The Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010.

Key Provisions Related to Nursing: The Patient Protection and Affordable Care Act (Public Law 111-148) clearly represents a movement toward much-needed, comprehensive and meaningful reform for our nation’s healthcare system. As the largest single group of clinical health care professionals within the health system, licensed registered nurses are educated and practice within a holistic framework that views the individual, family and community as an interconnected system that can keep us well and help us heal. Registered nurses are fundamental to the critical shift needed in health services delivery, with the goal of transforming the current “sick care” system into a true “health care” system.

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Patient Protection and Affordable Care Act Public Law 111-148

Nursing Workforce Federal support for the Nursing Workforce Development Programs contained in Title VIII of the Public Health Service Act (PHSA) is essential. These programs recruit new nurses into the profession, promote career advancement within nursing, and improve patient care delivery. These programs are also used to direct RNs into areas with the greatest need – including departments of public health, community health centers, and disproportionate share hospitals.

Primary Care Workforce

Section 5207 (p. 494) increases funding for the National Health Service Corps and extends the authorization of appropriations for the Corps each year through 2015. For fiscal years 2016 and years thereafter, the legislation establishes a formula for funding that is tied to increased costs in health care and the number of individuals residing in health professions shortage areas. Section 5209 (p. 495) removes the previously enacted cap of 2,800 commissioned officers in the National Health Service Corps regular corps. Section 5210 (p. 496) reconstitutes the Public Health Service Corps into two divisions: the commissioned Regular Corps and a Ready Reserve Corps for service in time of national emergencies. Ready Reserve Corps members will participate in routine training, be available for involuntary calls to active duty during national emergencies, and be available for service assignment in underserved communities. Section 5301 (p. 497) establishes a grant program for hospitals, medical schools, academically affiliated physician assistant training programs, and other entities to develop and operate accredited training programs for the provision of primary care. In particular, entities may use a grant to develop and operate a physician assistant education program and may use funds to train individuals who will teach in PA education programs.

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010.

In addition, eligible entities may use grant funds to provide financial aid to students and faculty, to enhance professional development among faculty in primary care programs, and to establish and maintain academic departments in primary care. The legislation requires the grant program to give priority to projects that train students to participate in patient-centered medical homes, train for the care of vulnerable populations, and establish formal relationships with federally qualified health centers or other clinics that serve underserved populations.

Nursing Workforce Development Programs Nurse-Managed Health Centers (NMHCs)

Section 5208 (p. 494) authorizes grants for NMHCs that provide comprehensive primary care or wellness services without regard to income or insurance status for patients. Such NMHCs must provide care to underserved or vulnerable populations and be associated with an academic department of nursing, qualified health center, or independent nonprofit health or social services agency. HHS would award grants subject to the financial need of the NMHC and other factors, as determined appropriate by the Secretary.

Advanced Nursing Education Section 5308 (p. 511) clarifies the scope of the Advanced Nursing Education grant program to ensure that accredited midwifery education programs are eligible for such grants. The Senate bill does not, however, give priority to recipients who will contribute to increased diversity among advanced education nurses, as section 2221(d) of the House bill does.

Nurse Education, Practice, and Retention

Section 5309 (p. 511) amends language related to Nurse Education, Practice, and Retention Grants by renaming the relevant statutory provision “Nurse Education, Practice and Quality Grants”. Section 5309 also adds two new grant programs specifically for nurse retention, the first of which would authorize HHS to award grants to accredited nursing schools or health facilities (or a partnership of both) to promote career advancement among nurses. The second new grant program would permit HHS to make awards to nursing schools or health facilities that can demonstrate enhanced collaboration and communication among nurses and other health care professionals, with priority going to applicants that have not previously received an award.

Nursing Student Loan Program Section 5202 (p. 489) provides updates to the loan amounts for the Nursing Student Loan program and specifies that, after 2012, the Secretary has discretion to adjust this amount based on cost of attendance increases.

Nurse Loan Repayment and Scholarship Programs (NLRP)

Section 5310 (p. 513) expands the Nurse Loan Repayment and Scholarship Programs (NLRP) to provide loan repayment for students who serve for at least two years as a faculty member at an accredited school of nursing.

Nurse Faculty Loan Program Section 5311 (p. 513) increases the Nurse Faculty Loan Program amounts from $30,000 to $35,000 in fiscal years 2010 and 2011 and declares that the amount of these loans will thereafter be adjusted to provide for cost-of-attendance increase for yearly loan rate and the aggregate loan. The legislation also creates a new

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010.

section that permits HHS to enter into an agreement with individuals with unencumbered RNs who have already completed, or are currently enrolled in, a master’s or doctorate training program for nursing. Under such an agreement, HHS would provide up to $10,000 per year to master’s recipients and $20,000 per year to those who earn a doctorate to individuals who spend 4 out of 6 years as a full-time faculty member at an accredited school of nursing.

