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Healthcare Policy and Patient Advocacy. Angela Mund CRNA DNP. Objectives. 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.

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  • 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
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
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
  • 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AANA continuing to follow and advocate for changes to outdated, inefficient TEFRA requirements for payment


Cost and Efficiency

federal supervision requirements
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
Chronic Pain Management
  • Medicare authorizes payment under Part B
  • Medicare administrative contractor refusing payment
  • Role of the Federal Trade Commission and Hospital Associations
  • Battles in Louisiana, Oklahoma, Missouri and Iowa
how are nurses and policy related
How are nurses and policy related?

Impact of policy on nursing practice

Impact of policy on patient care

Impact of policy on national and global health

Impact of policy on politics (legislative and regulatory)

professional responsibility
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
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 knowledge
basic policy elements
Basic Policy Elements
  • Reviewing Policies includes studying formal decisions and actions
  • A policy may include a network of interacting decisions rather than a single decision
  • Policies change over time
  • Review policies that were not acted on
  • Identify policies created out of clear decision-making to develop an effective process of policy making

Ham, et al 1992

influencing policy
Influencing Policy
  • Prepare, Prepare, Prepare
  • Speak the language of legislation and regulation
  • Understand committee structure
  • Ask the Ask!
the political process is rarely rational linear or expeditious

The political process is rarely rational, linear, or expeditious

Just take a look at attempts for Health Care Reform!

s 252

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
Ten Commandments
  • The Personal is Political


  • Friends come and go but enemies can accumulate
  • Politics is the art of the possible


  • Be polite, be persistent, be persuasive


ten commandments1
Ten Commandments

5. Talk to strangers

6. Give early and often

7. Take credit and control

(What is the role

of the PAC?)

ten commandments2
Ten Commandments

8. Politics has a chit economy

9. Reputations are permanent


10. Don’t take it personal


tips for lobbying
Tips for Lobbying
  • Be Prepared
  • Be Precise
  • Be a professional
tips for lobbying1
Tips for Lobbying
  • Communicate
  • Drive the Discussion
  • Cultivate Relationships
  • Lobby in person or on paper
political action committees
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 cycle
Healthcare PAC Contributions 2012 Cycle

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
AANA Levels of Giving to the PAC
  • Presidential Club
  • Congressional Club
  • Capital Club
how can you become involved
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 regulation?

How can you use the some/all of the political strategies to create influence?

areas for involvement
Areas for Involvement
  • Nursing Workforce Development (Title VIII)
  • Reimbursement
  • Health Care Reform
  • Patient Access to Providers
  • Nurse Practice Acts
barriers to involvement
Barriers to Involvement





Lack of leadership/mentoring

Initial disillusionment


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 changeKalisch &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 shoutersWe mustaffect change through discussion, debate, analysis, and research in a positive proactive mannerC. Bettin, AANA Senior Director of Commincations

rewards of advocacy
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
Nurses have the skills to be successful at influencing policy
  • Negotiation and communication
  • Problem solvers
  • Management of challenging personalities and conflict
  • Team players– Building Coalitions
nursing leadership from bedside to boardroom opinion leaders perceptions

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 Decision Makers

Doctors as Revenue Generators

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

What will be impact be of the IOM Report on the Future of Nursing and the APRN Consensus Document?

recommendations of the iom report
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 report1
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
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 (LACE)
aprn consensus model1
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
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 Board?
  • Timing of Full Implementation
  • Does your facility have a CRNA on the APRN Committee?
coalition for patients rights
Coalition for Patients Rights
  • Maureen ShekletonProfessional Relations SpecialistAmerican 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
Patients’ Access to Responsible Care Alliance (PARCA)
  • Provide Access to information for Legislators
  • Nondiscriminatory language for reimbursement in healthcare reform legislation- SUCCESS!!!
model for teaching healthcare policy
Model for Teaching Healthcare Policy
  • 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
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
what kind of degree would be required needed

Is there a role for a nursing specialty in Health Care Policy?

What kind of degree would be required/needed?

health policy and research
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 PhysiciansBrian Dulisse and Jerry Cromwell

Health Affairs, 29, no.8 (2010):1469-1475

Cost Effectiveness Analysis of Anesthesia Providers Paul F. Hogan Rita Furst Seifert Carol S. Moore Brian E. Simonson

NURSING ECONOMIC$/May-June 2010/Vol. 28/No. 3


Influence of Supervision Ratios by Anesthesiologists onFirst-case Starts and Critical Portions of AnestheticsRichard H. Epstein, M.D., C.P.H.I, M.S.,* Franklin Dexter, M.D., Ph.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), 5-8.

Kalisch, BJ & Kalisch, PA. (1982). Politics of Nursing. Philadelphia: JB Lippincott

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), 279-283.
  • Whitehead, D. (2003). The health-promoting nurse as health policy career expert and enterpreneur. Nurse Education Today, 23(8), 585-592.