Monday September 16th 2019

What the ACA means for nursing a year after open enrollment

Bonnie Clipper

In the first year since open enrollment in federal and state health insurance exchanges began in October 2013 as a provision of the Affordable Care Act (ACA), approximately 9.3 million Americans have gained coverage, according to a Rand Corporation survey in October. That number is expected to grow to an estimated 30 to 34 million in the next few years, as reported by The Heritage Foundation.

As RNs, we will all feel the effects of the dramatic increase in insurance enrollees. What can we expect? Here are a few considerations.

We will continue to see an increased demand for services, from many individuals who have delayed or neglected care in the past. An aging population and an increase in chronic conditions will compound the situation. While the need for RNs increases, existing nurses are retiring in larger numbers, further reducing the nursing workforce. Today, there are approximately 2.8 million employed RNs. According to the U.S. Bureau of Labor Statistics, approximately 20 percent will retire by 2022.  Further, expanded demand will require 574,400 additional RNs/APRNs.  This means that 1.13 million vacancies will emerge between 2012 and 2022, and projections show that the health care workforce will need to grow by 40 percent to meet the increased demand.  This will require continued expansion of federal Nursing Workforce Development (Title VIII) funding and 35 percent more nurse faculty members, according to ANA economist Peter McMenamin in his March 2014 blog, One Strong Voice.

Care delivery models

RNs have a unique opportunity to lead and contribute to the redesign of health care delivery models that focus on wellness and prevention rather than the management of disease or injury. Traditional nursing care delivery models tend to focus on episodic care management and often in acute care settings. This will need to change, with nursing assuming more accountability to manage an increase in patients across the care spectrum. A positive outcome of the changing health care system, the increase in the ranks of the insured will require additional nurse practitioners and nurse-run clinics. One of the hottest jobs in health care at this time is the nurse navigator. As new roles develop, we need to innovate and think differently rather than use our old paradigms.

Accountability and outcomes

Health care providers, including nurses, will all be held to a much stricter level of accountability to ensure that patients are receiving the highest quality of care in the most cost-effective manner and in the most efficient setting. As we continue to migrate from the fee-for-services reimbursement system to a system that is based on value, and then directly into a reimbursement system where the entire episode of care is paid as a bundle, we all have to change how we are delivering services. Bundled payments will provide a payment to all the providers (hospital, physicians, post-acute care, for example) for the care provided to a patient for an episode of care over a specific period of time, eliminating individual payments for providers, tests, treatments or procedures. As a result, we will improve care coordination, eliminate errors and complications, and eliminate waste such as duplicative tests and treatments.

The pressure to reduce costs won’t go away, including everything from reducing the costs of supplies, diagnostic tests and procedures, to staffing models. Much emphasis will be placed on where patients are receiving their care, because inpatient services are the most expensive way to deliver care. We will have to invest more heavily in outpatient settings and explore more partnerships with home health and community health providers.

Changing roles

To respond to change, we need to challenge ourselves to determine what tasks need to remain under the nurses’ purview and what can be shared with other disciplines. For example, we might collaborate with medical assistants to stretch our practice boundaries and retain what we need, since nursing is not about the tasks, such as phlebotomy, IV starts, for example, but rather the synthesis, integration, assessment, planning and education involved in care.

We need to find more effective ways to develop new nurses and retain those we already have. We need to be present and “at the table” to influence the changing care delivery models and reimbursement frameworks to ensure that RNs and, more importantly, patients are not left out of the process. This means continually advancing our education to establish credibility while we advocate for safe, cost-effective care. We need quality metrics to be reported in our organizations in such a way that every RN understands the role he or she plays as an individual in those outcomes.

And, we are going to have to collaborate with physicians and other disciplines to find ways to align across the scopes of practice that we have all held so tightly as our own. Collaboration is what is best for our patients; let’s work together to find the solutions.

— Bonnie Clipper is chief nursing officer for the Medical Center of the Rockies
and a Colorado Nurses Association member.

Resources, One Strong Voice, 2022: Where Have All Those Nurses Gone?

The Heritage Foundation, backgrounder No. 2887: Nursing shortage

Rand Corporation survey on newly insured Americans

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