By Cathryn Domrose Ask three nurses familiar with the Affordable Care Act what it will mean for the profession and you get three very different answers. One foresees disaster, as newly insured and aging patients overwhelm a system unprepared to support them. Another predicts improved care and new opportunities for nurses, as the bulk of healthcare moves from the hospital to the community setting. A third sees both better care and access for patients, but heavier workloads and more stress for clinicians. The only point nurses and health policy experts seem to agree on is that it's too early to know the full impact of ACA-spurred healthcare reform. "Certainly we've had challenges, but we've had great successes," said Marilyn Tavenner, RN, BSN, MHA, administrator for the Centers for Medicare and Medicaid Services, speaking about the ACA at a recent healthcare conference in San Francisco. "It's not an overnight process. It will take some time." The health insurance mandate has been in effect for less than five months, and many of the ACA's quality improvement projects are predicted to take years to come to fruition. Studies from states that have enacted early healthcare reforms provide some insight, though researchers caution these lessons may not apply to the entire country. When we asked researchers, healthcare economists, nurses who study health policy and nurse consultants what ACA-related reforms might mean for nurses and patients in the future, this is what they told us.
Will the ACA improve care?
This is probably the most pressing question for nurses, who want the best care possible for their patients. Early reports show hospital readmission rates for Medicare patients decreased for the first time in recent years, and preventable adverse incidents decreased by 9% from 2010 to 2012, according to the CMS, which attributes the declines to ACA reforms tying reimbursement to outcomes. Reports from two states that enacted healthcare reform before the ACA - Massachusetts, which required mandatory insurance starting in 2006, and Oregon, which expanded Medicaid to some residents in 2008 - show mixed results. In Massachusetts, researchers saw a 3% decline in mortality, which they attributed to healthcare reform, according to a report published in May in the Annals of Internal Medicine. The Oregon report, published last year in the New England Journal of Medicine, found no improvement in outcomes for people with hypertension, high cholesterol and high glucose levels, but did show increased use of healthcare services, higher rates of diabetes detection and management, lower rates of depression, more preventive care and reduced financial strain on patients. "When I put all of this information together, it suggests that people who gain access to health insurance are likely to be substantially better off," said Katherine Baicker, PhD, professor of health economics and chairwoman of the department of health policy and management at the Harvard School of Public Health, who participated in both studies. "And this is likely to come at a cost in the form of increased healthcare spending." Part of that cost could mean increases in premiums, co-pays and deductibles for people on private insurance, both through employers and the ACA exchanges, said Amy L. Anderson, RN, DNP, CNE, associate professor of nursing at Indiana Wesleyan University in Marion. She fears these cost increases, coupled with a shortage of providers, will mean less access to care, poorer quality of care and less patient satisfaction for everyone. Anderson believes people in rural areas will have an especially hard time getting care as healthcare becomes more consolidated and small hospitals close. Limited networks will keep people from seeing their provider of choice, she said. But Jean E. Johnson, RN, PhD, FAAN, dean of the George Washington University School of Nursing in Washington, D.C., expects transformative improvements in health, as people who have never had insurance or were denied insurance because of pre-existing conditions are getting care, particularly primary and preventive care. "People will still use the emergency room, but I think there will be a greater opportunity for health maintenance, health promotion and a more organized approach to healthcare," she said.
Will there be enough providers to take care of everyone?
