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.

Proposal

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.

Conclusion

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.

References

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 http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_79.pdf

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 http://web.pdx.edu/~nwallace/AHP/NPPC.pdf

Koh, H., Sebelius, K. (2010). Promoting prevention through the Affordable Care Act. New England Journal of Medicine, 363 (14). 1296-1299

Sick Around the World: Reflections

The complexity of the US health care system can overwhelm even an expert: both private and public come into play to provide a wide range of health services to the whooping three hundred million population of the country. The US is one of the richest countries in the world, yet, our health care ranks 37^th(!!) in terms of quality and fairness. Undoubtedly, the system has its flaws, which became recognized by the government. Health care reform is aimed at improving access to health care and controlling its rising costs. It makes me wonder if the government learned any lessons from other capitalist countries that recently faced the same challenge.

After watching an eye-opening movie by US correspondent T.Reid Sick Around the World, I came to realize that various developed countries addressed the problems of health care access, quality, and cost in various ways. We can learn our lessons from Taiwan, but would it be wise to adapt the reform that was implemented in the country which economy at the time much differed from the well-developed US economy? We can learn our lessons from Japan, but would it be wise to compare US population to the population of the country with the longest life expectancy that may be due to a much healthier lifestyle and diet? We can also learn our lesson from Germany, but would it be wise to compare our physicians’ cost of education and malpractice insurance to their colleagues’ from “the other side of the pond”? I suppose, out of five health care systems, an amateur spectator like me would consider the one of Switzerland. First, a health care reform took place in the country where the system used to be similar to ours, with voluntary coverage. Second, the reform was recent – 1990’s. Third, the country’s stable capitalistic economy can somewhat be compared to the economy of the US.

T.Reid makes a very important point when he says that everyone has the right to vote, everyone has the right for a fair trial, so everyone should have a right to health care. If Switzerland could do it with eight million people, so can we, with three hundred and eleven. There are several reasons, why I think the model works. One of the key features of the reform is to reduce health care costs, and Switzerland has done so by reducing administrative costs, which a sky-high in the US. Next, the insurance companies compete for clients despite being non-profit organizations and offering the exact same benefit packet to the public. In a healthy economy, competition should always be present to ensure that there is a continuing effort for improvement. No one can be denied health insurance due to a re-existing condition, yet there is still room for insurance companies to make profit on the supplemental insurance. Another crucial component of the Switzerland’s health care system is its affordability: even though a seven hundred and fifty dollars monthly premium is a costly expense, it is still much cheaper than what we pay in the US. On top of that, the government controls prices on prescription medications – a concept unheard of in the US where a poor elderly person can be spending over a half of their monthly income on drugs…

To sum it up, I would like to share a personal story. A young American couple had their first born in one of the local hospitals. Soon it became clear that the infant was seriously ill; it took the best physicians in the country almost two month to diagnose the baby with a rare genetic disorder – APEX syndrome. The family spent an entire year of the baby’s short life in the hospital. In the end, they were left with a profound sense of loss and a monstrous bill that the new family could afford, even with health insurance. Sadly, such stories happen in our country. In Switzerland, this would have been a huge national scandal.  So wherever we learn our lessons from, we are definitely over-due for some change in the health care system.

In Response to the Big Med

Can health care be managed in a way that combines quality control, cost control, and innovation?  With the presidential elections around the corner and the advent of the ACA, the question has never been more acute than now. Public health-care reform is sought to reshape the system with the goal to reduce cost and provide quality care for the population. Along comes the difference in opinions on the ways how re-structuring of the health care should be accomplished to decrease soaring costs and at times mediocre or unreliable services. According to some, we should take a look at the restaurant business and adopt their deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality.

