Medicaid expansion. Changing systems of payment. Electronic health record conversion. The phrases float at the bottom of a TV screen or flash in headlines, but what do they really mean? To help keep readers informed, Nurse.com highlights some important healthcare policy issues for nurses to watch.
Medicaid expansion
What's happening now: As part of the 2010 Affordable Care Act, states were supposed to expand Medicaid to cover people up to 138% of poverty level, but in 2012, the U.S. Supreme Court ruled states could opt out of the program. So far, 28 states and the District of Columbia have expanded their Medicaid programs, 16 have decided not to and six are considering doing so as of March 6, according to the Kaiser Family Foundation. Six states that have expanded Medicaid received waivers allowing them to make certain requirements such as charging co-pays or premiums.
How it affects nursing practice: Nurses always have advocated for patients to have access to healthcare, said Edward Briggs, DNP, ARNP, a family nurse practitioner and president of the Florida Nurses Association, which is working to convince Florida legislators to expand Medicaid. Evidence shows Medicaid expansion is reducing the number of uninsured people and providing more money for hospitals. States that have expanded Medicaid report decreases in amounts spent on charity care and increases in Medicaid revenues. Other reports indicate Medicaid expansion is resulting in more jobs for healthcare workers.
Some Florida hospitals also reported decreases in the amount of money spent on charity care last year, but Briggs fears hospitals will face cuts and closures as federal reimbursement programs for indigent care come to an end. In Florida, ED use is rising as uninsured people come in for primary care, said Briggs, who works in an ED. "I see folks who are trying to make ends meet, and they don't have access to healthcare."
What to watch: A number of nonMedicaid expansion states are working on compromise proposals and getting backing from the business community and hospital associations. State nursing associations are supporting these efforts.
But legislators in Tennessee and Utah recently voted down expansion programs proposed by Republican governors. Briggs said a similar program in Florida faces "an uphill battle," though it is backed by the state chamber of commerce and large businesses. Some opponents of Medicaid expansion believe it would put a financial burden on the state, which already spends a large portion of its budget on Medicaid. Others oppose the federal government being involved in healthcare. Briggs and others who support Medicaid expansion believe the best way to change peoples' minds may be to emphasize the economic benefits of covering more people.
Pay for performance
What's happening now: The U.S. Department of Health and Human Services plans to make 30% of Medicare payments to providers through alternative reimbursement models, such as accountable care organizations or bundled payment programs, by the end of 2016, increasing to 50% by 2018. The Centers for Medicare & Medicaid Services linked nearly 85% of traditional Medicare payments to quality through accountability programs, such as readmissions reduction and value-based purchasing, that hold back a percentage of payment if certain quality standards are not met. CMS plans to increase those to 90% by 2018, said Jean Moody-Williams, MPP, RN, deputy director, Center for Clinical Standards and Quality for CMS.
How it affects nursing practice: In the past, poor outcomes were seen as an inevitable consequence of illness and injury, but now providers are starting to identify areas for improvement "before bad things happen," said John Welton, PhD, RN, professor and senior scientist for health systems research at the University of Colorado College of Nursing in Aurora. HHS goals create incentives for hospitals to make changes, but Welton believes they focus too much on poor quality, including things related to nursing care such as pressure ulcers, infections and falls.
"In many ways, nursing care has been a part of a bundle for years and nurses now have an opportunity to more concretely define the value of those services for patients and families," said Moody-Williams. She cited SAMA Healthcare's primary care program in rural Arkansas, in which teams with a physician, NP, care coordinator and three RNs provide preventive care for about 19,000 patients, identifying those at high risk and finding community resources to help them.
What to watch: Right now, it's difficult to document and reimburse for RN care, but more specific and integrated data collection methods eventually will show all elements of nursing care for a single patient, Welton said. He and others are developing models to measure outcomes, effectiveness and performance of nursing care delivery systems and individual nurses. For example, Welton said, the model could show how different nurses manage pain and use the results to standardize best practices and outcomes.
Nurses need to be involved in developing and testing the measurements "rather than waiting to see what is imposed by the payers and policy makers," Welton said.
ICD-10 conversion
What's happening now: After Oct. 1, all healthcare services are required to upgrade to the World Health Organization's "International Classification of Diseases, 10th edition" as the standard numeric code system for diagnosis and medical billing. The new system of seven-digit codes is more complex and more accurately describes a patient's condition, said Linda Harrington, PhD, DNP, RN-BC, CPHIMS, FHIMSS, vice president and chief nursing informatics officer at Texas Division of Catholic Health Initiatives in Houston. But ICD-10 also is more cumbersome because there are many more diagnoses, she said.
How it affects nursing practice: ICD-10 conversion mostly will affect physicians and advanced practice nurses who make diagnoses, Harrington said. "But it does impact RNs in important ways where their documentation is used to code diagnoses and bill," she said.
Pressure ulcers, for instance, are diagnosed using nursing documentation to show their severity. Nurses need to make sure their documentation aligns with the 123 medical diagnoses for pressure ulcers in the ICD-10 system, she said, so physicians and others can accurately record a diagnosis. Also new for ICD-10 is the need to document whether a patient is left-handed, right-handed or ambidextrous, Harrington said, because a patient who becomes paralyzed from a stroke or other condition on the dominant side will require more rehabilitation, and reimbursement will be higher.
What to watch: The ICD-10 deadline has been moved several times, but Harrington and others believe the Oct. 1 date will be final. Harrington is concerned the literature and educational materials she's seen seem to downplay changes for bedside RNs.
"When people think medical diagnoses, they think physicians or APRNs, they don't think RNs," she said. Besides pressure ulcers, she has found about 25 areas that affect practicing RNs in their documentation and practice. CNOs need to pay attention to these changes, she said, "or they're going to be blindsided."
Cathryn Domrose is a staff writer.
