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The Affordable Care Act: Primary Care and the Doctor of Nursing Practice Nurse

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Breanna Lathrop MSN, MPH, FNP-BC
Donna R. Hodnicki, PhD, FNP-BC, FAAN

Abstract

The passage of the 2010 Patient Protection and Affordable Care Act (ACA) initiated the transformation of the United States healthcare system. The ACA fosters a preventive healthcare model that emphasizes primary care, funds community health initiatives, and promotes quality care. These changes increase the need for well-prepared healthcare professionals. Advanced Practice Registered Nurses (APRNs) who hold the Doctor of Nursing Practice (DNP) degree are prepared to meet this increased need by providing leadership in community health centers, serving on interdisciplinary teams, and advocating for and directing future policy initiates. In this article, the authors consider how the ACA will serve as a prevention model, describe the role of DNP nurses as primary care providers, explain how preventive healthcare can be enhanced through the use of a primary care model, and address associated challenges related to increasing preventive care in our healthcare system. They also discuss DNP nurse leadership opportunities related to community-based programs and policy strategies to strengthen primary care delivery. The authors conclude by noting the professional and legal barriers that need to be removed before DNP nurses will be able to provide the care they have been prepared to offer.

Citation: Lathrop, B., Hodnicki, D., (March 31,  2014) "The Affordable Care Act: Primary Care and the Doctor of Nursing Practice Nurse" OJIN: The Online Journal of Issues in Nursing Vol. 19 No. 2.

DOI: 10.3912/OJIN.Vol198No02PPT02

Keywords: Patient Protection and Affordable Care Act, ACA, healthcare reform, nurses, primary care, doctor of nursing practice, DNP, community-based programs, leadership, health policy, prevention, health insurance, APRN, DNP-APRNs, APRN practice barriers

The ACA establishes a new direction for the U.S. healthcare system that includes an emphasis on preventive services and primary care. The Patient Protection and Affordable Care Act (ACA), signed into law on March 23, 2010, is the most expansive healthcare reform legislation in the United States (US) since the creation of Medicare and Medicaid in 1965. The ACA establishes a new direction for the U.S. healthcare system that includes an emphasis on preventive services and primary care. It provides insurance coverage to millions who are currently uninsured and attempts to address areas of the current healthcare system that are in need of reform so that consumer needs for safe care and improved health outcomes are met.

The Institute of Medicine (IOM, 1999) has previously reported that 44,000 deaths occurred annually as a result of medical errors. The 2001 IOM report identified deficiencies in the quality of health care received by Americans; 50 million Americans remain without health insurance (Kaiser Family Foundation, 2012), and the cost for healthcare is increasing. The current healthcare system is failing even those with insurance. With $7,538 per capita annual spending, the cost for U.S. healthcare is at an all-time high and is nearly double that of any other Organization for Economic Cooperation and Development (OECD) nation (Kaiser Family Foundation, 2011). The ACA, upheld by the U.S. Supreme Court (National Federation of Independent Businesses v. Sebelius, 2011) will be fully implemented over the next two years.

APRNs have historically been champions of preventive healthcare and primary care. The ACA will initiate reform throughout the healthcare system and influence the provision of preventive and primary healthcare services. APRNs have historically been champions of preventive healthcare and primary care (Keeling, 2009). Implementation of the ACA presents an unprecedented opportunity for APRNs (nurse practitioners, certified nurse midwives, and clinical nurse specialists) to take a leadership role in offering primary care and strengthening preventive services. However, this opportunity for influence is dependent on having an appropriately educated nursing workforce which will include an increased number of nurses with doctoral education (Cleary & Wilmoth, 2011).

A relatively new member of the healthcare workforce, the APRN with a Doctor of Nursing Practice (DNP) degree (henceforth referred to as the DNP APRN or the DNP nurse) provide care and leadership in the areas of primary care and prevention (AACN, 2006). We will use the term DNP nurse in this article to refer to the APRNs and nurse administrators holding a DNP degree. Although the DNP nurse is prepared to work in direct patient care, academia, clinical research, or administration throughout the healthcare system, this discussion will focus specifically on the role of the DNP APRN in the provision of preventive services and primary care.

In this article, we will discuss how the ACA will serve as a prevention model, describe the role of DNP nurses as primary care providers, explain how preventive healthcare can be enhanced through the use of a primary care model, and address challenges related to increasing preventive care in our healthcare system. We will also consider the opportunities for DNP nurse leadership in developing community-based programs and advocating for policies to strengthen primary care delivery.  We will conclude by noting professional and legal barriers that need to be removed before DNP nurses will be able to provide all the care they have been prepared to offer.