Mandatory Funding Stream for Title VIII Programs

Section 5312 (p. 515) authorizes $338 million in appropriations to carry out nursing workforce development programs – including the advanced education nursing grants, workforce diversity grants, and nurse education, practice, quality and retention grants – in fiscal year 2010. For fiscal years 2011 through 2016, HHS may use “such sums as may be necessary” to carry out such programs.

Public Health Workforce

Section 5204 (p. 491) establishes a Public Health Workforce Loan Repayment Program to assure an adequate supply of public health professionals to eliminate workforce shortages in public health agencies. Under the program, HHS would repay up to one-third of loans incurred by a public health or health professions student in exchange for that student’s agreement to accept employment with a public health agency for at least three years. Individuals who service in priority service areas may be eligible for additional loan repayment incentives at the Department’s discretion.

Allied Health Workforce

Section 5205 (p. 493) authorizes an Allied Health Loan Forgiveness Program to assure there is an adequate supply of allied health professionals to eliminate critical allied health workforce shortages. Section 5206 (p. 493) authorizes HHS to make grants to accredited educational institutions that support scholarships for mid-career public health and allied health professionals who seek additional training in their respective fields.

Nursing Workforce Diversity Grants

Section 5404 (p. 531) expands the workforce diversity grant program by permitting such grants to be used for diploma and associate degree nurses to enter bridge or degree completion programs or for student scholarships and stipend programs for accelerated nursing degree programs. In carrying out this revised program, the legislation instructs HHS to consider recommendations from the National Advisory Council on Nurse Education and Practice and to consult with nursing associations, including the National Coalition of Ethnic Minority Nurse Associations.

Pediatric Health Care Workforce

Section 5203 (p. 489) establishes a loan repayment program for individuals who are willing to practice in a pediatric medical or surgical subspecialty or in child mental and behavioral health care for at least 2 years in an underserved area. Loan repayments recipients, including psychiatric nurses, social workers, and professional and school counselors, are eligible to receive $35,000 per year in loan repayments for participation in an accredited pediatric specialty residency or fellowship. The legislation directs HHS to give priority to applicants who have a familiarity with evidence-based health care and those who can demonstrate financial need.

Training for Direct Care Section 5302 (p. 499) establishes a grant program under which an institution of higher education can subsidize

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010.

Workers training of individuals at that institution who are willing to serve as direct care workers in a long-term care setting for at least two years after completion of their training. To be eligible for such a grant, the institution must partner with a nursing home, skilled nursing facility, or other long-term care provider.

Geriatric Nursing Career Incentives

Section 5305 (p. 504) includes a provision that authorizes HHS to award grants to advanced practice nurses who are pursuing a doctorate or other advanced degree in geriatrics and who, as a condition of accepting a grant, will agree to teach or practice in the field of geriatrics, long-term care, or chronic care management for a minimum of 5 years.

Advanced Practice Registered Nurses (APRNs)

In order to meet our nation’s healthcare needs, an integrated national healthcare workforce that looks beyond physicians must be put into action. Advanced Practice Registered Nurses (APRNs), in particular Nurse Practitioners and Certified Nurse-Midwives, are proven providers of high-quality, cost effective primary care. ANA has been advocating for the use of provider neutral language throughout the House and Senate bills. We also believe that any type of demonstration or pilot project that focuses on primary care should include nurse practitioners and certified nurse midwives and that nothing should preclude them from leading those models of care.

Advance Care Planning The bill does not contain a specific voluntary advance care planning consultation under Medicare, as provided under the House bill. However, Section 8002 (p. 710) creates a Community Living Assistance Services and Support (CLASS) independent benefit plan available for individuals with functional limitations. CLASS insurance would cover (p. 723), among other services, consultation with an advice and assistance counselor relating to the formulation of advance directives and other written instructions. Effective January 1, 2011.

Accountable Care Organizations (ACOs) – Medicare

Section 3022 (p. 277) establishes a shared savings program under which a group of providers and suppliers may form a legally structured ACO to manage and coordinate care for Medicare fee-for-service beneficiaries. An ACO that abides by a set of quality performance standards and meets a financial benchmark would be eligible for an incentive payment calculated as the difference between the benchmark set by HHS and the ACO’s per capita Medicare expenditures in a given year. An ACO must include primary care ACO professionals that are able to serve a minimum of 5,000 fee-for-service beneficiaries. The legislation defines the term “ACO professional” to include a physician assistant, nurse practitioner and clinical nurse specialist.

