The Accountable Care Act: With the implementation of President Obama's Patient Protection and Affordable Care Act (ACA), our nation's health care environment is gradually undergoing fundamental change. Change of such magnitude that we would suspect the majority of practitioners do not yet fully comprehend how it will eventually impact upon their daily professional lives. In December, 2014 the Commonwealth Fund (CF) reported that for the first time in modern U.S. history, the uninsurance rate fell precipitously – from 20 percent to 15 percent – among adults ages 19 to 64 by the end of the first open enrollment period for the ACA health insurance marketplace. An estimated 10 million fewer Americans were uninsured. And based upon preliminary figures for the still-open second enrollment period, the uninsured rate seems likely to plunge even further. In 2014, health expenditures grew more slowly than at any time since Medicare was enacted 50 years ago. Medicare spending alone is $1,200 less per beneficiary per year than predicted just four years ago.
The CF report further noted that the Republican Party will begin 2015 with firm control over both Houses of Congress (for the first time since 2006), 31 governorships, and an advantage of more than 800 members in state legislatures around the country. Whether divided government at the federal level will lead to an armistice over health reform, or intensified trench warfare, is anyone's guess. Full repeal of the ACA is unlikely as long as President Obama remains in the White House. However, more targeted attacks – perhaps through the budget reconciliation process – should be expected. At the state level, Republican control will likely mean slower-than-expected expansion of Medicaid eligibility. As an aside, we would note that this is in spite of the fact that during the initial U.S. Senate committee deliberations, a concerted effort was made to include Republican recommendations in order to develop bipartisan consensus – for example, carefully looking at the specifics of Governor Romney's Massachusetts Health Care Reform legislation.
More than 600 public and private accountable care organizations (ACOs) already exist, covering an estimated 20 million Americans. The percentage of private health insurance payments that are "value-based" jumped from 11 percent to 40 percent in the past year. ACOs and value-based payments are central components of the ACA and reflect efforts to encourage higher-quality care and lower costs through increased provider accountability for cost and quality. Systematic efforts to reduce hospital-acquired conditions were estimated to save 50,000 lives and $12 billion since 2010. And the practice implications not to be underestimated, five years after the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, there were $25.4 billion in incentive payments resulting in 80 percent of eligible professionals and 98% of eligible hospitals having qualified for these payments by adopting electronic health records (EHRs), potentially resulting in a transformative digital revolution within the health care system. This technological evolution alone will significantly increase the likelihood of systematically developing across-provider and across-clinical population and diagnostic comparisons (i.e., clinical effectiveness research) with its accompanying public health orientation. One must expect the utilization of data-based, gold standard protocols to increasingly impact clinical decision making and eventually include the all-important psychosocial-economic-cultural gradient of care.
Interprofessional Care: Under the visionary leadership of APA President Nadine Kaslow, the Council of Representatives endorsed moving towards Competency-Based Education and Training. Espousing a similar training philosophy, in 2009 the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools and Programs of Public Health formed the Interprofessional Education Collaborative (IPEC) in order to promote and encourage efforts to advance substantive interprofessional learning experiences with the goal of preparing future clinicians for the team-based care of patients. Fundamental to the ACA is the development of integrated systems of holistic patient-centered primary care, provided by integrated interprofessional teams of providers. Although psychology's training institutions are just beginning to appreciate the magnitude of this paradigm shift in orientation, studying health policy and developing skills to practice collegially with colleagues from other disciplines is one of the required competencies for the Doctor of Nursing Practice degree.
The Doctor of Nursing Practice – Growing Acceptance: The Alliance for Health Reform, which in our judgment is one of the most objective sources of non-partisan policy information for congressional staff, recently held a briefing entitled "Preparing the Nursing Workforce for a Changing Health System: The Role of Graduate Nursing Education." The key messages were: * Nurse practitioners can help alleviate the growing demand for primary care. Using nurse practitioners and physician assistants as part of a team can reduce the primary care shortage, improve access, and deliver more cost effective services. * Graduate nursing education demonstrations are showing early positive results. Cost estimates of advanced practice nursing (APN) clinical education derived from the Center for Medicare and Medicaid Services (CMS) graduate nursing education demonstration (GNE) show a favorable return on investment. Enrollments and graduations doubled during the first two years of the demonstration. * New models of care integrate nurses into the community. The CMS demonstration benefits the community by integrating more nurse practitioners into community clinics. And, * Advance practice nurses must receive post-baccalaureate training. APNs (nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, and certified nurse midwives) must complete baccalaureate plus master's or doctorate-level training. The American Association of Nurse Practitioners estimates that today there are 205,000 NPs, double the 2004 number.