The Affordable Care Act: A Prevention Model

A comprehensive summary of the ACA is beyond the scope of this paper, but a basic understanding of the provisions that impact primary care is essential for understanding the role of the DNP nurse as the nation implements the ACA. We have developed Table 1 to summarize the provisions within the ACA that have the potential to impact primary care (Patient Protection and Affordable Care Act [ACA], 2010). These provisions, designed to expand insurance, increase primary care access, and promote preventive health services, are important for improving healthcare outcomes. This section will discuss the ACA insurance expansion and preventive services enhanced through primary care and public health programs.

Table 1. Patient Protection and Affordable Care Act Provisions with the Potential to Impact Primary Care

Provisions increasing access to health insurance

Section

Provision

1311

Creates state-based American Health Benefit Exchange that allows individuals to purchase healthcare through state-run health plans

1402

Provides cost-sharing subsidies for individuals making between 100% and 400% of the Federal Poverty Limit (FPL)

1401

Provides premium tax credits to increase the affordability of state-based plans

1311

Establishes the Small Business Health Options Program Exchange which allows for small businesses to purchase group insurance

1421

Authorizes small business tax credits for businesses providing health insurance to employees

1501

Establishes a mandate requiring U.S. citizens and legal residents to purchase insurance or pay a tax penalty equivalent to 2.5% of their taxable income

1513

Imposes fines on employers with 50 or more full-time employees who fail to offer insurance to their employees

2101

Provides additional funding to the State Children’s Health Insurance Program (SCHIP) and extends SCHIP funding

2001

Encourages states to expand Medicaid to all individuals at or below 133% FPL

2714

Allows young adults to remain on their parents’ insurance plan until age 26 years

Provisions increasing access to preventive health services

Section

Provision

2713

Requires health insurance plans to increase coverage and access to preventive services

4004

Creates a national education and outreach campaign for prevention and health promotion

4103

Provides an annual wellness visit for Medicare beneficiaries without copay

4104

Eliminates Medicare cost-sharing (individual copay) for preventive services rated “A” or “B” by the U.S. Preventive Services Task Force

4106

Provides a 1% increase in states’ Federal Medical Assistance Percentage for states that eliminate Medicaid cost-sharing for “A” and “B” rated preventive services

Provisions increasing availability and access to primary care providers

Section

Provision

1202

Increases physician payments for primary care services provided by qualifying physicians and non-physician providers operating under a qualifying physician’s supervision

5101

Creates the Primary Care Medicine and Dentistry and the National Health Care Workforce Commission

5207, 5209, 5210

Increases funding for the National Health Service Corps and creates a Ready Reserve Corps

5301

Provides training grants for physicians in primary care specialties

5201-5203, 5308-5310

Provides funding for nursing education and loan repayment, including additional funding for APRN education

5313

Allocates funding for community health worker training

5601

Allocates additional funding for community health centers

5316

Provides demonstration grants to place Family Nurse Practitioners in Federally Qualified Health Centers and Nurse Managed Health Centers

5208

Provides funding for Nurse Managed Health Centers

5405

Establishes the Primary Care Extension Program which educates primary care providers and enables them to use evidence-based therapies in practice

5501

Provides a 10% payment incentive for primary care services

5509

Establishes a Graduate Nurse Demonstration Project in which Medicare dollars are used to support the education of APRNs

Provisions for preventive health and wellness programs

Section

Provision

4001

Establishes the National Prevention, Health Promotion and Public Health Council to coordinate federal public health efforts

4002

Establishes the Prevention and Public Health Fund to increase national investment in public health infrastructure

4101

Establishes grants for school based health centers

4201

Allocates grant funding to support evidence-based community prevention programs

4202

Establishes grants for 5 year pilot programs providing public health interventions, screenings, and referrals for adults 55-64

4303

Allocates resources for employer wellness programs

(ACA, 2010)

Insurance Expansion

The ACA expands and broadens the availability of healthcare services through healthcare insurance expansion for up to 32 million currently uninsured Americans (Congressional Budget Office, 2012). A state-based Health Benefit Exchange, known has the Health Insurance Marketplace, will allow individuals to purchase private health insurance plans; individuals making 400% or less of the Federal Poverty Level (FPL) will qualify for cost-sharing subsidies and premium tax credits to make the health plans more affordable. A state-based Small Business Health Options Program Exchange will allow for small businesses to purchase group insurance and include tax credits for those businesses providing health insurance to employees. A business with 50 or more full-time employees will be subject to fines for failing to offer insurance. By 2016, U.S. citizens and legal residents will be required to purchase insurance or pay a tax penalty equivalent to 2.5% of their taxable income. Young adults will be permitted to remain on their parents’ insurance plan until they are 26 years of age; lifelong spending limits and annual coverage limits will be eliminated (ACA, 2010).