Health policy experts agree more people will seek care in coming years, partly because of expanded insurance through the ACA, but mostly more than 80%, according to the U.S. Health Resources and Services Administration because of an aging population with multiple chronic conditions. Whether there will be enough providers to care for them is uncertain. A study released in November by the HRSA projects a national shortage of more than 20,000 primary care physicians by 2020. But when the report includes nurse practitioners and physicians assistants, who provide a growing rate of primary care services, the national shortage drops to 6,400 primary care providers, about the same shortage as today, said Edward Salsberg, MPH, former director of the workforce center that produced the report and now research faculty at the George Washington schools of nursing and public health. Salsberg said the country has doubled the number of new RNs entering the workforce in the past decade, and he does not foresee an immediate national RN shortage despite an increase in healthcare demand. "Shortages probably will continue in certain rural communities and other areas where RNs and PCPs are less likely to practice," he said. Others see cause for serious concern, both in primary and acute care. Massachusetts, which had a high ratio of providers to population before healthcare reform, has reported shortages of both primary care physicians and specialists in the last eight years, Anderson said, as well as long wait times for new patients in some areas of the state. She also cites a 2012 report from the American Journal of Medical Quality projecting significant RN shortages by 2030 in most states, with the South and West particularly hard-hit. Judith Shindul-Rothschild, RNPC, PhD, associate professor at Boston College Connell School of Nursing in Massachusetts, is worried a shortage of residencies for graduating medical students will create a bottleneck of prospective physicians. NPs could help alleviate shortages, she said, but by how much depends on whether state laws restricting NP practice are changed. "Thats a slow-moving process," Shindul-Rothschild said. "The demand is going to be there before the providers are."
Will nurses workloads increase?
Shindul-Rothschild, who supports the ACA because she believes it will improve access to care for patients, fears it also could result in increased workloads and stress for hospital nurses if they don't take steps to protect themselves, such as advocating for safe staffing ratios. Her study of nurses in Massachusetts published in August 2013 in the journal Policy, Politics and Nursing Practice shows that despite an increased demand for hospital services after the states mandatory insurance law was enacted, nurse hiring rates stayed flat and nurse-to-patient ratios increased. Instead, hospitals increased administrative spending, according to the study. She envisions a scenario similar to one in the 1990s, when managed care requirements led hospitals to slash nursing staff. She contrasts this concern with recent studies showing how care deteriorates when staff mixes have fewer RNs, which could result in financial penalties for hospitals under the ACA. She predicts hospitals will be squeezed from two sides: one that demands cost-cutting - particularly as accountable care organizations take on the risks of caring for a large groups of patients - and another that demands quality care. Anderson believes this squeeze could lead to a vicious cycle of hospitals struggling with reduced reimbursement and non-payment from patients who can't afford deductibles and co-pays, cutting staff and causing the quality of care to drop, then having to pay penalties, digging themselves into a deep financial hole. Some hospitals cited healthcare reform as part of the reason they were laying off staff last year, according to news reports. But they also cited sequester cuts in federal compensation, a declining patient population and state failure to expand Medicaid. Increased workloads are a valid concern for nurses, as employers look for ways to cut costs, said Alice Benjamin, RN, MSN, ACNS-BC, PCCN-CMC, clinical nurse specialist for the critical care coronary and advanced heart failure units at Cedars Sinai Medical Center in Los Angeles. But the evidence is clear, she said, that cutting nurses to save money is an unwise investment that will cost hospitals more in the long run. They will see longer hospital stays, more falls and more infection rates,? which will reduce reimbursements, she said. If healthcare reform is successful in keeping more people out of hospitals and providing more care in the community, demand for acute care and hospital RNs' workloads may not increase, Salsberg said. Inpatient care may, in fact, decrease. Patient satisfaction scores could become a huge ACA-imposed burden on already taxed RNs, predicted Michele Gonsman, RN, BSN, ALNC, CPSS, a legal nurse consultant who has published a book called The Affordable Care Act for Nurses. "A low satisfaction score may result from something the nurse can?'t change," she said, "citing examples of patients who complained about the quality of hospital food or not getting immediate attention because the nurse was busy with a sicker patient. We need feedback, but the ACA has tied patient satisfaction to provider reimbursement." Improved technology, including electronic health records and remote monitoring, may eventually help contain workloads, especially for home health nurses, Gonsman said. "Employers need to make sure nurses understand the work they do to lower hospital re-admissions and adverse events improves patient care and is valued by the hospital," Benjamin said. To help reduce heart failure re-admissions at Cedars Sinai, nurses educate patients and families about the condition, make follow-up phone calls, make sure patients leave with printouts and appointments, and make sure they have transportation to appointments. Because of nurses' efforts, she said, "we're closing the gap."
