Meeting the Needs of the Newly Insured: A Look at the Numbers

The title of a recent article from Kaiser Health News (KHN) (Ollove, 2014) posed the question, "Are There Enough Doctors for the Newly Insured?" A news article with such a title is misleading. The article was stimulated by a story in Stateline, the daily news service of The Pew Charitable Trusts. Unfortunately, this headline and the article content create a false impression that we will continue with Medical Model health care where the pivotal provider is a medical doctor. However, the Affordable Care Act (ACA, 2010) provisions are designed to foster wellness, health promotion, and disease prevention though interprofessional provider teams working collaboratively in Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs), whereas the Medical Model focuses on physician diagnosis and treatment of acute and chronic illnesses. Missing in the headline as well is the acknowledgement that health care also involves other primary care providers such as nurse practitioners, physician assistants, pharmacists, social workers, dieticians, dental specialists, and mental health care providers who focus on prevention of disease and promotion of wellness. Such providers are also members of interprofessional teams providing care for the newly insured.

The KHN article (Ollove, 2014) also provides statistics derived from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA, 2014) regarding the numbers of providers needed to improve access to health care. These numbers demonstrate that there will be access issues for the newly insured.

"Nearly 20% of Americans live in areas with an insufficient number of primary care doctors. Sixteen percent live in areas with too few dentists and a whopping 30% are in areas that are short of mental health providers. Under federal guidelines, there should be no more than 3,500 people for each primary care provider, no more than 5,000 people for each dental provider; and no more than 30,000 people for each mental health provider" (Ollove, 2013, 2014, p. 1; HRSA, 2014).

Again, this information does not view providers through a broad lens; instead, the focus is on the traditional view of doctors, dentists, and psychiatrists and how shortages of these providers will hamper access for the newly insured. The following reinforces this view: "Many primary care doctors and dentists do not accept Medicaid patients because of low reimbursement rates...and many psychiatrists refuse to accept insurance at all" (Ollove, 2014, p. 1). It is not until page 3 of the article that advanced nurse practitioners (APNs), physician assistants (PAs), and pharmacists are mentioned as potential primary care providers, even though the ACA (2010) provisions list them as primary care provider members of the interprofessional team. The lead-in to a discussion of alternative primary care providers begins with, "A more controversial idea is to allow nurse practitioners, physician assistants, pharmacists, and dental aides to do some of the work usually reserved for doctors and dentists. Many states have passed such legislation while other are eyeing similar measures" (Ollove, 2014, p. 3). The KHN article also states that the American Dental Association opposes use of mid-level dental workers, even for routine preventive and restorative work, and some groups representing physicians are resisting allowing APNs to write prescriptions and admit patients to the hospital. Polly Bednash, Executive Director of the American Association of Colleges of Nursing, responded to such resistance with, "Health care is not a zero-sum game where there is a limited amount of care to be given. If there's more care needed than we can deliver in the world, we have to decide who else can provide quality care" (Ollove, 2014, p. 3).

What is needed in health care today to meet the needs of the newly insured is visionary thinking and innovation. We cannot afford to deliver Medical Model health care using fee-for-service methods. Rather, we need to consider outcomes that need to be achieved; methods to deliver disease prevention, wellness, and health promotion; as well as acute and chronic disease care and valid and reliable measures of processes and outcomes.

The Institute of Medicine's (IOM) report, The Future of Nursing (2010), demonstrated such visionary thinking with its recommendations. It speaks directly to the topics in this column.

  • Nurses should practice to the full extent of their education and training.
  • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
  • Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
  • Effective workforce planning and policy-making require better data collection and an improved information infrastructure.

As you know, AAACN has been working over the past 18 months to develop the dimensions, competencies, and a model of Care Coordination and Transition Management (CCTM) (Haas, Swan, & Haynes, 2013). This work on the CCTM model and competencies is now the basis for the CCTM Core Curriculum text (Haas, Swan, & Haynes, in press) and a series of modules that began in February 2014 to educate registered nurses working in ambulatory care. The Core Curriculum text and CCTM course are designed to assist ambulatory care nurses to develop the knowledge, skills, and attitudes needed to successfully assume the role of the RN working in CCTM.

The Core Curriculum is evidence-based and provides cutting-edge methods to be used by the registered nurse delivering care coordination. Alternatives to face-to-face office visits are presented. For example, telehealth methods are discussed in depth, such as the use of Skype® and telemonitoring. There is discussion of methods for interprofessional communication, interagency communication, and measurement of outcomes.

True to the recommendations of the IOM report, The Future of Nursing (2010), AAACN has provided a visionary new role for registered nurses that will enhance access for the newly insured and provide high quality care for all patients served. For further information on the CCTM Core Curriculum text and course, visit www.aaacn.org/cctm.


References

Affordable Care Act (2010). Read the law. Retrieved from http://www.hhs.gov/healthcare/rights/law/index.html

Haas, S., Swan, B.A., & Haynes, T. (2013). Developing ambulatory care registered nurse competencies for care coordination and transition management. Nursing Economic$, 31(1), 41-48.

Haas, S., Swan, B.A., & Haynes, T. (Eds.). (in press). Care coordination and transition management core curriculum. Pitman, NJ: American Academy of Ambulatory Care Nursing.

Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Retrieved from http:// www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading- Change-Advancing-Health/Recommendations.aspx

Ollove, M. (2014). Are there enough doctors for the newly insured? Kaiser Health News. Retrieved from http://www.kaiserhealthnews. org/Stories/2014/January/03/doctor-shortage-primarycare- specialist.aspx

U.S. Department of Health and Human Services, Health Resources Services Administration (HRSA). (2014). Shortage designation: Health professional shortage areas & medically underserved areas/populations. Retrieved from http://www.hrsa.gov/shortage

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at shaas@luc.edu