Primary Care and Preventive Services Access in Participating States

Primary care and preventives services are expanded through Medicaid and Medicare. The State Children’s Health Insurance Program is reauthorized, and Medicaid is expanded to all individuals at or below 133% of FPL. ACA places new restriction on health insurance plans by requiring increased access to and coverage of preventive services. The ACA increases Medicaid payments for primary care services provided to qualifying physicians. Non-physician providers, including nurse practitioners (NP), may qualify for the increased payments but only when operating under a qualifying physician’s supervision. It is important to note that this payment criterion could impose a financial restriction on higher reimbursement for NPs who are already providing primary care services in states with ‘independent practice’ legislation, meaning there is no requirement for physician collaboration to provide care. Increased funding is provided to the National Health Service Corps to support nursing and medical education that can increase placement of primary care providers in underserved areas. Funding for additional community health centers is provided (ACA, 2010).

Public Health and Preventive Programs

The ACA establishment of the Community-Based Collaborative Care Network Program, comprised of consortiums of providers, is tasked with coordinating and integrating heath care services for low income and uninsured populations (Kaiser Family Foundation, 2013). The National Prevention, Health Promotion, and Public Health Council has been designed to coordinate federal public health efforts, and the Prevention and Public Health Fund was created to increase a national investment in the public health infrastructure. An emphasis on evidence-based, community, prevention programs and employer wellness programs will be provided through grant funding (Kaiser Family Foundation, 2013).

These ACA provisions offer a promising future for primary care and prevention services but will yield little tangible success without adequate funding, knowledgeable implementation of the provisions, and an increased number of primary care providers to meet the expanding numbers of persons seeking primary care and prevention services. The DNP nurse has the educational preparation to play an essential role in supporting and leading this transformation of healthcare to improve healthcare outcomes.

The Doctor of Nursing Practice Nurse as Primary Care Provider

In order to achieve the ACA outcomes, nurses will need to be full partners with physicians and other healthcare professionals... The Doctor of Nursing Practice degree is a practice doctorate, with an emphasis on the translation of research evidence to the practice context (Dreher, 2011). The focus of the degree is on demonstrating clinical practice expertise (Chism, 2010); providing both direct patient care and clinical leadership; and utilizing evidence-based practice and information technology skills to improve patient healthcare outcomes (AACN, 2006). DNP programs, based on the American Association of Colleges of Nursing (AACN) Essentials of Doctoral Education for Advanced Nursing Practice (2006), henceforth referred to as the Essentials, emphasize the achievement of eight essential competencies (see Table 2). The Essentials competencies include the utilization of leadership skills to improve patient outcomes, the creation of new care delivery models that will meet the increasing demand for services, and the development of policy to enhance services and remove practice barriers. In order to achieve the ACA outcomes, nurses will need to be full partners with physicians and other healthcare professionals to develop healthcare strategies that will increase primary care services to meet the consumer need for safe, quality healthcare (IOM, 2010).

Table 2. The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006)

Essential Focus

Outcome Competency

I. Scientific underpinnings for practice

Apply a strong scientific foundation to develop, implement, and evaluate healthcare delivery approaches.

II. Organizational and systems leadership for quality improvement and systems thinking

Use advanced communication, business, and policy skills to improve patient outcomes through the development, evaluation, and improvement of practice initiatives.

III. Clinical scholarship and analytical methods for evidence-based practice

Translate research into practice through critical literature review, evaluation, and integration and dissemination of new knowledge.

IV. Information systems/technology and patient care technology for the improvement and transformation of healthcare

Use information technology to manage patient information, evaluate program outcomes, and apply new knowledge to improve patient care.

V. Healthcare policy for advocacy in healthcare

Design, advocate for, critically analyze, and implement health policy to improve healthcare delivery and promote health equity.

VI. Interprofessional collaboration for improving patient and population health outcomes

Engage in interprofessional collaboration through effective communication, team building and leadership skills.

VII. Clinical prevention and population health for improving the nation’s health

Incorporate concepts of public health, prevention and health determinants in the integration and evaluation of evidence-based prevention strategies.

