BKulzer.Module3.HCA320
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Dec 6, 2023
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Physician Nurse Partnership
Brooke Kulzer
Aspen University
HCA 320
Dr. Terri Crowder, DNP, RN, CNS, ACNS-BC, CCRN
October 17
th
2022
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Physician Nurse Partnership
The past of healthcare remains very evident in our country as evidenced by the changing
healthcare system, values and outcomes. From the identity of the male physician to the evolution
to primary care and preventative care, the health care system is looking to change towards
outcomes, not dollars and cents. This article will discuss the past of medicine in America, where
we stand at present, and a glance into the future. The distinction between the fee for services
healthcare to the value-based care system and all that entails.
With nurses being the catalyst
holding the keys to filling the void between the physician and the bedside. All while impacting
care for patients ensuring the healthcare system stands accountable for the changing medical
industry in America.
Current Policy
The healthcare system in America serves to stand as a product of many different policies
throughout the history of our country. At present, the latest overhaul of our modern medicine
system remains following the introduction of the Affordable Care Act in 2010. While this large
piece of legislation served many goals and purposes, it also changed health care policy and
remains the large great change in recent past (Salmond & Echevarria, 2017). And the streamline
attempt to maximize value and coordination of quality, there remains an element missing. Many
believe this change over the past decade trying to find the place for the Affordable Care Act and
management of Medicaid and Medicare to maximize outcomes for patients leaves nurses on the
edge of a transformation as a collaborative member of the health care team (Fraher et al., 2015).
Physicians care has also shifted in the past decade from fee-based patient centered care to
more of focus on skills, preventative care, and collaboration with the health care team (Salmond
& Echevarria, 2017). This is a vast shift from the past of healthcare with the male physician
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directing the traditionally female task completers in health care. Those nurses and tasked with
patient care were to only follow the orders, and never free think or make suggestions regarding
patient care or plan of care.
As the shift focuses on outcomes versus individualized care, the
team becomes more important then ever to achieve an outcome with the patient. And while the
physician structure as the order originator has evolved to the leader and primary collaborator of
the team. And as a change occurs in medicine, the ideals around health care promotion need to
change as well (Fraher et al., 2015).
Health care promotion and preventative care remained a lacking health care measure
prior to the Affordable Care Act (ACA) in 2010 (Seiler et al., 2014).
This extension of the ACA
strived to overcome public health issues around preventative care in America. It attempted to
shift the thinking from problem solving to problem avoiding. But the shortage of primary care
physicians created a backlog of patients wanting to see their medical team and left the emergency
room and like services overwhelmed at times. It left patients confused on where to go for care,
and when to present for care. Access while improved, showed the need for nurses to fill in the
education gap for those customers to understand the importance of preventative and primary care
to avoid costly and resource depleting other visits (Fraher et al., 2015)
Distinction Between Fee for Service and Value Based Care
The distinction between fee for service and value-based care can be seen with a simple
definition of each term. Fee for service healthcare model is the current model in place in
American medicine (Nickitas
et al., 2018). Value based care system is defined by the Centers of
Medicare and Medicaid Services (2022) as a program that rewards health care providers with
incentive payments for the quality of care the patients receive with Medicare.
But broken down
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further, the value-based care healthcare model is truly a biproduct of the outcome-based care and
cost attentive care initiatives as further defined by Nickitas (2018).
Value based programs have
good attributes but struggle with measuring the outcomes. In order to ensure reimbursement,
there needs to be an outcome that is being measured. And in the industry of healthcare, many
variable plays into effect with the outcome. The changing world of reimbursement is directly tied
to cost and quality of care (Nickitas et al., 2018). Going hand in hand with the change in
American healthcare from fee-based services to value-based system is the identified need to keep
the individual well through primary preventative care as a means to drive down overall costs for
providers, patients, and consumers.
While value-based care systems and focus on outcomes have proven some improvements
and cost cutting measures have proven effective, there remains a long way to go on the
improvement spectrum (Gondi et al., 2022). With our country still have private and public
insurance, there is not the same measure outcome metrics to hold private insurance companies to
the same standards as government-based care. Many rural institutions remain limited by staff and
lack thereof to institute meaningful change to the healthcare model. The ACA remains a means to
institute change, but the extensions and expansion acts need to have buy in from the individual
states and make the outcomes worthy of the change to the healthcare systems.
