Second Issue, Series Three
Access to Quality Care: A Nurse’s Perspective
The state of healthcare in 2014 necessitates that patients play an active role in the management of their health. But who, among Americans, has access to healthcare? This access occurs when an individual is fortunate enough to have available the timely use of services, so he or she can achieve the best health possible. These services include such primary preventive services as blood pressure checks, cancer and cardiovascular screenings, or what is known as “well visits.” Americans older than 65 years of age have access to healthcare through a government-sponsored Medicare benefit. Individuals with very low incomes and those with chronic conditions, such as cancer, often have access to care through Medicaid. Many other individuals without healthcare coverage, however, do not fall within these categories. Healthcare disparities, including low socioeconomic status, ethnic inequalities, and a lower level of education, exist and are all factors that prevent access to care.1 Limited access to care because of geographic location, lack of insurance, or ethnic inequalities may lead to delays in time to diagnosis of cancer, lengthier recovery, or other negative sequelae.2,3
Access to healthcare services is one issue, but access to quality care is an equally important matter to address. The National Healthcare Quality Report, sponsored by the Agency for Healthcare Research and Quality, suggests that lack of health insurance is the most significant contributing factor limiting access to quality healthcare for the prevention and treatment of a variety of conditions, such as cancer.4 Individuals who are uninsured or underinsured are less likely to engage in preventive healthcare, routine dental screenings, and healthy diet and exercise behaviors.
The concept of uninsured and underinsured individuals has been described more often in the past few decades. A person who is uninsured simply lacks medical insurance coverage. Years ago, it used to be true that you either had insurance or you did not. However, as drug development and medications have become more expensive, each has individually led to escalating healthcare costs. Just because an individual has health insurance does not mean that the insurance will cover his or her medical needs, which leads to high copays.5 When a person is underinsured, he or she has medical expenses that are greater than 10% of his or her annual income, or has health plan deductibles that are equal to or greater than 5% of his or her annual income.6 As such, health maintenance organization (HMO) insurers have protected themselves by creating tiers for service and a capitated benefits system.
Capitation is a type of healthcare reimbursement that affects both insured and underinsured patients with cancer. Capitation occurs when an HMO determines a fixed-rate payment for services rendered regardless of the volume of services rendered.7 The HMO will pay a set amount to hospitals and providers regardless of level of complications that may develop, for example, during a hospital stay. Treatment (such as expensive, “newer” chemotherapy) may be postponed until the patient is discharged from the hospital if such therapy is not deemed to be critical to the well-being of the individual or not related directly to the individual’s hospital admission.
Patients with cancer who are not admitted to the hospital may also have their benefits “capped.” Once the dollar amount has been met, the patient will no longer receive coverage through that plan. This capitated system will become more common in the future of healthcare in the United States and is an issue that will be addressed in an upcoming Conquering the Cancer Care Continuum article.
The significance of escalating healthcare costs has been highlighted in recent years because of the economic downturn that the United States has experienced within the last decade. Individuals lost their jobs and lost insurance benefits as a result. Further, a dearth of qualified providers were left to deliver healthcare, as hospitals were negatively affected as well. Nurses cannot be entirely responsible for repairing all of the broken issues with regard to access to care. But given these issues, I can think of 3 ways in which nurses can improve patient access to quality care: (1) maximization of nursing scope, (2) policy change, and (3) community involvement.
In 2011, the Institute of Medicine (IOM) called on nurses to bridge the gap in which patients do not have access to healthcare, and to practice to the full extent of their education and training.8 Licensed practical nurses (LPNs), registered nurses (RNs), and advanced practice nurses (APNs) are viewed as an effective, cost-effective, well-trained group of professionals who provide quality care at a variety of levels. Each nurse has the ability to contribute to the healthcare team and to enhance the delivery of quality care. Yet, there are very different scopes of practice, in particular where APNs are concerned. APN practice is often restricted by individual states or hospitals. This is true despite research showing that states with fewer restrictions on APN practice have lower hospitalization rates and improved health outcomes in their communities.9
I have seen a change in my state of Ohio in the 2 years since the IOM report. I am pleased to report that while my organization has always supported nurses and the role played by APNs, there has been an increase in statewide policy changes that have allowed patient access to quality healthcare in a timely manner. APNs in many therapeutic areas and with specialty training can conduct consultations independently, admit patients to the hospital when appropriate, and practice medicine independently. My APN colleagues across the country have also reported an increase in their independence, along with the ability to continue a collaborative practice with other members of the healthcare team.
However, allowing nurses to practice medicine and provide treatment to patients will not solve all of the problems associated with access to care. So, in what other ways can nurses improve access to quality healthcare? At 3 million members strong, they can use their voice to enact policy changes within their institutions, at a community or at a national level. Influencing different practice patterns among states that restrict LPN, RN, and APN practice can allow all nurses to maximize their scope of practice to expedite patient care. Nurses should learn about the barriers in their nursing practice that may negatively impact patient access and should determine ways in which to address these barriers.
Finally, community health and cancer screening workshops are routinely held and sponsored by academic institutions and religious groups. Community workshops offer free blood pressure, cancer, and other preventive health screenings. Raising awareness of these programs among groups and at-risk individuals, and even volunteering at these workshops, can all help to engage patients.
Although access to quality care will often exist, we as nurses should be aware of the disparities in access to care and do whatever is in our power to improve services for our patients.
- Hadley J. Sicker and poorer—the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income. Med Care Res Rev. 2003;60(2 suppl):
3S-75S; discussion 76S-112S.
- Martins T, Hamilton W, Ukoumunne OC. Ethnic inequalities in time to diagnosis of cancer: a systematic review. BMC Fam Pract. 2013;14:197.
- Hadley J. Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297:1073-1084.
- Agency for Healthcare Research and Quality. National Healthcare Quality Report. In: Services US DoHaH, 2013 ed. http://www.ahrq.gov/research/findings/nhqrdr/nhdr13/2013nhdr.pdf. Accessed October 9, 2014.
- Faiman B. Oral cancer therapy: policy implications for the uninsured and underinsured populations. J Adv Pract Oncol. 2013;4:354-360.
- Nunley RM; Washington Health Policy Fellows. Issues facing America: underinsured patients. 2008. http://www6.aaos.org/news/PDFopen/PDFopen.cfm?page_url=http://www.aaos.org/news/aaosnow/mar08/reimbursement1.asp. Accessed October 3, 2014.
- Gapenski LC. Understanding Healthcare Financial Management. 5th ed. Chapter 17: Capitation, rate setting, and risk sharing. Chicago, IL: Health Administration Press; 2009:613-646.
- Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. http://www.rwjf.org/content/dam/farm/reports/reports/2011/rwjf67190. Accessed October 3, 2014.
- Oliver GM, Pennington L, Revelle S, Rantz M. Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nurs Outlook. 2014. pii: S0029-6554(14)00150-X. doi: 10.1016/j.outlook.2014.07.004. [Epub ahead of print].
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