The idea to adopt a restaurant business model can raise an eyebrow or a mocking laugh in some, while it can seem appealing to others. Children of consumerisms, Americans expect quick, cheap, and reliable services. In a restaurant, every dish involves deviation from a set recipe and attention to detail for personal adjustments. We expect the restaurant chains, like Cheesecake Factory, manage to accomplish consistent quality results over and over again across the entire country. Similarly to the pager beeping that informs you about the table becoming available, we expect the emergency room staff to inform us about the time it is going to take to be seen by a physician, or the cardiac surgeon implanting the exact high-quality valve in the heart of our loved one as he did for some high-profile executive three surgeries ago.
I admit, I initially scoffed on the idea of adopt a restaurant business model to the health care, thinking, “Who is this person comparing intricacies of illnesses and individual health factors to the restaurant dishes?” Intrigued, I kept reading and found out that the author is a pretty much a colleague of mine who works in another hospital in the city and has not lost touch with reality. Sharing a personal experience in health care affirmed the thought that there is truth in what is said. Some patients chose a physician who has titles and titles after his name, but then they have to rely on doctors who may have insufficient information or economic incentives to pick the costliest treatment.
There are two sides to the coin. I think it is our duty as health care professionals to be informed about the best evidence regarding treatment options, and either to follow the best standards or to develop new standards. If the evidence shows that prescribing a blood-thinning medicine during the hospital stay prevents the formation of blood clots caused by decreased mobility, then it is only common sense to prescribe it to the qualified patients (note to deviate from a set recipe for contra-indications). Fewer blood clots leads ultimately to better patient recovery and lower hospital bill. Adhering to the best-researched evidence can after all allow the providers to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality.

The other side comes from the financial aspect of healthcare, ethical concerns, time that it takes to prove the effectiveness of certain interventions, and the nature of healthcare settings. Changes in healthcare seem to be harder to implement than in other customer-oriented areas. For example, I almost want to bet on the fact that it is easier to approve a new dish for a menu in a Cheesecake Factory at the Prudential than it is to implement the use of LUCAS chest compression system in a near-by BIDMC Emergency Room with well-trained, qualified personnel. Another example is treating a patient for pneumonia according to an algorithm that has been proven to be effective: one adhere to the best standard ever yet not to achieve the same result due to unforeseen factors like co-existing illnesses, constantly mutating microbes, religious beliefs against blood products, unnecessary tests the patient demands because “I read it on-line”, and what not. I am not saying that delivering quality care is an un-achievable goal in healthcare, I simply b

Read more: Atul Gawande: Big Med…Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?

http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande#ixzz27V3AdyYM

Health, Wellness, and Health Experience

    “…As you move toward wellness”, says the yoga coach to the class, experiencing relaxation during their final breathing exercise.  “As you get your health back”, says the nurse discharging the patient, recovering from a flare-up of colitis. Wellness and health, illness and disease: are they antonyms and polar opposites or are they simply parts that come together to make an entirety? 

    Historically, wellness and illness were considered mutually exclusive: the meaning of wellness as the opposite to illness can be traced to the 1600’s (Zimmer, 2010). Nowadays, the definition of wellness encompasses health, and underlines the dynamic nature of the concept (Mosby's Medical, 2002). Depending on the background, a great degree of variability exists in the definition of wellness and the degree of separation of illness from health. For example, in traditional Western medicine disease is the central concept of patient care, a hospitalized individual is viewed in disconnect from his usual state of health and well-being.

Luckily, nurses seem to sense the changes before they even occur, and the advent of holistic nursing influenced the shift of traditional paradigm from health as an opposite of disease to wellness being a multi-dimensional phenomenon. According to Keegan, health/wellness and disease/illness constitute parts of a process of human health experience (Keegan, 2009, p. 106). If human health experience is a dynamic process, then its multi-faceted, transforming elements are bound to influence each other.

    The concept of health/wellness (along with nursing, patient, and environment) is an important building block for nursing theory and practice (Edwards, 1997). For me, nursing practice is built on the interaction of these four components. It is mostly the interaction between the four components that forms human health experience; hence my nursing care should start at some point on a continuum from wellness to illness and aid individuals in achieving their optimal level of wellness. In the effort to accomplish this goal, I find vital to consider the patient himself, as well as opportunities and constraints of the environment. I think that patients’ physical and emotional environment should be viewed inseparably from the health/wellness and disease/illness because of their constant two-way influences and interactions. 

  Health attitudes and beliefs are an essential part of patients’ emotional environment.Keegan notes that health attitudes determine patients’ willingness to accept medical treatment and their perception of the extent of illness (Keegan, 2009, p. 108).

