Nursing and Policy - Association of Veterans Affairs Nurse Anesthetists

Healthcare Policy and
Patient Advocacy
Angela Mund CRNA DNP
• Discuss the history of nursing and policy
• Compare and contrast policy and politics
• Describe the policy process and areas for
personal involvement
• Discuss the current literature as related to
health policy
History of Nursing and Policy Making
• Florence Nightingale
– Parliament and The Crimean War
• Lillian Wald and Lavina Dock
– Licensure and Rights to Healthcare
Advent of Advanced Practice Nursing
Historical Aspect
• 1970’s-Department of Health, Education, and Welfare
– Committee to Study Extended Roles for Nurses
• 1980’s
– Tax Equity and Fiscal Responsibility Act of 1986
• Medicare IG search into fraudulent billing practices
– Cost containment, Prospective Payment System 1983
• Bundled payments based on DRGs
• CRNA services became practically unreimbursable
– Consolidated Omnibus Budget Reconciliation Act of 1986
What are the legislative and
regulatory challenges that are
occurring now?
• Medicare Part A: Payments to hospitals, ASC, etc
• Medicare Part B: payment regulations for healthcare
providers who are eligible to receive direct reimbursement
– Provisions for medical supervision
• greater than 4 concurrent cases: MDs 3 base units
plus 1 additional base unit if present for induction
– Provisions for medical direction
• TEFRA requirements 7 conditions of payment
• According to HCFA not a quality of care issue but
elements of an anesthetic that an MD should be
present for if they want to get reimbursed
AANA continuing to follow
and advocate for changes
to outdated, inefficient
TEFRA requirements for
Cost and Efficiency
Federal Supervision Requirements
• Medicare Part A
• November 13th, 2001
– After consultation with stakeholders, each state
Governor can send a letter to CMS requesting
exemption from federal supervision
• 17 states have “opt’ed out”
Chronic Pain Management
• Medicare authorizes payment under Part B
• Medicare administrative contractor refusing
• Role of the Federal Trade Commission and Hospital
• Battles in Louisiana, Oklahoma, Missouri and Iowa
How are nurses and policy
• Impact of policy on nursing practice
• Impact of policy on patient care
• Impact of policy on national and global
• Impact of policy on politics (legislative and
Professional Responsibility
Never doubt that a small group of thoughtful
committed citizens can change the world.
Indeed, it is the only thing that ever has.”
Margaret Mead
AANA Code of Ethics
• 6.4 The CRNA participates in research activities to improve
practice, education, and public policy relative to the health
needs of diverse populations, the health workforce, the
organization and administration of health systems, and
healthcare delivery.
• 3.3 The CRNA participates in activities that contribute to the
ongoing development of the profession and its body of
Basic Policy Elements
1. Reviewing Policies includes studying formal decisions and
2. A policy may include a network of interacting decisions
rather than a single decision
3. Policies change over time
4. Review policies that were not acted on
5. Identify policies created out of clear decision-making to
develop an effective process of policy making
Ham, et al 1992
Influencing Policy
• Prepare, Prepare,
• Speak the language of
legislation and
• Understand committee
• Ask the Ask!
Movement of Legislation (in brief!)
• Drafting of
• Bill introduction
(first reading)
• Referral to
• Floor Vote
• Bill sent to
Governor or
• Veto Process or
• Bill becomes Law
• Law is sent to
• Interpretation
of law into
rules and
The political process is rarely
rational, linear, or expeditious
Just take a look at attempts for Health Care Reform!
Title: A bill to amend title 38, United States
Code, to enhance the capacity of the
Department of Veterans Affairs to recruit and
retain nurses and other critical health-care
professionals, to improve the provision of
health care veterans, and for other purposes.
Ten Commandments
1. The Personal is Political
2. Friends come and go but enemies can accumulate
3. Politics is the art of the possible
4. Be polite, be persistent, be persuasive
Ten Commandments
5. Talk to strangers
6. Give early and often
7. Take credit and control
(What is the role
of the PAC?)
Ten Commandments
8. Politics has a chit economy
9. Reputations are permanent
10. Don’t take it personal
Tips for Lobbying
• Be Prepared
• Be Precise
• Be a professional
Tips for Lobbying
Drive the Discussion
Cultivate Relationships
Lobby in person or on paper
Advocacy at
Political Action Committees
• Pay to Play
• The role of the Lobbyist
• Bipartisenship
– How do I know who is getting my money?
• Do PAC’s influence legislation?
• Reporting
Healthcare PAC Contributions 2012
• American Association of Nurse Anesthetists came in 18th
• 44,000 members (including students)
• The ANA came in 17th
– Represents over 3 million nurses
• Only other nursing PAC to make top 100
– American College of Nurse Midwifes
• 12,000 members
AANA Levels of Giving to the PAC
• Presidential Club
• Congressional Club
• Capital Club
Open Secrets
How can you become involved?
• Local Politics
• State Level
– Committees and State Boards
• Federal Level
– AVANA Committees
– AVANA Board
• What are some challenges you
experienced in your practice that could be
impacted by changes in legislation or
• How can you use the some/all of the
political strategies to create influence?
Areas for Involvement
Nursing Workforce Development (Title VIII)
Health Care Reform
Patient Access to Providers
Nurse Practice Acts
Barriers to Involvement
Lack of leadership/mentoring
Initial disillusionment
What components do you think
would be useful?