VIII. Advanced nursing practice

Demonstrate refined clinical skills as expert practitioners in the design, implementation, and evaluation of nursing interventions.

The National Governors Association (NGA) has noted that as millions of Americans who previously lacked insurance enter the healthcare system over the next decade, the nation will require a concomitant increase in the number of healthcare providers to meet the increased healthcare needs arising from this influx (NGA, 2012). The U.S. Health Resources and Services Administration (HRSA) estimates that more than 35.2 million people, living within the 5,860 Health Professional Shortage Areas (HPSA) nationwide, do not currently receive adequate primary care services (HRSA, 2012). As of July 2012, an additional 15,168 practitioners were needed to provide primary care for the 54.5 million people living in designated, primary care HPSAs (HRSA, 2012). Underscoring the importance of primary care, the American Hospital Association (AHA) convened a roundtable of clinical and health system experts, including physician and nursing leaders, to examine the future primary-care-workforce needs as well as the role hospitals and healthcare systems can play in delivering primary care. The roundtable recommended a new primary care delivery model that would include the hospitals, in partnership with communities, to form primary care teams to deliver quality care (AHA, 2011).

...as millions of Americans who previously lacked insurance enter the healthcare system over the next decade, the nation will require a concomitant increase in the number of healthcare providers...The ACA also provides opportunities for the DNP nurse to meet primary care needs through the utilization of technology as a means to improve care delivery and measure outcomes; to identify, develop, and implement quality improvement projects; and to enhance systems thinking and evaluation (AACN, 2006). The uses of electronic health records, electronic databases, Internet searches for evidence-based-research findings, and electronic applications are technological advances that have the ability to support improved care delivery and evaluation of care outcomes. Synthesis and analysis of electronic data, and subsequent identification of issues that need to be addressed can be enhanced with the use of technology.

DNP nurse leadership is needed both at the point of care delivery and at administrative levels to implement the use of technology to document care; collect and analyze essential data; and identify areas of care that need a change in their practice approach. Policy strategies are also needed to address healthcare disparities and implement best practices that improve healthcare access and the prevention of complications. DNP nurses can use their educational preparation to provide leadership in the use of technology during the nation’s transition to a prevention model of healthcare delivery offered, within a collaborative, interdisciplinary context, to meet primary care needs.

Utilization of a Preventive Healthcare Model in Primary Care

Driven by rapid advancements in technology and a relentless quest for extending life, the current healthcare system devotes the majority of healthcare dollars to disease management and end-of-life care. Thorpe (2005) found that two-thirds of the increase in healthcare spending is a result of an increase in the treatment of disease (measured as the number of medical conditions treated multiplied by spending per case). Healthcare dollars are increasingly directed toward advanced treatments, yet the use of healthcare resources directed toward prevention has remained low. A study by the Centers for Disease Control (CDC) (2012) found that only half of U.S. adults receive recommended preventive services, such as mammography, cholesterol screenings, and colonoscopies. Individual and preventable behaviors, such as smoking and lack of exercise, account for nearly 50% of all premature deaths (Hardcastle, Record, Jacobson, & Gostin, 2011). As the US devotes healthcare resources to the diagnosis and treatment of chronic diseases, opportunities for preventing both acute and chronic diseases are lost. The increased use of clinical, preventive services could save two million life-years and $3.7 billion annually (Maciosek, Coffield, Flottemesch, Edwards, & Solberg, 2010).

The DNP nurse is especially well prepared to educate providers on the use of evidence-based preventive care and to assist the U.S. healthcare system in its transformation toward this model.The ACA provides a strong emphasis on preventive medicine and primary care through insurance reform, increased reimbursement for primary care providers, funding to educate these providers, and incentives to attract providers into primary care. The DNP nurse is especially well prepared to educate providers on the use of evidence-based preventive care and to assist the U.S. healthcare system in its transformation toward this model.

Nursing’s emphasis on preventive healthcare can be traced to Florence Nightingale’s Notes on Nursing, first published in 1859. She recognized that patient care must first be focused on providing a healthy home environment which she described as having pure air, pure water, efficient drainage, cleanliness, and light (Nightingale, 1946). Nursing has continued this focus by its attention to illness prevention, health promotion, and the teaching of self-care management (Mundinger, 2002). The primary care services provided in Nurse Managed Health Centers (NMHCs) emphasize health promotion and disease prevention (Vonderheid, Pohl, Tanner, Newland, & Gans, 2009). A survey of 60 NMHCs found that provision of health maintenance services far surpassed that of chronic illness management (Barkauskas et. al., 2006). While data on NMHCs remains limited in terms of clients served and services provided (Barkauskas et. al. 2006), existing data indicate that NMHCs provide greater use of preventive services along with care that is high in quality, patient satisfaction, and cost effectiveness (Coddington & Sands, 2008). Coddington, Sands, Edwards, Kirkpatrick, and Chen (2011) noted that DNP nurses at a nurse managed pediatric clinic reported quality of care measures as meeting or exceeding national benchmarks. It is important that nurses share their strategies for encouraging and providing preventive services with other healthcare professionals.