Medical Home – Medicare Section 3502 (p. 395) authorizes HHS to establish a grant program for states or state-designated entities to establish community-based interdisciplinary, interprofessional teams to support primary care practices within a certain area. Such “health teams” may include nurses, medical specialists, pharmacists, nutritionists, dietitians, social workers, and providers of alternative medicine. Under the program, a health team must support patient-centered medical homes, which are defined as a mode of care that includes personal physicians, whole person orientation, coordinated and integrated care, an evidence-informed medicine.

Increase in Medicare Section 5501 (p. 534) provides a 10 percent bonus payment under Medicare for fiscal years 2011 through 2016

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010.

Payment for Primary Care Services

to primary care practitioners (including nurse practitioners, clinical nurse specialists, and physician assistants) and general surgeons practicing in health professional shortage areas. The legislation would offset fifty percent of the cost of such bonuses through an across-the-board reduction in other services.

Certified Nurse-Midwives Section 3114 (p. 305) would increase the reimbursement rate for Certified Nurse-Midwives for covered services from 65 percent of the rate that would be paid were a physician performing a service to the full rate. It would make the increased reimbursement rate for CNMs effective 1/1/2011. Effective January 1, 2011.

Independence at Home program

Section 3024 (p. 286) creates the Independence at Home Demonstration program for chronically ill Medicare beneficiaries to test a payment incentive and service delivery system that utilizes physician and nurse practitioner directed home-based primary care teams aimed at reducing expenditures and improving health outcomes. Participation of Nurse Practitioners and Physician Assistants (page 287): “Nothing in this section shall be construed to prevent a nurse practitioner or physician assistant from participating in, or leading, a home-based primary care team as part of an independence at home medical practice…”

Nurse Home Visitation Services

Section 2951 (p. 216) authorizes states, with federal grant support, to establish nurse home visitation programs for maternal, infant, and early childhood purposes. Unlike the House bill, there is no provision that would allow optional coverage of nurse home visitation services under State Medicaid programs.

Increase in Medicaid Payment for Primary Care Services

The Medicaid incentive program was not in the Patient Protection and Affordable Care Act, but was included in the Health Care and Education Reconciliation Act of 2010. Section 1202 (page 64) would require State Medicaid programs to reimburse for primary care services furnished by physicians at no less than 100% of Medicare rates for those services furnished by physicians in 2013 and 2014. The federal government would pay 100% of the incremental costs attributable to this requirement. This provision is only a 2-year mandate.

Medical Home – Medicaid Section 2703 (p. 201) creates a state option under Medicaid to provide coordinated care through a “health home” for individuals with chronic conditions. Under this option, states could receive 90 percent FMAP funding to support a Medicaid enrollee who designates a provider or a team of professionals as their health home. Such health homes would provide comprehensive care management, care coordination, and chronic disease management. Providers must also meet certain standards established by HHS to participate in the option.

Accountable Care Organizations (ACOs) – Medicaid

Unlike the House bill, the final bill does not contain a provision that would establish a State Medicaid pilot program for ACOs. However, Section 2706 (p. 207) authorizes a demonstration project for pediatric ACOs that serve State Medicaid and State Children’s Health Insurance Program beneficiaries. Under the demonstration program, HHS would authorize states to govern the program for pediatric ACOs. In addition, the Department would provide incentive payments for those pediatric ACOs that both meet federal performance guidelines and achieve savings greater than the annual minimal savings level established by the State.

School-Based Health Clinics Section 4101 (p. 428) establishes a grant program for school-based health clinics that serve a large population of children eligible for medical assistance under the State Medicaid plan or under waiver authority for this

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010.

plan. However, unlike the House bill, the Senate bill does not require State Medicaid programs to reimburse school-based health clinics receiving grants under the program on the same basis as they would FQHCs.

Graduate Nurse Education (GNE)

Section 5509 (p. 556) would appropriate $50 million per year for FY2012 through FY2015 to establish a graduate nurse education demonstration program in Medicare. Up to five eligible hospitals would receive Medicare reimbursement for the educational costs, clinical instruction costs, and other direct and indirect costs of an eligible hospital’s expenses attributable to the training of advanced practice nurses with the skills necessary to provide primary and preventive care, transitional care, chronic care management, and other nursing services appropriate for the Medicare-eligible population. For this demonstration, the term “advanced practice nurse” shall include a clinical nurse specialist, nurse practitioner, certified registered nurse anesthetist, and certified nurse midwife.

