1. Cupec, Pamela Ann MS, RN, ONC, CRRN, ACM
  2. President of NAON 2013-2014

Article Content

At the end of each year, it is traditional to compose a list of resolutions for the coming months ahead, and after the noisemakers are put away and the champagne corks have popped, many of those same resolutions are also tucked away for another year. We resolve to exercise more, drink less, do more community service, and complete a higher degree of education. Many things do get accomplished; some items return to our to-do list for another time.

Pamela Ann Cupec, MS... - Click to enlarge in new windowPamela Ann Cupec, MS, RN, ONC, CRRN, ACM President of NAON 2013-2014

In Roman mythology, the god Janus, with two faces, is called upon in times of transition and in change, with one face looking forward and one behind. It is fitting, then, that one of the most dramatic changes to our health care system takes places this first month of the year, in January of 2014, with the enactment of the Affordable Care Act. This time, tackling the health of the nation is finally on the horizon.


The enactment of the Affordable Care Act, signed into law on March 23, 2010, is pivotal in the way our nation will care for our own. This law not only was designed to extend quality health care to the nation; we are able to extend to all of our citizens the access to decent, affordable health care coverage like never before. True, it is far from a perfect system, with the intent of the rollout to occur over several years and having to overcome many glitches in the beginning, but it will steer our country in the correct direction. The overall intent is to rein in the costs of health care, improve the quality and efficiency of the care offered, make preventive care accessible, and hold the payors more accountable. The Act allows access to coverage for those who never had insurance, those who were unable to obtain care because they had pre-existing conditions, or to make sure that products being offered by the insurance companies were meaningful and provided adequate coverage to meet needs of the consumer.


For most of us working in health care, it is a given that our employers offer health care and even though we grumble at the increase in our copays, or the change in the prescription plan, we still know that there is that coverage if we get sick or if our family members require services. Working as a case manager, I get to see those decisions on a daily basis, when people opt to not carry insurance in lieu of having more money available for food, child care, or gas for the car. They get ill, slip and fall, or were planning on signing up the following month. Now we can see neighbors and family members who we did not know were struggling finally able to have one less thing to worry about, not to play a game of chance with their health care. We will have patients who do not have to fret once they are in a hospital setting, about how much all of this is going to cost, how they going to afford it, and how soon can they leave so they will not be charged any more than necessary.


Several months ago, on our adult orthopaedic unit, there was a patient in her 50s who came in for a total knee replacement. She was a supervisor at a convenience store, but the long hours and constantly being on her feet took a toll, and with bone-on-bone osteoarthritis, she was ready for new knees. Her insurance was one I had not dealt with previously, so I was curious about her coverage when I called them. They had approved her surgical procedure, and approved her stay for up to ten days. Great, I thought, many insurance companies will only authorize two or three days for a total joint replacement. There was a catch, however. That particular insurance was only paying a mere $200 a day for coverage while the patient was in the hospital, and the rest would be an out-of-pocket expense for the patient. Even though the cost varies from facility to facility, a typical cost of a hospital room rate charge is about $1200 to $1500, and that does not include such things as physician visits, medications, testing, or procedures. Two hundred dollars a day for hospital coverage was not even covering the room that she occupied there, let alone the care she was receiving or even the therapy sessions.


Needless to say, the patient was anxious not to spend any more time than necessary in the hospital, so we tried to streamline her care. Of course she was having pain issues, needed a unit of packed blood cell, and not able to advance as quickly in therapy. These issues inadvertently added to her length of stay, and because she was having a difficult time making progress, we offered her the option of going to a skilled facility in preparation to getting her back home alone in her two-story home. As luck would have it, there was a female bed available on our transitional care unit on the other end of the floor. When I called the insurance company for a skilled authorization, they told me that unfortunately, she did not have any skilled level of care in her benefit, no acute rehabilitation days in her plan, and while we were at it, absolutely no home care benefit either. Those luxuries would be paid out of pocket, too. I already knew the answer to the next question, and no, her insurance did not have any coverage for injectable medications, and naturally, her anticoagulation was an injectable. Guess who had their medication changed to a more affordable oral agent?


The discharge plan for this patient only had one option, and that was to return to home. She stayed an extra day to get a few more sessions of physical therapy as well as to become more proficient in going up the steps because her home has two stories. Family members were able to spend a few more days with her than originally planned to help in her transition home. The financial counselors of the hospital assisted the patient in applying for medical assistance to for the acute stay. Remember, this patient was a hard-working employee who had insurance, but her benefits were next to nothing. This is but one of many examples in which health care reform has been absolutely necessary and vital for the overall health of the country.


Health care reform is not a new idea, and not an easy topic to rework. We need to be observant of changes around us, and the transition of care delivery and management to more efficient and effective levels. As the largest segment of health care is delivered by nurses, at the bedside, at physician offices, and in surgical suites, and the bulk of patient-centered research is done by nurses, we are the ones who can make the biggest impact in changing the landscape of health care.


The time is an exciting and challenging era in health care, especially for nurses. We represent the largest force in the health care market, and have 24/7 responsibility and accountability for patient care. In a recent December 16, 2013 press release from the American Nurses Association (ANA), a Gallup poll rated nursing as the most trusted profession, based on honesty and ethical standards (ANA, 2013).


Nurses are seen on the front lines of health care, no matter what setting or practice, and in a role of advocacy, teaching, and prevention. Facilities are redesigning care delivery, and organizations are becoming more focused on patient outcomes and quality of care provided, not just sheer volume of services provided (Doyle, 2014). Payment and reimbursement levels from insurance carriers such as Medicare are determined by different indicators, including data on readmission, patient satisfaction, quality outcomes, and patient safety (Doyle, 2014). This is a shift of focus to one more in line with patient performance indicators and quality of care, rather than for services provided.


In 2008, a two-year initiative was launched by the Robert Wood Johnson Foundation in collaboration with the Institute of Medicine (IOM) to look at the nursing profession and to report on the future of nursing. In the report that followed in 2010, recommendations were made to enhance the practices of nurses. These recommendations were also to be reflective of the changes in the environment of health care, pulling nursing to the forefront in decisions, expansion of practice roles, and effecting design changes in the system.


Four of the key messages from the report include practicing to the full education and training of a nurse; the achievement of higher levels of education and training, with a nod to the academic system to improve seamless flow and progression in education; data collection and improved infrastructure to support trends; and to be full partners with physicians and other health care professionals in redesigning health care (IOM, 2010).


The nursing profession must evolve to meet the demands of health care reform, moving to the center as champions for patients, providing preventive care in a wider base, and focusing on quality patient-centered outcomes. This is the time to seek higher degrees, to stretch the boundaries of our practice, to expand our focus and expertise. The eyes of the nation are cast upon the profession, and now the time is upon us, with the two faces of Janus, in transition and exciting changes ahead.


Ever Growing. Ever Strong. Ever Green.




American Nurses Association. (December 16, 2013). Nurses Retain Top Spot as Most Ethical Profession. News release. Retrieved from [Context Link]


Doyle F. (2014). Understanding HVBP. What It Means to the Supply Chain Professional and How it Correlates to CQO. Supply Chain Strategies and Solutions. January/February, pp 6-8. [Context Link]


The Institute of Medicine/Robert Wood Johnston Foundation. The future of nursing: leading change, advancing health. October 5, 2010. Retrieved from [Context Link]