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3 Objectives What is a Policy What is Healthcare Policy How does Policy influence our healthcare Escape Fire Patient Protection and Affordable Care act (aka Obama care) King v. Burwell. Nurse practitioner as a care provider Case of Medicare Physician Fee Schedule Proposed Rule How policy affects practice of APRN Get Involved

4 What is a Policy? The Center for Disease Control and Prevention (CDC, 2014) defines “policy” as a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions.

5 “Healthcare Policy” aka Healthcare reform The health of our nation can be influenced by public health policies, such as a tobacco control policy, and by policies in many other sectors. For example, transportation policies can encourage increased physical activity and school nutrition policies can ensure healthier meals are provided in schools. (CDC,2014) Health care policy targets the organization, financing and delivery of health care services. For example, health care may be delivered through a managed care provider or a preferred provider network. It may be financed through employer-sponsored health insurance, individual policy, or Medicare. And the care you get may be pegged to federally funded research that has identified the most effective treatments.

6 3 types of Universal Health This system is completely government run. In at least one country, the government places its citizens into one of two categories. The medical services available to an individual are then based on their category. If they need services that are not included in their category, they must petition their government. The government provides or mandates a minimum amount of insurance coverage for every citizen. The government mandates that all citizens purchase insurance, whether from private, public, or non-profit insurers. In this case, insurance companies must accept all applicant, regardless of health.

7 Escape Fire Movie

8 Patient Protection and Affordable Care Act (PPACA) Affordable Care Act(ACA) or Obama Care o Insurance Mandate type of universal health care o Signed into law in March 2010. o ACA requires all citizens to purchase an acceptable health insurance policy or pay a penalty. o Some changes started immediately while others would be phased in over the next 5 years

9 Affordable Care Act (ACA) cont. o Individuals can purchase competitively-priced health insurance on American Health Benefit Exchanges (“exchanges”) that may be run by either the States or the federal government. o Authorizes a federal tax credit for low- and middle-income individuals o According to the U.S. Department of Health and Human Services, by 2014 ACA will expand coverage to nearly 32 million uninsured citizens. o Starting in 2011, the law began to focus on preventative services: This includes immunizations, diabetes and cancer screenings, counseling for smoking and alcohol abuse, and more. o Other parts outlined that went into effect in 2011 were: ◦ no annual or lifetime limits on essential health benefits ◦ Children stay on a parents plan until 26y/o ◦ Children with pre-existing health problems can be covered

10 Who This has Affected Insured by employer Many health care reform changes that affects your health plan may already be in place. If there are additional changes that will affect your plan, you should have receive details under the current enrollment period. Insured on their own Some plans are being updated to include certain protections healthcare reform requires Not insured As of January 2012, U.S. citizens can no longer be denied coverage. Financial help may also be available if you qualify.

11 ACA Definitions: o Subsidies: a sum of money granted by the government or a public body to assist an industry or business so that the price of a commodity or service (mandated health insurance) may remain low or competitive. o Exchange: A health market place where bargains and sales take place. A negotiation by which one person transfers to another funds that he has in a certain place, either at a price agreed upon or which is fixed by commercial usage o State exchanges: Health care policy program market places offered by a state that a person lives in (ex. Covered California). o Federal Exchanges: Health care programs offered by the federal government (ex. Medicare, Medicaid)

12 ACA Section 1311 “A State shall use amounts awarded under this subsection for activities… related to establishing an American Health Benefit Exchange.” ACA Section 1321 If a State elects not to establish its own exchange or will not be ready to operate its exchange in 2014, ”the Secretary [federal government] shall establish and operate such Exchange within the State…”

13 ACA Section 36B of Internal Revenue Code Refers to all federal exchanges in requiring all exchanges to report to the federal government on the amount of advance payments of premium credits that taxpayers receive. Section 1401 authorizes subsidies (nominally, “tax credits”) for exchange enrollees whose household income falls between 100 and 400% of the federal poverty level, who are not eligible for qualified employer coverage or other government programs, and who enroll in coverage “through an Exchange established by the State.”


15 King v Burwell


17 o Federal government’s ability to distribute tax credits o Discounted health coverage o Some people live in States that made their own exchanges o California, Kentucky, and Maryland o Majority live in states like Florida, Pennsylvania, and Texas, o Federally-run exchanges

18 If the justices uphold the latest Obamacare lawsuit, here's the average increase in premiums for people who now receive tax credits.

19 HALBIG V BURWELL Letter of the law should be implemented as it is written DC Circuit judges ruled that is was ILLEGAL for IRS to extend subsidies to federally-run exchanges Does not take context into consideration Currently reviewing appeal en banc for reconsideration in December KING V BURWELL The language of the ACA is ambiguous and subject to multiple interpretations Chevron Deference Upheld the rule as a permissible exercise of the agency’s (IRS’) discretion Fourth Circuit judges said they could not confidently conclude which was the correct interpretation Whether the Internal Revenue Service may permissibly extend tax-credit subsidies to coverage purchased through exchanges established by the federal government under Section 1321 of the Affordable Care Act.

