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Tuesday, November 6, 2012

Improving the Cost of Care through the Affordable Care Act

On March 23, 2010, an ambitious legislative achievement ensued:  the Affordable Care Act was signed by President Obama.  The ACA put forward a vast reform of the nation’s health system that would relieve a large measure of human suffering and build a road to the healthier nation.  The controversial yet timely reform would ensure universal health coverage and attempt to control the explosive trend of rising medical costs.  The US health care costs are by far the most expensive in the world, and ways to control these costs should reflect the ways the consumers spend one of the six dollars they earn on illness-related expenses.  The ACA attempts to control such costs in a rational and obvious but long-ignored way of preventing expenditures before they occur.
Chronic diseases, such as cancer, high blood pressure, heart problems, diabetes, and stroke are responsible for seven out of ten deaths yearly and since most of the health care dollars are spent at the end of at times life-long struggle with these illnesses.  Since high prevalence of such diseases contributes to the sky-rocketing health care costs, it is vital to recognize that prevention of these illnesses could cost far less than their treatment.   Thus, the meaningful cost attainment can be achieved by ensuring that during ACA implementation the lawmakers and the public health workers continue to focus on disease prevention.

The ACA and Prevention  
ACA ensures that prevention becomes a key in reducing health care costs in several ways.  First, it ensures universal coverage.  Second, it provides individuals with improved access to clinical preventive services.  Third, a National Health Council is created to design a focused strategy to ensure the health of the nation. Fourth, under the ACA, a special Public Health Fund is designed to support the needed infrastructure for early detection and prevention of diseases, as well as management of medical conditions before they progress to severe stages (Koh,H., Sebelius, K., 2010).  Historically, primary care physicians have been the major providers of preventative services, but for more than a decade, there has been reduced interest in primary care among new medical graduates (Cassidy, A., 2012).  Because of this issue, it is important to focus on the role of advanced practice nurses (APNs) as health care providers, and key contributors of cost-effective, reliable old-standing as well as innovative preventative services.
Since the number of physicians going into primary care has been falling over the years, and since more than three million American families annually have already received care at some 1100 new retail clinics staffed primarily by APNs, it is vital to re-examine the role of APNs as providers of preventative health measures and in the end as a means of reducing health care costs (Aiken, L., 2011).  APNs’ scope of practice allows them to provide most of the preventative and screening services, such as administering vaccinations, making referrals for colon cancer and breast cancer screening, performing PAP smears to screen for cervical cancer, etc. 
Moreover, literature demonstrates that APNs are efficient in providing primary care services, including provision of screening and counseling (Naylor, M., Kurtzman, E., 2010).   Research demonstrates that comparison of the quality of care provided by physicians and nurse practitioners shows similar clinical outcomes (Cassidy, A., 2012).  Nurses are famous for focusing on patients as persons; nurses take the best from medical, social and behavioral sciences and then blend it with caring.  Nurses, like no other health care professionals are able to teaching and supporting patients in their journey to prevent diseases from occurring.  Yet, APNs cost the health care about half of what the physicians do.

It is important for the policy-makers representing the Commonwealth of Massachusetts to be aware of these trends, as well as their increasing significance in the light of the ACA, the emphasis on reducing health care costs and improving preventative care.  Massachusetts has always been famous for its progressive legislative achievements.  Recently, the innovative state health care legislation became a hot discussion topic for the law-makers on the federal level.  The representative of the Commonwealth has an excellent opportunity to demonstrate to the federal government that the state sought to fill the gaps in the primary care workforce through the extended use of APNs.
There are other ways that the representative of Massachusetts can continue strengthening the role of the APNs during the Health Care Reform implementation stage. Since the goals of ACA is to create a robust primary care, to strengthen preventative care, and to reduce the costs, the law-makers can aid goal achievement by encouraging the implementation of practice guidelines to ensure high-quality non-physician provided care.  Another way of supporting the role of APNs would be to ensure competitive compensation for the provided services, especially on the basis of their ability to demonstrate evidence-based practice approaches and improved patient outcomes combined with fewer office visits and reduced hospital admission rates.  Next, it is vital to continue supporting the autonomy of APNs as well as to institute medical malpractice laws that have non-physician providers in mind.  Since medical malpractice laws have been a matter of state regulation, it is up to the state legislators to protect the growing body of APNs.
Last but not least, the legislature needs to provide incentives for the registered nurses to advance their education and enter primary care.  Current model allows nurses to receive financial assistance for college expenses.  The problem with such program is that the nurses need to be employed in strictly defined facilities in rural areas.  Frequently, the geographic location of qualifying health care facilities makes colleges that provide graduate-level nursing education remote and inaccessible to the nurses. In the end, the nurses face a choice to either continue their employment and not use the grants they qualify for, or to quit the employment in order to pursue their education, which disqualifies them from a grant.
The tendencies towards reducing healthcare costs place an emphasis on providing quality, evidence-based, inexpensive care.  The APN workforce presents a potential answer to this difficult task of providing cost-effective care, including preventative services.  In fact, I believe that the changes in the health care system because of the APA would allow the APNs to unleash their professional potential.

Aiken, L. (2011). Nurses for the future. New England Journal of Medicine, 364. 196-198. doi: 10.1056/NEJMp1011639
Cassidy, A. (2012). Nurse Practitioners and primary Care. Health Affairs, 31 (10). Retrieved from
Naylor, M., Kurtzman, E. (2010). The role of Nurse Practitioners in reinventing primary care. Health Affairs, 29 (5). 893-899. doi: 10.1377/hlthaff.2010.0440 Retrieved from
Koh, H., Sebelius, K. (2010). Promoting prevention through the Affordable Care Act. New England Journal of Medicine, 363 (14). 1296-1299