    Keegan notes that health attitudes determine patients’ willingness to accept medical treatment and their perception of the extent of illness (Keegan, 2009, p. 108). I find this very true. From the side of the white coat, IV antibiotics, charts, and EKGs, it is hard to see pain, fear of unknown, and an overwhelming intimidation from high-tech medical equipment. As I was looking for examples to illustrate “the other side” of health experience, I referred yet again to my beloved New Yorker. In a story called Sudden Illness, Laura Hillenbard describes her experiences with “un-wellness” and navigation of health care (Hillenbard, 2003). In leu of discussing patients’ perception of their health and health experiences this article can be an eye-opener. I think that recognizing that patients have both differences and similarities in ways of perceiving, knowing, and practicing care can allow nurses to communicate with patients more efficiently, and, ultimately, develop a trusting relationship. 

for those who like the New Yorker, here is a link to the article

http://archives.newyorker.com/?i=2003-07-07#folio=056

References:

Edwards, S. (1997). What is philosophy of nursing? The Journal of Advanced Nursing , 25, 1089-1093.

Hillenbard, L. (2003, July). Sudden Illness. The New Yorker , 56-65.

Keegan, L. (2009). The Art of Holistic Nursing and the Humand Health Experience. In B. Dossey, & L. Keegan, Holistic Nursing: A Handbook for Practice (pp. 101-112). Sudbury, MA: Jones and Bartlett Publishers.

Mosby's Medical, N. a. (2002). Wellness. Elsevier.

Zimmer, B. (2010, April 16). Wellness. The New York Times , pp. Retrieved on June 30, 2012 from http://www.nytimes.com/2010/04/18/magazine/18FOB-onlanguage-t.html.

Did you know that you start reducing your risk for osteoporosis during your teenage years? I didn't.

Theories of health behavior may have some answers and may be useful to us as nurses to provide better care. Health Belief Model is a theory that focuses on the individual as the locus of change (Martins, 2011). This model is centered around the premise that people take health actions to avoid diseases. The perceived susceptibility to disease, the perceived threat to disease, and the perceived benefits of some behavior all affect the likelihood of taking some sort of preventative action.  I am not a big fan of theories; my nursing practice is directed by research, so I only “buy it” when I see well-designed studies that show practical applications of theories. 

Health Belief Model turns out to be one of such cases. Despite existing since 1950’s, is has not lost its up-to-date practical application. In last year’s March issue of the American Journal of Health Behavior, Gammage and Klentrou published an article about the use of the Health Belief Model to predict osteoporosis preventing behaviors (Gammage & Klentrou, 2011). Osteoporosis is a disease that affects bone mass, and despite the fact that it affects mostly older women, disease prevention establishes around early adulthood years with lifestyle factors affecting a healthy bone mass formation.

The purpose of the study was to examine whether the variables from the Health Belief Model (HBM) could predict preventative health behaviors such as calcium intake and physical activity in teenage girls. The study was conducted among a relatively small sample of five hundred and ten high school girls who completed questionnaires that looked at the HBM variables. In the end, the investigators examined the anthropomeric measures, such as height, weight, and the percent of body fat. Questionnaires were designed to assess belief about calcium intake and exercise to prevent osteoporosis, the researchers used a health beliefs scale, a self-efficacy scale and other tools to apply the Health Belief Model. What I liked the most about the study is a detailed description of the tools used in the experiment, including the validity of the tests, and the statistical analysis of the data. The results were organized in easy-to-comprehend tables, demonstrating means, medians, and standards deviations.

The researchers reported interesting results: while the girls perceived osteoporosis as a severe disease, they did not see themselves as being at risk. Gammage and Klentrou found out that the barriers to taking calcium supplements were low, and the girls had knowledge about the benefits of taking the supplements. The average calcium intake in the sample population was found to be adequate, yet about half of the girls did not reach the recommended levels of intake. What I found alarming is that physical activity was found to be low, indicating an area of the health care needs that could potentially be addressed by community health nurses. Gammage and Klentrou suggest that the girls, who place more value on the benefit of exercise, tend to better engage in physical activity. 

For more information:

Gammage, K., & Klentrou, P. (2011). Predicting Osteoporosis Prevention Behaviors: Health Beliefs and Knowledge. American Journal of Health Behavior , 371-382.

Martins, D. (2011). Thinking Upstream: Nursing Theories and Population-Focused Nursing Practice. In M. Nies, & M. McEwen, Community / Public Health Nursing: Promoting the Health of Populations (pp. 37-49). St.Louis: Elsevier.

Nurses' Week is around the corner

Nurses Week is around the corner, and for the second year in a row I am helping organize the events for this week in our hospital. Today,  I was thinking about the theme for the National Nurses' Week and how it applies to all of us. Here is what I came up with:

Dear Nurse,

You advocate, you lead, you care.