DNP nurses are prepared in the implementation of clinical prevention and population health strategies to meet the Healthy People recommendations.Despite the ACA emphasis on prevention and primary care, there has been criticism for its considerable focus on clinical medicine and its lack of inclusion of public health priorities (Cogan, 2011; Hardcastle et. al., 2011). The public health community is advocating for an increased integration of public health components along with clinical medicine. Nurses, whose education emphasizes prevention and holistic care (AACN, 1996; AACN, 2006; Tracy, 2009), are well positioned to assist in facilitating this integration. DNP nurses are prepared in the implementation of clinical prevention and population health strategies to meet the Healthy People recommendations (AACN, 2006). These nurses are prepared to lead a collaborative effort that sets a national agenda related to identifying population health outcomes, creating new models that promote prevention, and developing strategies for community outreach and education.

Although public health professionals are knowledgeable in behavioral health, health policy, and prevention, they may lack clinical training and the opportunity to work directly with patients needing preventive services. Although medical schools have started to recognize the need for a greater emphasis on primary care and prevention, the U.S. healthcare system remains dominated by an individual-based, curative-medicine model (Cogan, 2011). DNP nurses can bridge this gap by applying public health models of prevention to clinical medicine and educating their healthcare colleagues to do the same.  

Challenges of Implementing the ACA

This section will address two challenges related to implementing the ACA. These challenges include the need for more providers and the need for more creative approaches to implement care.

Need for More Primary Care Providers

The ACA will necessitate an increase in primary care providers. A survey conducted by the Kaiser Family Foundation found that of the 24 million Americans who will likely gain health insurance through the Health Insurance Marketplace by 2019, 37% will have gone more than two years without a check-up, and 29% will have had no interaction with the healthcare system in the year prior to obtaining coverage. In addition, 13% report their health as poor or fair compared with only six percent of those currently privately insured (Trish, Damico, Claxton, Levitt, & Garfield, 2011). With the implementation of the ACA, the healthcare system will experience an influx of patients with complex medical needs, thus increasing the demand for clinicians who can meet these needs.  DNP APRNs are increasingly available and prepared to address these needs as expert healthcare providers.

...most newly insured patients will access care through primary care clinics that are already experiencing a shortage of providers. Additionally, most newly insured patients will access care through primary care clinics that are already experiencing a shortage of providers. Only 30% of U.S. physicians practice in primary care (Goodson, 2010); and only about 25% of current medical school graduates plan careers in primary care (Schwartz, 2012). The Agency for Healthcare Research and Quality has estimated that among NPs, 52% of all NPs were providing primary care in 2010 (Inglehart, 2012).

Need for Creative Care Management Strategies 

It will be essential for healthcare providers to use creative strategies to incorporate prevention while also addressing the immediate needs of the millions of Americans who will be entering the healthcare system. Group self-care-education sessions, and the use of informatics to track the frequency of routine health screenings are strategies that can help to meet preventive care needs while using providers’ time expeditiously. DNP nurses have designed, implemented, and evaluated group-care strategies to address chronic diseases, such as diabetes, metabolic syndrome, and hypertension, and have demonstrated that health outcomes can be improved using these strategies (Dickman, Pintz, Gold, & Kivlahan, 2010; Greer & Hill, 2011; Riley, 2012).

Statistics suggest that the need for primary care DNP nurses will increase with ACA implementation. Hence it is essential that these nurses be recognized for their ability to provide safe, quality, healthcare that improves outcomes, rather than being viewed as a physician substitute. DNP APRNs are prepared to offer a holistic approach to healthcare, an approach that recognizes the patient as a unique individual within an encompassing social, physical, and energy environment (Tracy, 2009).

