in practice settings, and use data management systems for decision making; demon- strating skills in assessing data integrity and quality; and leading the adoption and implementation of information systems (AONE, 2015a).
Quality of Care
The IOM defines quality health care as “the degree to which health services for in- dividuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr, 1990, p. 128). The AHRQ states that “quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible” (1998, p. 1).
Quality of care typically reflects the positive effects of health care and performance of health-care systems (Docteur & Berenson, 2009). According to the 2014 National Healthcare Quality and Disparities Report, the current National Quality Strategy has six priorities. These priorities and their current findings, as of 2014, conclude (AHRQ, 2015):
1. Patient safety: 50% of measures improved with a 17% reduction in hospital- acquired infections
2. Person-centered care: Improved steadily, especially in children
3. Care coordination: Improved with enhanced discharge processes and health information technologies
4. Effective treatment: Achieved high levels of performance in hospitals, led by mea - sures reported by the Centers for Medicare and Medicaid Services (CMS) on Hospital Compare
5. Healthy living: Improved in about 50% of measures, led by selected adolescent vaccines
6. Care affordability: Worsened from 2002 through 2010 and then leveled off Patient safety problems appear to be greater in the United States, where patients are more likely to report mistakes or adverse effects with regard to safe medication practices (Docteur & Berenson, 2009). The United States also has “the highest rates of problems such as being given the wrong medication or dosage, experiencing a medical error, or facing delays in hearing about abnormal test results,” with rates reported as high as 34% (Docteur & Benson 2009, p. 8).
Fatalities resulting from medical errors in the United States were estimated to be 98,000 per year by the IOM in 1999. A newer, evidenced-based estimate was provided by James (2013), with a lower estimate as high as 210,000 fatalities per year and an upper estimate of premature death from medical harm as high as 400,000 per year. In addition, James stated that “serious harm seems to be 10–20 fold more common than lethal harm” (James, 2013, p. 122).
High quality implies excellent health outcomes, and there is the assumption that
“Americans with good insurance coverage uniquely benefit from prompt availabil- ity and accessibility of cutting-edge medical procedures, medicines, and devices, as well as highly educated and well-trained health-care professionals, who know and consistently do what is best for their patients” (Docteur & Berenson, 2009, p. 2). As a whole, the United States actually has an inferior quality of care compared with poorer populations. Life expectancy in the United States, which is below average when compared with that in other developed countries, is among the worst performers. The United States has “a much higher prevalence of nine of ten conditions, including cancer, heart disease, and stroke, in its population over 50”
(Docteur & Berenson, 2009, p. 4).
According to the Organization for Economic Co-operation and Development (OECD, 2015), in comparing the United States with other member states, “the qual- ity of acute care in hospitals in the United States is excellent, but the U.S. health system is not performing very well in avoiding hospital admissions for people with chronic diseases.” The OECD found that for conditions such as heart attack, stroke, and general lifesaving, the system performed well. For chronic conditions such as asthma, chronic obstructive lung disease, and diabetes, the United States fell short in areas involving patients in self-care and providing effective counseling for diet and the importance of regular exercise to moderate these chronic conditions (OECD, 2015).
Nurses at all levels need to be familiar with the safety and quality of care they provide patients and the issues associated with safe provision of nursing care.
Knowledge deficits were noted by James (2013) to be a major contributor to indi- vidual and system deficiencies leading to medical errors and patient harm. These deficiencies can be rectified with comprehensive continuing education within all of the health professions (James, 2013).
Nurse leaders and managers need to assist staff in attaining adequate continuing education with a focus on evidence-based practice. Evidence-based practice and the methods by which it is implemented have only recently been included in the nursing curriculum at the baccalaureate (BSN) level. Older staff members and those