Shared Power and Collaboration
Starting as a new graduate nurse in 2007, what I did not realize is that I was entering the
healthcare industry during a time of shift and change. Beginning with the change of physician’s
role and gender equality in the profession, to the introduction of advanced practice registered
nurses, to the change in the nurse’s role in the healthcare team. Equality became a common
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thread between all of these changes. And while the nurse’s foundation and education remain
unchanged, the potential of this team member looked different depending on where I was within
my health care organization.
This led to a specialty change to Emergency Medicine in 2010. I loved the fast
pace free thinking. And what attracted me the most was the continual learning and autonomy to
start care for our patients. Working in a busy metro Emergency room left patients waiting to be
seen by the providers. We had a strong midlevel presence at one point, but many left and were
not timely replaced. This again left long waits for providers. But as a nursing team, we identified
orders that could be done as standing orders based on chief complaints. This expedited care for
the patient and made it easier for the physician team to catch up when the work was being done
before they met the patient.
There were struggles, and there will continue to be with ordering tests and labs
before the physician sees the patient. But often, the blood work is in the lab for additional tests
without needing to draw more blood. What lacks is the ability to order pain medications before
the provider has assessed the patient. The nurses are able to offer Tylenol and ibuprofen, rest, ice
heat and elevation. But often, the patient correlates the narcotics or medication with patient
satisfaction.
The nurses have learned what the expected plan of care should entail and can hold
their physician counterpart accountable for ensure a proper scope of care is ordered. It is not a
perfect system but allows nursing to advocate for the work up and timeliness of care that the
patient deserves. Personally, I love the free thinking and processing teamed with assessing the
patient. They eagerly tell me their story, and I am equipped to be the medical translator and
explain why I would expect this work up and why. I fill the void between the medical jargon and
what the patient is experiencing. And this leads to greater patient satisfaction. It also holds the
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medical team accountable to ensuring timely results and work up. This impacts the patient
positively in terms of waiting times and turnaround. However, it does not ensure there is not
wasteful test ordering and waste not occurring. It does show the importance of collaboration
between the interdisciplinary teams, especially the nurse physician relationship with the best
outcome for the patient as the most important outcome.
And there remains room for impact for the patient. With the projected shortcomings of
providers and shortage of workers, what does the best expediated care for the patient entail? With
the introduction of virtual healthcare during the Covid pandemic, there is a new access to the
healthcare provider. And the nurses future role remains undefined and educationally based to
make an impact with preventative care, health care education, and bedside care for those
choosing to enter the hospital for care.
Conclusion
The Affordable Care Act served to be a major game changer in modern American healthcare.
With a change from fee-based systems to value based preventative care, the importance of
proactive care versus problem solving allowed bedside nurses to use their education to maximize
the physician presence. There is a long way to go with the incorporation of advanced practice
providers along side of physicians. But having collaborative care to maximize time, resources,
and dollars will ensure the patient outcome benefits from the collaboration of all the members of
the team.
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References
Centers for Medicare & Medicaid Services, 2022.
Data | CMS
. [online]
Cms.gov.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Value-Based-Programs/Value-Based-Programs
Fraher, E., Spetz, J., & Naylor, M. (2015). Nursing in a Transformed Health Care System: New
Roles, New Rules. Robert Wood Johnson Foundation Interdisciplinary Nursing Quality
Research Initiative.
Gondi, S., Li Y., Drzayich AD, Boudreau E., Shrank WH., Powers BW. (2022) Analysis of
Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries.
JAMA Netw Open. 2022;5(3
):e222916. doi:10.1001/jamanetworkopen.2022.2916
Nickitas, D. M., Middaugh, D. J., & Feeg, V. (2018).
Policy and politics for nurses and other
health professionals
(3rd ed.). Jones and Bartlett.
Salmond, S. W., & Echevarria, M. (2017). Healthcare Transformation and Changing Roles for
Nursing. Orthopedic nursing, 36(1), 12–25.
https://doi.org/10.1097/NOR.0000000000000308
Seiler, N., Malcarney, M., Horton, K., & Dafflitto, S. (2014). Coverage of Clinical Preventive
Services under the Affordable Care Act: From Law to Access. Public Health Reports,
129(6), 526-532. https://doi.org/10.1177/003335491412900611