Power is an inevitable part of human
interaction, and those persons, including
nurses, who deny this fact will be at a
serious disadvantage when trying to
make change
Kalisch &Kalisch, 1982
• Numbers
– Role of the professional organization
• Expert power
• Public Respect and Admiration
– Use the Media
As patient advocates we cannot be
spectators or sideline shouters
We must affect change through
discussion, debate, analysis, and research in a
positive proactive manner
C. Bettin, AANA Senior Director of Commincations
Rewards of Advocacy
Personal Satisfaction
Professional Satisfaction
Sense of Accomplishment
Sense of Control over patient outcomes
Nurses have the skills to be
successful at influencing policy
• Negotiation and communication
• Problem solvers
• Management of challenging personalities and
• Team players – Building Coalitions
Nursing Leadership
from Bedside to
Boardroom: Opinion
Leaders Perceptions
Robert Wood Johnson Foundation Survey (2010)
Barriers to Nurses’ Ability to Contribute to
Improvements in Planning Policy Development, and
Management of Health Systems and Services
Question Wording: Please
tell me if you think each of
the following is a major
barrier, a minor barrier, or
not a barrier to nurses’
ability to contribute to
improvements in planning
policy development, and
management of health
systems and services?
Not Important
Doctors as
How to Ensure That Nurses Take on More
Leadership in Improving Health Status and
Delivering Healthcare Services
Question Wording: What,
if anything, do you think
could be done to ensure
that nurses take on more
leadership in improving
health status and delivering
healthcare services in the
United States today?
(Open-end question;
Percent shown)
What will be impact
be of the IOM Report
on the Future of
Nursing and the APRN
Consensus Document?
Recommendations of the IOM Report
• 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
education progression
Recommendations of the IOM Report
• Nurses should be full partners, with
physicians and other healthcare
professionals, in redesigning healthcare in
the United States
• Effective workforce planning and policy
making require better data collection and an
improved information infrastruture
APRN Consensus Model
• National Council of State Boards of Nursing
• Ensure patient safety and expand patient
access to APRNs
• Standardization
• 4 essential elements:
– Licensure, accreditation, certification, education
APRN Consensus Model
• Services or care provided by APRNs not
defined or limited by setting but rather by
patient care needs
• What does this mean for us?
Licensed Independent Pracitioners
Consensus Model as Framework; IOM Recommendations
All APRNs must be LIPs
Privileges granted through Medical Staff Board
However…”APRNS will practice within the privileges that are
granted at the local level by the Professional Standards
• Timing of Full Implementation
• Does your facility have a CRNA on the APRN Committee?
Coalition for Patients Rights
• Maureen Shekleton
Professional Relations Specialist
American Association of Nurse Anesthetists
• > 35 Member organizations (diverse group)
• State Action Coalitions
• Offset the AMA SOPP initiative
– Limits patients’ choice of providers
– Attempts to define the SOP of CRNAs
Patients’ Access to Responsible Care
Alliance (PARCA)
• Provide Access to information for Legislators
• Nondiscriminatory language for reimbursement
in healthcare reform legislation- SUCCESS!!!
Is there an optimal time
to study health policy?
Model for Teaching Healthcare
• Information
• Commitment
• Initiative
• Involvement
Educators will need to demonstrate the
relevancy of policy to practice
Maynard (1990) Political Influence: a Model for Advanced Nursing Education
Health Care Policy for Advocacy in
Health Care (DNP Essential #5)
“The DNP graduate integrates practice
experiences with two additional skill sets: the
ability to analyze the policy process and the
ability to engage in politically competent
action” (AACN)
“Nurses will not be effective in politics and
policy making until they value their voices,
develop policy agendas that embrace their
core values, and learn the skills of policy
making and influencing”
– Peters
Is there an optimal
route for nurses to
study health policy?
Lobbying in Washington DC
Is there a role for a nursing
specialty in Health Care
What kind of degree would be required/needed?
Health Policy and Research
• Nursing Research
– Supply the data and background information for
creating policy
• Policy Research
– Analysis of the problem, provide alternative
recommendations for future initiative
No Harm Found When Nurse
Anesthetists Work Without
Supervision By Physicians
Brian Dulisse and Jerry Cromwell
Health Affairs, 29, no.8 (2010):1469-1475
Cost Effectiveness
Analysis of Anesthesia
Paul F. Hogan
Rita Furst Seifert Carol S. Moore Brian E. Simonson
2010/Vol. 28/No. 3
Influence of Supervision Ratios by
Anesthesiologists on
First-case Starts and Critical
Portions of Anesthetics
Richard H. Epstein, M.D., C.P.H.I, M.S.,* Franklin Dexter, M.D.,
Anesthesiology, V 116 • No 3 March 2012
“If nurses want to be sought out as health care
resources and have their views reflected in
health care policy, Nurses have to get off the
porch to run with the big dogs”
-Mary Wakefield RN PhD
Abood, S.(2007). Influencing health care in the legislative arena. Online
Journal of Issues in Nursing.
Aroskar, MA. Molodow, DG & good, CM (2004). Nurses’ voices: Policy,
politics and Ethics. Nursing Ethics, 11(3), 266-276.
Boswell, C., Cannon,S., & Miller J. (2005). Nurses’ political involvement:
Responsibility versus Privilege. Journal of Professional Nursing, 21(1), 58.
Kalisch, BJ & Kalisch, PA. (1982). Politics of Nursing. Philadelphia: JB
Peters, RM (2002). Nurse Administrators role in Health Policy: Teaching
the Elephant to Dance. Nursing Administration Quarterly, 26(4), 1-8.
Twedell, D. & Webb J. (2007). The Value of the Political Action Committee:
Dollars and Influence for Nurse Leaders. Nursing Administration Quarterly, 31(4),
Whitehead, D. (2003). The health-promoting nurse as health policy career expert
and enterpreneur. Nurse Education Today, 23(8), 585-592.

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