A recent editorial in The New York Times rhetorically asked: "Are Midwives Safer Than Doctors?" Citing the findings of Britain's National Institute for Health Care Excellence that it is safer for healthy women with uncomplicated pregnancies to give birth under the supervision of midwives than in a hospital maternity ward run by doctors, the Times concluded that there is "no good reason that midwives should not play a more important role in childbirth here, despite a longstanding turf war between obstetricians and midwives that has tended to keep midwives under the thumb of doctors." Last year there were more than 3.9 million births in the U.S., only nine percent of which were attended by nurse midwives. The professional society for obstetricians consistently raises the traditional "public health hazard" argument. Notwithstanding, the Times concluded: "In a time of spiraling medical costs and increasing demand for health care, midwives can offer a cost-effective way of providing good maternity care. They could also provide greater geographical reach: Nearly half the counties in the United States have no maternity care professional, either midwife or obstetrician." [This, of course, has historically been the essence of psychology's public policy argument for expanding its coverage.]
Serving at the Department of Defense (DoD) Uniformed Services University of the Health Sciences (USUHS), I have become particularly interested in programs targeting military personnel, their families, and veterans. Last fall, the Jonas Center for Nursing and Veterans Healthcare announced its Policy Scholars Program, which in conjunction with the American Academy of Nursing, will recruit 12 doctoral and post-doctoral nursing students for a two-year experience whereby they will be matched with an expert panel to learn from leading nursing experts about major health policy issues. The underlying strategic objective is to develop leadership in the policy work that is needed to create healthy communities and to transform the nation's health care system. "The Jonas Policy Scholars will create a pipeline of early-career nursing scholars who will contribute to shaping practice, education, and research policy relevant to nursing and the work of the Academy of Nursing; provide a mechanism for Academy expert panel leaders to mentor early-career Jonas Policy Scholars on key issues relevant to the panel's area of focus and strategies for shaping those policies; and support expert panel chairs in advancing work to inform and shape policy and improve the health of the public."
The Jonas Center for Nursing and Veterans Healthcare was established in 2006 by Barbara and Donald Jonas and is dedicated to improving healthcare by advancing nursing scholarship, leadership, and innovation. Its two main programs are the Jonas Nurse Leaders Scholar Program, which aims to address the dire shortage of nursing faculty by preparing nurses with doctoral degrees to step into this critical role; and the Jonas Veterans Healthcare Program, which seeks to improve the health of veterans by supporting doctoral-level nursing candidates committed to advancing veterans' healthcare. These programs currently support more than 600 doctoral scholars nationwide, with the goal of supporting 1,000 Scholars by 2016.
A Personal View: "As a Psychiatric Mental Health Nurse Practitioner who is not only educated to provide psychotherapy and pharmacotherapy but also trained to embrace a holistic model of care, I am especially grateful to have the training and skills to provide acupuncture therapy to psychiatric patients. In my practice, acupuncture has been an effective adjunct treatment of complex psychological and physical trauma acquired from combat. I found that my patients benefited from the unique practitioner-patient interaction that happens during acupuncture treatment. Patients verbalized satisfaction as they report relief from debilitating symptoms such as insomnia, pain, and anxiety. They appreciate the relaxation component that happens outside psychotherapy when they receive acupuncture. They become proactive in their care by requesting and calling for more acupuncture time. Albeit some of the effects of acupuncture are short term for those who have severe psychiatric symptoms, the momentary relief they gain could be revitalizing and result in increased function even for a few days. After an acupuncture therapy, some of my patients report: 'I haven't slept that well in a long time since deployment;" 'I was able to spend time with my child without feeling tired and fatigued;' 'I did not have an anxiety attack this week.' These momentary gains in quality of life are significant as we care for those who have experienced trauma in combat settings [LCDR Jane Abanes]." Prior to enrolling in the USUHS Daniel K. Inouye Graduate School of Nursing Ph.D. program, Jane was Head, Mental Health Department & Substance Abuse Rehabilitation Program, Naval Health Clinic Hawaii.
Unmet Needs; Uncharted Waters; Unprecedented Opportunities? I recently participated in a conference call for a HRSA national advisory committee during which it was noted: "Mental health disorders rank in the top five chronic illnesses in the U.S. An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime. In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders." And the band begins to play. We all live in a yellow submarine. Aloha,
Pat DeLeon, former APA President – Division 29 – February, 2015
