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  1. 1. Running head: THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 1 The Affordable Care Act: Funding for Primary Care Training and Implications for Practice Jonathan D. Brouse Maryville University
  2. 2. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 2 The Affordable Care Act: Funding for Primary Care Training and Implications for Practice Introduction: The U.S. Primary Care Provider Shortage Fundamentally, for the United States (U.S.) to build, implement, and sustain a high- performing health care system envisioned by the Affordable Care Act (ACA), existing provisions to bolster primary care provider supply must be fully funded and evaluated (Schwartz, 2011). Since its inception, the ACA has expanded health care access to millions in America, thereby generating significant downstream impact upon demand of primary care physicians, physician assistants (PAs) and nurse practitioners (NPs) alike (Allen et al., 2013). Nationally, an expected shortage of 91,500 physicians is projected to occur by 2020 (Allen et al., 2013). Meanwhile, Aiken (2011) noted that nursing programs have dismissed tens of thousands of qualified applicants on account faculty shortage juxtaposed with budgetary constraints. Without a dramatic increase to the US primary care workforce, cost containment, improved quality, and enhanced provider access will not be achieved (Schwartz, 2011). Although US Congressional efforts to dismantle or defund the ACA place the health reform law at risk, the insidious threat of a primary care bottleneck exists (Schwartz, 2011). Presently, the U.S. Health care delivery is plagued by a confluence of systemic challenges facing the core of its primary care capabilities (Naylor & Kurtzman, 2010). Continued pressures mounting from gaps in quality outcomes to increasing patient acuity, compounds concerns regarding workforce adequacy in addition to resultant lags of quality (Naylor & Kurtzman, 2010). Likewise, health care consumption will be spurred by the impending “silver tsunami” of 80 million Americans retiring over the next two decades as expanded coverage is set to newly integrate 32 million Americans (Schwartz, 2011). Finally, Naylor & Kurtzman (2010) note, “Questions regarding the value of the primary care system, as evidenced by the performance on
  3. 3. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 3 numerous economic indicators, health outcomes, and multiple dimensions of patients’ experience, have been raised, especially in comparison to other developed countries” (p. 295). Disregarding ACA provisions, it is expected that the primary care demand will increase by 29% starting in 2005 and leading up to 2025 (Schwartz, 2011). Since 2011, 80 million baby boomers joined the Medicare-eligible ranks, while this “silver tsunami” increasingly adds 10,000 per day through the year 2029 (Schwartz, 2011). Since 2002, medical schools have expanded efforts to meet the projected need and have grown class sizes by 18%; yet, the shortfall continues (Allen et al., 2013). Further, Naylor & Kurtzman (2010) underscores the point that, “gaps in quality care accompanied by workforce shortage that threaten the provision of services” (p. 894). Hence, the primary care shortage is likely to experience a perplexing bottleneck to realizing a successful and optimal ACA implementation, resulting in millions of Americans disillusioned by the unmet promise of system access despite coverage (Schwartz, 2011). Even with expanded provisions to the 3P’s of primary care policy (pipeline, practice, and payment reform) within the ACA, present funding and efficacious implementation remains susceptible unless greater strides to rebuild the primary provider workforce occurs (Naylor & Kurtzman, 2010). Affordable Care Act Provisions for Expanding Primary Healthcare Providers On March 23, 2010, President Obama signed the historic legislation known as the Patient Protection and Affordable Care Act (ACA), which represented the most profound transformation of the U.S. healthcare system since the inception of Medicare and Medicaid (Manchikanti et al., 2011). According to Allen et al., (2013), the ACA presents a new element to the pursuit of expanding primary care provider supply. In meeting the envisioned goals of maximizing efficiency, quality, and cost-containment, many hospitals throughout the U.S. are strategically aligning into integrated health systems; yet, this alignment process entails assimilating physician
  4. 4. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 4 practices, which results in fewer independent physician practices and hospitals (Allen et al., 2013). To that end, “some plan to become or align with accountable care organizations (ACOs)—the defining organizational structure under the ACA, designed to reduce cost while improving quality, safety, and efficiency” (p. 1862). The ACA: Attending to the Primary Care Provider Shortage - Implications for Nursing Granted the urgency to dramatically bolster the primary care workforce overall, greater pecuniary support is required to expand the pipeline of primary care providers, including advanced-practice registered nurses (APRNs) (Naylor & Kurtzman, 2010). To help ensure sufficient primary care access as new coverage expands to millions of Americans, the ACA provides significant investments that further expand the role of APRNs and PA’s alike (Paradise, Dark, & Bitler, 2011). On September 27, 2010, the U.S. Department of Health and Human Services (HHS) indicated that initial grant awards provisions On the surface, the education of nurses may seem less pressing than ensuring care for millions of Americans in a manner that is efficacious, safe, and affordable for all (Aiken, 2011). However, Aiken (2011) cautioned that, “if we don’t alter the historical patterns of nursing education, the country’s nursing resources will be crippled for the foreseeable future” (p. 196). In underscoring the urgency of the faculty shortage, Aiken (2010) added, “Within the next 10 years, half of nursing-school faculty members will reach retirement age; the anticipated attrition represents a crisis in the making, with potentially far-reaching consequences for the replenishment of the nurse workforce, which is itself on the verge of losing some 500,000 nurses to retirement” (p. 196). Fortunately, the ACA has begun to address the nurse faculty bottleneck that precluded optimal enrollment of qualified students from entering into practitioner roles. According to Naylor and Kurtzman (2010), the ACA provides relief in that, “it expands