DNP nurses have the knowledge and ability to offer a holistic and unique understanding of the challenges facing many of the newly insured, so as to provide compassionate, comprehensive, and coordinated care to meet their diverse needs. The millions of Americans who will enter the healthcare system with unique social and cultural backgrounds, expectations, and misconceptions, in addition to their medical needs, will present new challenges for providers. When compared with currently insured individuals, these newly insured are likely to be poorer and less educated (Trish et. al., 2011). Currently more than 50% of patients seen at Nurse Managed Health Clinics are uninsured (Van Zandt, Sloand, & Wilkins, 2008). Until recently, the majority of APRNs in the healthcare system frequently provided services to underserved populations (Mundinger, 2002).

Leadership in Community-Based Programs

The implementation of the ACA not only provides an opportunity for DNP APRNs to demonstrate their expertise in direct patient care, but also creates new avenues for community leadership and programmatic design. ACA nurses are prepared both to help communities understand the ACA legislation and to design new community health initiatives as described below.

The ACA benefits will not be fully utilized by patients without the strong presence of both providers and health educators in the community. Because the ACA is a complex law, the majority of Americans have little understanding of its components or potential impact on their lives. Unfortunately, many persons who could benefit from the provisions of the ACA are at risk for missing this opportunity to gain coverage. A recent survey by the Kaiser Family Foundation found that 47% of the uninsured do not think the new healthcare reform legislation will affect them (Altman, 2011). DNP nurses are prepared to design the outreach programs needed to educate the community about the legislation and how to benefit from its provisions. For example, APRN nurses providing care to uninsured patients can help these patients understand their options for obtaining coverage, educate Medicare beneficiaries about their access to preventive healthcare services without cost-sharing, and encourage all patients to ask their primary care providers about obtaining these services.

The ACA (2010) also authorizes grants for community-based, prevention programs (Community Transformation Grants), work-based wellness programs, and school-based health centers. DNP nurses have the advanced education necessary to design, implement, and evaluate such programs. They can combine their high level clinical expertise and increased leadership competencies to create new, community health initiatives. For example, the nursing-focused Transitional Care Model, created by Naylor, is already being utilized in the implementation of the ACA (Cleary & Wilmoth, 2011). Naylor’s model encompasses comprehensive hospital planning and home follow up for older adults. Additionally, Walker’s (2012) Skin Protection for Kids program, designed to educate parents and teachers about sun damage- and sun-protection strategies, has also brought health promotion activities out of the clinical setting and into the community. New ACA funding for work-based wellness programs and school-based health centers provides nursing entrepreneurs new opportunities for clinical practice.

Creation of community outreach and care prevention programs will rely heavily on interdisciplinary collaboration to improve quality of care, decrease healthcare costs, and enhance positive healthcare outcomes. Creation of community outreach and care prevention programs will rely heavily on interdisciplinary collaboration to improve quality of care, decrease healthcare costs, and enhance positive healthcare outcomes (Chism, 2010). The ACA actively encourages interdisciplinary collaboration within the medical home delivery model and the new Community-Based Collaborative Care Network Program. Doctorally prepared nurses are particularly equipped to lead and contribute to interdisciplinary teams practicing in medical homes (AACN, 2006 Garnica, 2009). It is essential to recognize and utilize the strengths of various healthcare disciplines and promote collaboration and compromise when needed. Successful interdisciplinary collaboration, along with the creation of adequate policy to support change, will ensure the best use of resources to provide direct patient care and program development to meet the need for healthcare services and system delivery model revision.

Advocacy and Policy Development to Strengthen Primary Care Delivery

Although the ACA has been signed into law, health policy advocates are needed to support full implementation of its provisions. The IOM (2010) Future of Nursing Report recommends that nurses be “full partners with physicians and other healthcare professionals in redesigning healthcare in the United States” (p.3). To accomplish this goal, nurses must serve on strategic committees and have a presence at all levels of state and national decision-making committees. The provisions and regulations established in the ACA will be enacted over this decade. During this time, modifications will be necessary as unforeseen problems are encountered. DNP nurses are prepared to advocate for the patient, create innovative changes in the healthcare delivery system, and improve the context of care for healthcare providers during this transitional period. It is important that DNP nurses also advocate for the funding of nursing education grants and for the ability of APRNs to provide care within their full scope of practice (IOM, 2010).

DNP education emphasizes a system-wide approach and macroscopic view of healthcare, preparing graduates to assume leadership in changing healthcare systems (Talbert & Dennison, 2011). DNP nurses are currently developing policy knowledge and advocacy skills through internships and participation in professional organizations (Davis & Mangini-Vendel, 2011). Because policy makers rarely have clinical experience, they often develop policies that do not reflect or target the clinical needs of the population. Doctorally prepared nurses are needed to bridge this gap between clinical medicine and clinical nursing, and policy development.

