Claims Data, Nurses Have Pivotal Roles in the Future of Healthcare Delivery

The Affordable Care Act has left many healthcare professionals pondering the future of healthcare delivery. This all-encompassing discussion has many layers; however, at the American College of Cardiology 62nd Annual Scientific Session and Expo, a panel of experts discussed some of the specific variables—such as the need for better data and a more prominent role for nurses—as they relate to healthcare delivery in this transitory time.

Thomas Lewandowski, MD, FACC, FASE, President and Governor, WI Chapter of ACC Appleton Cardiology ThedaCare, spoke about healthcare delivery reform and some of the current challenges facing leaders in separate sectors of the healthcare industry. For instance, Dr Lewandowski mentioned that, while some provider systems suffer from complacency due to transitions from fee-for-service models to models where providers assume most of the risk, insurers must tackle the issue of the status quo versus the cost of new billing system bundles and shared savings. The larger question, says Dr Lewandowski, is whether it is acceptable for other organizations to define “value” and also dictate how that value will be assessed.

Dr Lewandowski discussed some of the conclusions made by the Wisconsin medical society Wisconsin Health Improvement Zone (WHIZ) regarding the current deficiencies in the use of claims-only data. In short, which often times is used for comparison between providers and hospitals, is problematic for the following reasons:

• Without clinical outcomes, there is no assessment of quality.
• Administrative “risk-adjustment” is only valid across populations.
• Coding and billing practices vary by organization.
• There is no assessment of the appropriateness of care provided.

In addition to these issues, the nation at large is extremely inconsistent when it comes to all-payer claims databases. A state-by-state map by Dr Lewandowski illustrated this point; as of February 22, 2012, only 10 states had an existing database, while the rest of the country ranged from a current implementation process to no interest in having one at all. Dr Lewandowski presented a number of charts and graphs displaying proposed processes like value modifier scores, but the underlying point to all of the complex propositions was simple: until there are better ways to address the vast number of variables in practice environments (differences in coding, incomplete data entry, individual practice styles, etc), it is going to be difficult to achieve the healthcare reform that officials and legislators aim to enact by way of the Affordable Care Act. The goal of altering practice with evidence-based feedback is an ongoing process that leaves much work to be done.

Eileen Pummer, MSN, CPQH, A.A.C.C. Alameda Health System, also presented during the discussion, and her focus was on increasing healthcare accountability. Pummer spoke about some of the key factors to advancing healthcare, particularly as they pertain to the nursing community. Aside from achieving higher levels of education and training, Pummer believes that nurses should be full partners on any coordination of care team. In addition, she says that effective workplace planning and policy making requires better data collection and information infrastructure. Pummer also outlined goals which she believes are necessary to truly improve the quality of care provided to patients as the healthcare industry continues to evolve. She hopes that, by the year 2020, the following will have occurred:

· The number of nurses with a BSN degree reaches 80% (in 2011-2012 this number was approximately 49%, although there was a 22% increase in the number of students enrolled in RN to BSN programs).

· The number of nurses with a doctorate degree will double (there was an 8.2% increase in master’s program enrollments in 2011-2012).

· Advanced practice nurses will be able to practice to the full extent of their training and education, something that is not the norm right now.

The future of healthcare delivery still leaves a lot of questions unanswered. However, nurses—particularly those with higher education—have much to offer when it comes to providing patient care. Healthcare professionals have a moral obligation to work together and improve care for their patients, and that begins with better communication and teamwork from those who are involved in this care.