  5. 5. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 5 eligibility criteria so that faculty at nursing schools qualify for loan repayment and scholarship programs, and it establishes a federally funded student loan repayment program for nurses with outstanding debt who pursue careers in nursing education” (p. 897). Transforming health care for the advanced practice registered nurse (APRN) through the political process begins with a focused approach upon emphasizing nursing education and engaging the public in recognizing that nursing care provides an indelible component to quality care outcomes (Tilden, 2010). Several important implications concerning the role of the advanced practice nurse in shaping health care policy stem from the 2010 Institute of Medicine (IOM) Report, The Future of Nursing, which calls for greater emphasis upon improved curriculum to health policy education. According to the IOM report, a key lesson provided from the past 2 decades is the degree to which “health systems and policy shape the health both of populations and individual patients,” (Tilden, 2010, p. 559). Yet, few nursing students fully appreciate the gravitas of health policy in its ability to not only affect nursing practice, yet, in the end, direct patient outcomes (Tilden, 2010). Since nursing education curricula often exposes students to little more than a token policy course, the resultant naiveté of nurse graduates abounds, as with the perception that “nurses generally view themselves as being shaped by, not shaping policy” (Tilden, 2010, p. 559). When compared to the preeminent presence of medicine in driving legislative reform, it has been well documented that nurses themselves often opt to a back seat policy approach (Tilden, 2010). Later Tilden (2010) indicates that missed stakeholder opportunities to shape policy are alarmingly common to the nursing profession. Nowhere is this more prominently evidenced than within the Centers for Medicare and Medicaid Services (CMS) stipulation that withholds reimbursement for “never events” (e.g., pressure ulcers, injuries, surgical site
  6. 6. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 6 infections, and catheter-related infections). Despite these conditions being preventable by means of nursing intervention, the profession has yet to convince an American public or Congress, of its vital importance to both the protection from and prevention of such health risks (Tilden, 2010). In rectifying the “outgrowth of the inattention” facing nursing curricula to the matter of health policy and the nursing profession, it is necessary to visit the recommendations placed forth by the Health People Curriculum Task Force (Association for Prevention Treatment and Research [APTR], 2014). This panel consisting of multi-disciplinary health specialties including medicine, PAs, nursing, pharmacy, and representative educational associations contributed four following domains quintessential to health policy curricula and instruction: 1. “Organization of clinical and public health systems (concerning the pieces of the system; concerning clinical care to public health structures)” 2. “Health Services financing (underlying determinants of cost and options for payment and cost containment; comparison to health systems of other countries)” 3. “Health workforce (understanding the roles and responsibilities of other health professionals)” 4. “Health policy process (introduction to the impact of policy on health and clinical care, the process involved in developing policies, and opportunities to participate in those processes, whether within a local institution or state or federal legislation)” (Allan et al., 2004). As emphasized in the preceding points, adequate health policy curricula is needed at every level of nursing education. Yet, at the graduate level, APN students “need to be actively involved in political processes that affect the care they will deliver in the future” and therefore, educational experiences should suffuse a hands-on approach along with explicative learning experiences
  7. 7. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 7 (Tilden, 2010, p. 561). To that end, an example curriculum objective for APN students includes expecting students to demonstrate the link between evidence and policy (i.e., discerning the role APNs perform in illuminating practice issues and garnering attention of policy creators). Finally, interprofessional groups can collaboratively engage students together in directing policy projects (Tilden, 2010). Pros and Cons of the ACA Legislative Provisions in Addressing Primary Care Shortage Commentary - Scope of Problem and Fulfilling the Promise of Improved Primary Care First and foremost, sustaining meaningful efforts to drive ACA’s patient-directed goals of effective, accessible, quality-outcomes based care rests upon ensuring an expanded pipeline to primary care practitioners (Jacobson & Jazowski, 2011). Doing so relies in part upon channeling public funding for nurse education in order to steer change in healthcare delivery according to the IOM’s recommendations (i.e., streamlining efficient pathways to obtain further advanced education after initial licensure) as this will lead to greater potential for optimal outcomes (Institute of Medicine [IOM], 2011). Furthermore, a combination of financial resources via public and policy-driven initiatives to expand Conclusion Great strides to nursing education are required, from inclusion of greater health policy curricula to producing graduates with requisite nursing acumen to practice safely and effectively. While there will be inherent challenges to adapting entrenched paradigms to nursing curriculum and instruction, it is possible to create inroads to existing models of nursing education (APTR, 2014). By structuring content around knowledge, related competencies including policy-related
  8. 8. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 8 learning opportunities, students can master requisite legislative techniques to play important policy stakeholders in order to influence both practice and ultimately, patient care outcomes (Tilden, 2010).