Quality Many recent studies have demonstrated what most health care consumers already know: nursing care and quality patient care are inextricably linked, in all care settings but particularly in acute and long-term care. Because nursing care is fundamental to patient outcomes, we are pleased that both bills place a strong emphasis on reporting, both publicly and to the Secretary, of nurse staffing in long-term care settings. The availability of staffing information on the Nursing Home Compare website would be vital to helping consumers make informed decisions, and the full data provided to the Secretary will ensure staffing accountability and enhance resident safety.

Comparative Effectiveness Research

Section 6301 (p. 609) would establish a non-profit Patient-Centered Outcomes Research Institute to perform and synthesize research on comparative effectiveness. The purpose of the Institute would be to assist patients, physicians, purchasers, and policy-makers in making informed health decisions. In particular, the legislation envisions that the Institute will advance the quality and relevance of evidence concerning the manner in which health conditions can effectively be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis that considers variations in patient sub populations, and through the dissemination of research findings. Any findings made by the Institute to be construed as a mandate on practice guidelines or coverage decisions. The Agency Healthcare Research and Quality would be responsible for disseminating the findings made by Institute researchers to build data capacity for comparative effectiveness research (CER) and to train researchers in CER methods.

Nursing Home Transparency – Nursing Home Compare Medicare Website

Section 6103 (p. 586) would direct the Nursing Home Compare Medicare Website to release information on staffing data for each facility, including resident census data, hours of care provided per resident per day, staffing turnover and tenure. Furthermore, it would need to be in a format for consumers to compare differences in staffing between facilities and State and national averages for facilities. Moreover, the format is to include: differences in types of staff; relationship between staffing levels and quality of care; explanation that appropriate staffing levels vary based on patient mix. Effective not later than 1 year after the date of

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010.

enactment. (p. 588)

Nursing Home Transparency – Whistleblower Protection

Section 6105 (p. 593) directs the Secretary to create a standardized complaint form and requires states to establish complaint resolution processes. It also provides whistleblower protection for employees who complain in good faith about the quality of care or services at a skilled nursing facility. Effective 1 year after the date of enactment (p. 594).

Nursing Home Transparency – Staffing Accountability

Sections 6101 through 6121 (starting on p. 581) would require Medicare skilled nursing facilities and Medicaid nursing facilities to disclose information on their ownership and organizational structure to government authorities and would mandate that such facilities implement a compliance and ethics program within 3 years of the legislation’s enactment. Furthermore, these sections would require facilities to report in detail their expenditures on wages and benefits for direct care staff and to develop a program under which facilities can report staffing information in a uniform format based on payroll data, including agency or contract staff. Unlike the House bill, the Senate nursing home transparency provisions require a GAO study and report on the Five- Star Quality Rating System and authorize a national demonstration project to develop best practices related to “culture change” and information technology in nursing facilities.

Additional Nursing Provisions

Center for Quality Improvement

Section 3501 (p. 389) establishes a Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality to support the identification of best practices for quality improvement in the delivery of health care services. The Center’s activities will include identifying health care providers that employ best practices and finding ways to translate these practices rapidly and effectively into practice elsewhere. The Center is also charged with supporting research on health care delivery system improvement by establishing a Quality Improvement Network Research Program, under which funding recipients will test, scale, and disseminate information about interventions that improve quality and efficiency. Section 3501 also directs the Director of AHRQ to award technical assistance grants to struggling health care providers and organizations so that such entities can understand, adapt, and implement the best practices identified by the Center. Unlike the House bill establishing the Center, the final bill does not reference the nursing profession.

School-Based Health Clinics Section 4101 (p. 428) would establish two new grant programs for school-based health centers. The first program would authorize grants to provide for construction of, and equipment for, new school-based health centers. The legislation appropriates $50 million in each of fiscal years 2010 through 2013 to carry out this grant program. The second grant program would provide funding to existing school-based health centers for

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010.

operation, equipment acquisition, training, and salaries of personnel. HHS may give priority under this program to communities that have a shortage of primary care for children or a high per capita number of children who are uninsured.

Nurse-Managed Health Centers

Section 5208 (p. 494) establishes a new program to support nurse-managed health centers (centers operated by advanced practice nurses that provide comprehensive primary care and wellness services to underserved or vulnerable populations). It also authorizes to be appropriated $50,000,000 for FY 2010 and such sums as may be necessary for FY 2011 through FY 2014.

Pipeline to Nursing This program is not in the final bill.

Student-to-School Nurse Ratio

This demonstration program is not in the final bill.

Indian Health Section 5507 (p. 545) would establish a demonstration grant program to provide educational and training opportunities for low-income individuals for positions in the health care field that pay well and are expected to be in high demand. The demonstration program will primarily serve State Temporary Assistance for Needy Families recipients, but HHS is required to award at least three demonstration grants to eligible entities that are Indian tribes, tribal organizations, or Tribal colleges or universities.

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