DNP nurses involved in healthcare reform over the next decade need to be aware of both the strengths and the weaknesses of the ACA. DNP nurses involved in healthcare reform over the next decade need to be aware of both the strengths and the weaknesses of the ACA. Although this law engages a more macroscopic view, it is primarily a health insurance reform that leaves many important health outcomes unaddressed. Medical care prevents only 10 to 15% of premature deaths (Williams, McClellan, & Rivlin, 2010). Health and longevity are strongly influenced by other social determinants, such as education, food and housing access, and socioeconomic status (Lathrop, 2013). DNP nurses, given their holistic approach to healthcare and system-wide perspectives, can point out the health implications of state and national policies. They can follow the encouragement of  Williams et al. (2010) to advocate for the adoption of a culture of health in which the health impact of all policy decisions is considered during policy development, to improve healthcare outcomes.

Removal of Professional and Legal Barriers Impeding Primary Care Delivery

Now is the time for nurses to address legal restrictions and other professional barriers that limit their ability to perform within the full scope of practice for which they are prepared. The ACA offers vast opportunities for DNP nurse leadership in healthcare restructuring, improving direct patient care, creating innovative programmatic development, and providing political advocacy. However, barriers threaten to prevent the full realization of DNP leadership potential in healthcare reform. Because DNP nurses will be providing primary care to an increasing number of Americans, the IOM report (2010) explicitly noted that full scope of practice without restriction is needed. The following paragraphs both describe current barriers to DNP nurse practice, including limitations in reimbursement, collaboration, and scope of practice, and suggest ways to remove these barriers  

Reimbursement Limitations

Barriers exist for the reimbursement of care provided by all APRN nurses. Nurses are actively meeting the new quality and preventive care standards established in the ACA, and they should be compensated for the services they provide in a manner equal to that of other providers offering the same services. Currently NPs providing Medicare services to residents in long term care facilities are reimbursed at only 85% of the Medicare physician rate for the same services (AANP, 2013). We encourage DNP nurses, armed with research evidence of equal abilities and equivalent patient outcomes, to advocate for equal reimbursement for all providers who give the same care.

Collaboration Barriers

DNP nurses also face barriers within their collaborative relationships. Interprofessional conflict between medicine and nursing has existed since the early 20th century (Keeling, 2009). Some physicians continue to see the expanding role of nurses as a threat and seek to limit the authority of nurses at both legislative and practice levels. As an increasing number of nurses pursue doctoral education, new conflicts are arising. In a recent editorial in the Journal for Nurse Practitioners, one physician argued, “The use of the prefix ‘Dr.’ or ‘Doctor’ by NPs who have completed the DNP degree could lead to confusion and misconceptions by patients” (Ralston, 2011, p. 563). We authors do not believe that this statement has any factual basis. In a recent health policy report, Iglehart (2013) suggested that the ACA may turn these turf battles between physicians and APRNs into larger public health issues if newly insured individuals have difficulty accessing care. There is a need for greater collaboration among physician and nurse leaders in addressing these issues; the impetus for this collaboration may need to come from the federal level.

Scope of Practice Impediments

APRNs in general lack full autonomous practice in the majority of states and District of Columbia; only 17 states and the District of Columbia provide full scope of practice for APRNs under the licensure authority of the state board of nursing. The remaining 33 states have a reduced or restricted scope of practice with the mandate of some degree of physician involvement (AANP, 2014). Restrictions continue without evidence to support regulations, and in spite of current evidence that supports high quality and safe care provided by NPs.  Restrictions continue without evidence to support regulations, and in spite of current evidence that supports high quality and safe care provided by NPs (Horrock, Anderson, & Salisbury, 2002; Lambing, Adams, Fox & Divine, 2004; Munginger et al., 2000). Research has demonstrated that NPs provide comparable care by physicians in the acute care setting (Lambing et al., 2004). Mundinger et al. (2000.) have noted that nurse practitioners and primary care physicians have comparable patient outcomes in ambulatory settings. When compared with physicians, NPs provide more information to patients, identify physical abnormalities more often, have higher communication scores, and receive higher satisfaction evaluations related to their patient consultations than do physicians (Horrock, et. al., 2002). Despite evidence of safe care and equivalent outcomes, state regulation of NP practice varies significantly, limiting NP’s abilities to meet the growing healthcare needs of the nation (Rudner, O’Grady, Hodnicki, & Hanson, 2007). With the implementation of the ACA and the resulting influx of patients needing care, the restrictions on APRN practice must be removed for patients to receive the full extent of the care they need. There is some discussion that physician groups have financial concerns in regards to broadening APRN state regulations (NGA, 2012).  However, when comparing physician salaries in states with expanded APRN practice to states without such expansion, evidence does not support this concern (Pittman & Williams, 2012).