  9. 9. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 9 References Aiken, L. H. (2011, January 20). Nurses for the future. The New England Journal of Medicine, 364, 196-198. Allan, J., Barwick, T. A., Cashman, S., Cawley, J. F., Day, C., Douglass, C. W., ... Wood, D. (2004). Clinical prevention and population health curriculum framework for health professionals. American Journal of Preventive Medicine, 27, 417-422. Allen, S. M., Ballweg, R. A., Cosgrove, E. M., Engle, K. A., Robinson, L. R., Rosenblatt, R. A., ... Wenrich, M. D. (2013, December 01). Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Care Act: The WWAMI Program as a case study. Academic Medicine, 88, 1862-1869. Andrulis, D. P., Siddiqui, N. J., Purtle, J. P., & Duchon, L. (2010). Patient Protection and Affordable Care Act of 2010: Advancing health equity for racially and ethnically diverse populations [Report]. Retrieved from Care%20Act.pdf Association for Prevention Treatment and Research. (2014). Clinical prevention and population health curriculum framework. Retrieved February 14, 2015, from Fairman, J. A., Rowe, J. W., Hassmiller, S., & Shalala, D. E. (2011, January 20). Broadening the scope of nursing practice. The New England Journal of Medicine, 364, 193-196.
  10. 10. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 10 Hertz, B. T. (2013, February 25). How the ACA is reshaping medicine. Improvements in compensation, payer collaboration offset by provider shortages, incentive uncertainty. Medical Economics, 90, 30, 32, 39. Retrieved from aef7051-60d4-4e83-af6b-dc396d723bb5%40sessionmgr4004&vid=29&hid=4208 Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Jacobson, P. D., & Jazowski, S. A. (2011, August 1). Physicians, the Affordable Care Act, and primary care: Disruptive change or business as usual? Journal of General Internal Medicine, 26, 934-937. Kaiser Family Foundation. (2012). Disparities in health and health care: Five key questions and answers [Issue brief]. Retrieved from brief/disparities-in-health-and-health-care-five-key-questions-and-answers/ Kaiser Family Foundation. (2013). Summary of the Affordable Care Act [Fact sheet]. Retrieved from Lesko, S., Fitch, W., & Pauwels, J. (2011, September). Ten-year trends in the financing of family medicine training programs: Considerations for planning and policy. Family Medicine, 43, 543-550. Retrieved from Manchikanti, L., Caraway, D., Parr, A. T., Fellows, B., & Hirsch, J. A. (2011). Patient Protection and Affordable Care Act of 2010: Reforming the health care reform for the new decade. Journal of the American Society of Interventional Pain Physicians, 14, E35-E67.
  11. 11. THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 11 Retrieved from;14;E35- E67.pdf Naylor, M. D., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29, 893-899. Paradise, J., Dark, C., & Bitler, N. (2011). Improving access to adult primary care in Medicaid: Exploring the potential role of nurse practitioners and physician assistants [Issue brief]. Retrieved from Schwartz, M. D. (2011, November 1). Health care reform and the primary care workforce bottleneck. Journal of General Internal Medicine, 27, 469-472. Tilden, V. (2010). The future of nursing education [Policy brief]. Retrieved from Institute of Medicine website: change-advancing-health.aspx Zweifler, J., Prado, K., & Metchnikoff, C. (2011, February). Creating an effective and efficient publicly sponsored health care delivery system. Journal of Health Care for the Poor and Underserved, 22, 311-319. Retrieved from accountid=40561