20 Why is this case such a big deal?

21 Potential Implications o Private Insurance becomes extremely unaffordable ◦ Healthy people drop ◦ Only very sick keep coverage ◦ “Death Spiral” o Over 7 million people will be subject to individual mandate penalties, 57 million subject to employer mandate. ◦ Individual Mandate Exemptions ◦ Some people may have to pay back the government o The IRS is given power to interpret the law as they see fit o Ruling will set a precedent for authority an agency such as the IRS has to rewrite the law or execute laws as they interpret them

22 Let’s hear from both sides AFFIRMING Congress intended to include federal exchanges under the broad term of “Exchanges” Federal exchange is the State Exchange in states not establishing their own exchange ACA was intended to give all people access to affordable care no matter where they live Tax credits are available to all taxpayers who obtain coverage in an exchange, according to section 36B of ACA Chevron Deference allows for executing agencies to interpret the law and carry it out as such OPPOSING The wording of the sections in the law explicitly state that subsidies and tax credits would be extended to State-run exchanges There is no mistake in the way the law was written. “Congressional intent is the legislation the Congress enacted.” Congress planned to draft the law in such a way that left federally-run exchanges without access to subsidies The part of the law that calculates subsidies specifies that those subsidies are only available to people “enrolled in through an Exchange established by the State under 1311” It does not reference section 1321, which sets up the federal and partnership marketplaces the subsidies were supposed to act as a carrot, encouraging states to set up own exchanges


24 How should healthcare work?

25 Nurse Practitioners Fight TO GAIN AUTONOMY

26 Advanced Practice Nurse (APN) A registered nurse with a master’s or doctoral degree in nursing who demonstrates expert knowledge, skills, and attitudes in the practice of nursing.

27 Comparison of Old Sick Care Paradigm with New Healthcare Paradigm OLD PARADIGM Hospital-based acute care Physician in charge Nurse as subordinate Physician as primary decision maker Segmented care focused on separate body parts/systems Primary care physicians and specialist separated Paper records; some electronic health records (EHRs) Free-for-service Hierarchical organizations Positivist, linear thinking NEW PARADIGM Short-tem hospital, outpatient surgery, mobile/satellite clinics, telehealth/telemedicine Team approach Nurse as full team member Relevant professionals and patient make treatment decisions Seamless, coordinated, holistic care Patient-centered home health HER system that generate data used for change packages Value-based organizations Complexity science: patterns noted in chaos, networks essential, quantum principles.


29 3 Levels of Practice State practice and licensure law provides for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments- including prescribe medications- under the exclusive licensure authority of the state board of nursing. State practice and licensure law reduces the ability of nurse practitioners to engage in at least one element of NP practice. State requires a regulated collaborative agreement with an outside health discipline in order for the NP to provide patient care. State practice and licensure law restricts the ability of a nurse practitioner to engage in at least one element of NP practice. State requires supervision, delegation, or team-management by an outside discipline in order for the NP to provide patient care.

30 Full practice rights Reduced Practice rights Restricted Practice Rights NOTE THAT IN THE STATE OF CALIFORNIA RIGHTS ARE RESTRICTED

31 Do nurses want to be doctors?

32 Nurse Practitioners can help

33 Case Study

34 Medicare Physician Fee Schedule Proposed Rule On August 24, 2010, ANA submitted comments to the Centers for Medicare and Medicaid Reimbursement (CMS) regarding the 2011 Physician Fee Schedule proposed rule. Under recent legislation, reimbursement to all Medicare Part B providers, including APRNs, has increased by 2.2%. Under the Affordable Care Act (ACA), Medicare reimbursement for certified nurse- midwives (CNMs) is on par with that of physicians, just as it is for certified registered nurse anesthetists. Nurse practitioners and clinical nurse specialists continue to be compensated at 85% of what physicians receive for providing the same services. Discuss why NPs and CNs are not reimbursed at 100% What could be done to change this? What players/stakeholders would you involve in trying to change this? What implementation variables should be addressed?

35 Get Involved! o Learn and understand the issues regarding healthcare policies o Join professional nursing organizations ◦ American Nurses Association ◦ California Association for Nurse Practitioners o Write to your legislative representative ◦ 31st District – Gary Miller – Rancho Cucamonga, Redlands, Colton, Loma Linda ◦ 34th District – Xavier Becerra – El Sereno, Boyle Heights, Montecito Heights, Cypress Park, Glassell Park, Mt Washington, Highland Park ◦ 35th District – Gloria Negrete McLeod – Ontario, Chino, Pomona, Bloomington, Montclair ◦ 39th District – Ed Royce – Diamond Bar, Fullerton, La Habra, Yorba Linda, Chino Hills, Hacienda Heights o Organizations often have templates for letters and emails specific to your area of interest o Become a Legal Nurse Consultant

36 References o Vox o ACA Health Reform Navigator system/app/pages/search?scope=search-site&q=internal+revenue+code o The three types of universal healthcare: america-sick/ america-sick/ o o What is a policy:


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