Requiring licensure, accreditation, certification, and education in all states, as described in the Consensus Model for APRN Regulation (NCSBN, 2008), will provide standardization to APRN regulation through legislation. Arbitrary restrictions, which limit APRN scope of practice but are not supported by evidence, need to be removed from state nurse practice acts and healthcare agency policy. The National Governors Association (NGA) Report has noted that although every state’s board of nursing has signed onto the APRN Consensus Model, only five states had achieved full implementation of this model, and only ten states had even pending legislation related to the model in their 2012 legislative sessions (NGA, 2012). APRNs will have the greatest potential for impacting care when practicing within the full scope of their education and accreditation (Rudner, O’Grady, Hodnicki, & Hanson, 2007). The unrestricted contribution of APRNs will be of even greater importance as millions of newly insured Americans access healthcare upon implementation of the ACA. Expanding the utilization of advanced practice nurses has the potential to increase access to healthcare for many current and future patients, particularly in underserved areas (NGA, 2012).

Although all advanced practice nurses are prepared to advance the healthcare of our citizens, DNP nurses have the additional foundation needed to fully implement healthcare reform, the competency to meet the expanding needs for primary care and improved healthcare outcomes, and the skills to advocate for legislative changes. We encourage DNP nurse leaders to focus on the promotion of equal reimbursement, mutually beneficial interdisciplinary collaborative relationships, and full scope of practice in order to maximize nursing’s contribution to the provision of healthcare.

Summary

The proliferation of DNP programs coincides with an exciting and transformative time in U.S. healthcare history. The proliferation of DNP programs coincides with an exciting and transformative time in U.S. healthcare history. As of April 2013, there are currently 217 DNP programs in 40 states plus the District of Columbia, with an increase of graduates from 1,595 in 2011 to 1,858 in 2012 (AACN, 2013). The ACA provides for reform in the current healthcare system. Nurses are at the forefront of this healthcare reform, and the advanced education provided to DNP nurses will be crucial in the success of this reform. DNP nurses have the ability to provide leadership in the use of evidence-based clinical care; the restructuring of the healthcare system; the greater focus on prevention; and the utilization of new care delivery models, community outreach programs, and work- and school-based health centers. An increased presence in the legislative process is needed as states and the federal system prepare to adapt to new regulations for the implementation of the ACA.

In this climate of healthcare reform, DNP nurses have the additional preparation and the desire to serve as leaders to improve, in concert with other healthcare providers, the health of this nation. They are primed to eliminate barriers to APRN practice and advocate for a new age of healthcare with increased access to care and improved healthcare outcomes for all.

Authors

Breanna L. Lathrop MSN, MPH, FNP-BC
Email: breanna.lathrop@gmail.com

Ms. Lathrop serves as a practicing family nurse practitioner at a primary care clinic in a federally designated health professional shortage area in Atlanta, GA. She has devoted her career to providing healthcare to uninsured and underserved populations. Completing her Master’s in Public Health, in the area of health policy, stimulated her interest in healthcare reform. She received her Bachelor of Arts in Nursing degree from St. Olaf College (Northfield, MN) and her MSN and MPH degrees from Emory University in Atlanta, GA. She is currently a Doctor of Nursing Practice (DNP) degree candidate at Georgia Southern University (Statesboro, GA.)

Donna R. Hodnicki, PhD, FNP-BC, FAAN
Email: dhodnick@georgiasouthern.edu

Dr. Hodnicki is Professor Emeritus at Georgia Southern University in Statesboro, GA and Clinical Faculty at Duke University School of Nursing in Durham, NC. Her background includes 30 years devoted to the education of Advanced Practice Registered Nurses. As Graduate Program Director she led the development of the Post-MSN DNP program at Georgia Southern University and served as faculty in the DNP program for 6 years. She also served as co-editorial director for the American Journal for Nurse Practitioners for 12 years. Her research emphasis has focused on advanced practice nursing issues. She received her RN diploma from Providence Hospital School of Nursing in Southfield, MI, her BSN and PhD degrees from the Medical College of Georgia in Augusta, GA, and her MSN as a family nurse practitioner from the University of South Carolina in Columbia, SC.

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© 2014 OJIN: The Online Journal of Issues in Nursing
Article published March 31, 2014


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