You know that everyday work is important for the patients and families, but the challenges can sometimes be so overwhelming. During such times, you may just need a little pick-me-up to help you keep going. These words of inspiration are dedicated to YOU.

--  you advocate; you fight for your patients’ well-being, you go through the trouble of making the fifth phone call to the doctor to make sure your cancer patient gets enough pain medication. You know that “Knowing is not enough; we must apply. Willing is not enough; we must do”. (Goete)

 --  you lead, you go through a stress of a specialty certification because you want to lead new nurses to excellence in care. You know that “If your actions inspire others to dream more, learn more, do more and become more, you are a leader”. (John Quincy Adams)

  --  you care.  You hold the hand of the patient, and tell them that everything is going to be just fine. To be a nurse for you is to do what nobody else will do, a way that nobody else can do, in spite of all we go through because you care. “They may forget your name but they will never forget how you made them feel”. (Maya Angelou)

Happy Nurses’ Week!

Body Image and Self-Esteem in High School Students

 I am too fat. I am too skinny. My butt is too big. My hair is too curly. Does any of this sound familiar? To me, these statements help define the issues that the teenage girls have to deal with, the emotions that come along, the behavior that results from the issues and emotions. So this week’s post is devoted to the health behavior as it relates to the body image in teens.
During one of my first visits to a high school somewhere in the United States, I took a tour of the school to familiarize myself with the surroundings in case we get called into one of the buildings for an emergency. When I was walking in the health education section of one of the buildings, my gaze got drawn to a very colorful board made up of clippings from what looked like students’ essays. I came closer, and here is w hat I saw:

  The board was a collection of the thoughts on body image. At the beginning of the semester, one of the health education teachers made up a collage that reflected the feelings the students experienced regarding their body image. She kept the postings anonymous, and displayed the collection on the wall to make the rest of the students realize they were not the only ones to go through changes that affected their body and their self-esteem.
 

 
 
 
 
 
 
 
 
 
 
 
 
 A few weeks later, I was lucky to visit this teacher’s health education class, and I was even luckier to visit it during the time, when body image and disordered eating were discussed with the students. Part of the homework for the class was to visit the board that I mentioned earlier and to make observations about it. I was amazed by the feedback that the students provided about the postings, the students’ comments were very insightful and mature for the age. Here is what I heard:
“All [the postings] were about physical things”
“I can relate to some of them”
“I noticed that some of those things you could change by exercising, or eating right. Other things, you could change my dying your hair, or dressing in different clothes. But doing so can change who you truly are”
“A lot of the postings were about weight. I noticed that it was about what [the students imagined] people thought about you and your body”
“I think about my body image all the time; you can’t escape it, it is everywhere: it is in the mirror, in the movies, and your friends talk about the looks”
The issue of body image and self-esteem is very important during the high school years. Body image is how people feel about their own physical appearance, while self-esteem is about how much people value themselves. Self-esteem is important because feeling good or bad can affect how people act. This is where theories of health behavior may provide some information about why people feel a certain way about themselves, and why people act a certain way. These answers may be useful to the nurses so that they can provide better care. For example, a problem of body image and self-esteem can be viewed from the macroscopic approach of conceptualization of the health problem (Yes, I do think that body image is a community health problem, because it leads to multiple problems including eating disorders, cutting, and suicide). According to this model, the individual, here a teenager, is in the middle, the center contains the problem of interest: inadequate self-esteem based on the distorted body image. In this context, interventions would focus on individual high school students, or a small group of students with this problem.
The rest of the class time was built according to the principle of microscopic approach; the teacher incorporated various activities to examine the students’ attitudes to body image, to examine the prevalence of distorted body image, to locate the sources of influences, and to introduce ways the students can optimize coping with the developmental changes occurring to their bodies as well as mental issues that accompany these changes. She explained that the student struggle with the issue of self-esteem at this vulnerable age, because puberty causes changes in the body. By asking the class respond to how they felt about other people criticizing the way they looked, she examined the sources of influences. Since all the activities were conducted in a very informal manner, and the students could move freely in the classroom, they felt more comfortable expressing their feelings.
I think that this class taught me about the ways to talk to the girls if they come to the nurses’ office to discuss body-image issues, help me find ways to examine causes of disordered eating, and allow me find strategies to make these girls feel like they are not the only ones, that there are things they can do, and that after all, there is a person they can trust and always talk to.