How will the ACA affect nurses jobs?
Johnson said she's hearing about upswings in new graduate RN hiring in hospitals along the Atlantic Seaboard, though she believes ultimately more nurses will move out of the hospital into the community. She predicts expanding roles for nurses as care coordinators in hospitals, clinics, insurance companies and ACOs. Gonsman is hearing about nurses working for pharmacists and medical offices as case managers; for insurance companies in fraud recovery; in home health using telemedicine; and everywhere as informaticists. But care coordination programs take an upfront investment that facilities facing pressure to cut costs may be reluctant to make, Gonsman continued. Consolidation could further shrink the job market and keep salaries down, she said, as smaller hospitals close and fewer employers compete for nurses. But if you'?re willing to move, you can find employment, she said. "If hospital hiring remains flat, as it did in Massachusetts, the new nursing jobs may not open up fast enough. I think the demand for nurses in care coordination will rise," Salsberg said. Its just unsure how much. "Other professions such as social workers or physicians will be vying for care coordination jobs," said Mark V. Pauly, PhD, professor of healthcare management at the Wharton School of the University of Pennsylvania. "Nurses have to be able to demonstrate they can do a better job at coordinating care [than people in other professions]. ... Part of the job of nurses is to remind people that what they do really matters." This is particularly true if cost-cutting means job-cutting, he said. Because all healthcare providers need to increase their quality of care, they will want to keep and hire nurses with the right education usually a BSN or higher and skills. Nurses who are aware of their role in the system, he said, and who can demonstrate the part they play in delivering the high-quality care demanded by healthcare reform should be too valuable to be laid off.
Where will people seek care?
A major goal of the ACA is to move care from the hospital into the community, something that was happening before healthcare reform but is projected to increase. In recent years, outpatient spending has grown at a faster rate than inpatient spending, with outpatient care accounting for about 60% of all hospital revenue in 2012, up from 10% to 15% in the 1990s, according to the Wharton School of Business at the University of Pennsylvania. HRSA steadily has increased and expanded its network of community clinics, which saw a 2.5 million increase in patients from 2009 to 2012. Retail clinics also are growing rapidly and are expected to double from about 1,500 in 2012 to nearly 3,000 by 2015, according to Accenture, a global management consulting company. Despite predictions of newly insured patients swamping EDs, policymakers say it's too early to know how EDs will be affected. Administrators at safety-net hospitals in the 25 states that expanded Medicaid reported decreases in ED visits and increases in visits to PCPs, according to a May 27 report by Kaiser Health News. But 46% of respondents to a survey by the American College of Emergency Physicians published in April said the volume of emergency patients at their hospitals had increased at least slightly, including 9% who said it increased significantly between January and April of this year. Based on the Massachusetts experience, Shindul-Rothschild believes EDs will be the first place many newly insured patients will show up when they need care. Studies from that state showed a slight increase in ED use between 2004 and 2009. "The EDs are overwhelmed to begin with," said Gonsman, a former ED nurse. Part of the problem, she said, is PCPs or urgent care clinics won't accept Medicaid, the waiting times are long or patients don't want to take time off work and they know the ED is legally obligated to see them. "The best way to avoid inappropriate ED use," said Benjamin, "is to make sure we're educating our consumers? and connecting them into a primary and preventive care system." Oregon saw an initial increase in ED use by its newly insured Medicaid patients. But after implementing measures such as having community health workers refer patients to more appropriate settings, and increasing coordinated care to keep patients out of the hospital, ED use among Medicaid users was nearly 10% lower over the first six months of 2013 than it was in 2011. As care moves increasingly into the community, Johnson said, nurses need to prepare themselves to follow it. Home care, transitional care and outpatient care will become increasingly important settings for providers and patients. "As a profession," she said, "we need to be looking beyond the hospital." Cathryn Domrose is a staff writer.
