IndexAbstractPolitical PerspectivesHistorical PerspectivesRole ImplementationPersonal PerspectivesAbstractAffordable Care Act healthcare reform is a current hot topic in the United States and is quickly becoming a reality. One of the main objectives of this law is access to care. There is a large population of disadvantaged citizens in this country without access to healthcare, let alone primary care. Access to primary care has been shown to directly impact a person's overall health. Nurses represent an alternative to traditional primary care doctors. Not only are the services the same as those of traditional doctors, but they can provide such care at a lower cost. Financial concerns are a deciding factor in whether people seek assistance on a regular basis or not. Deploying more nurses as primary care providers is a valid response to the current health crisis in this country. The purpose of this article is to illustrate the importance of nurse practitioners to primary care, as well as personal motivations for pursuing the profession. Say no to plagiarism. Get a tailor-made essay on "Why Violent Video Games Shouldn't Be Banned"? Get an Original Essay Policy Perspectives Almost everyone who works in the healthcare field is aware that there is legislation passed and being written for healthcare reform. This has been the cause of great anxiety, discussion and uncertainty throughout the healthcare field. These reforms refer to the Patient Protection and Affordable Care Act (ACA) of 2010 (Fiscella, 2011). In the article Fiscella describes the six areas on which the reform focuses: “relative access to insurance coverage and costs, strengthening primary care, improvements in health information technology, changes in doctors' remuneration, adoption of a national quality and improved monitoring and accountability disparity” (p. 78). These are disturbing for many providers and are difficult to stomach especially with the current financial crisis in this country. While the financial crisis has made us more aware of spending in all areas of our lives, it has also strengthened the sense of personal sustainability and therefore led people to focus on their livelihood, not specifically on the good common. The United States is unique in the world of healthcare; as there is no centralized state control over healthcare. There are government coverage programs for special populations under Medicare, Medicaid, Native American coverage, and veterans. Aside from those who are eligible for these programs, there is no universal health coverage. This leaves a large gap of people without access to care due to lack of insurance. One of the objectives of the reform laws is to provide insurance and health coverage to the country's population. Many around the world are covered by government health plans; however most in this country fear it for various reasons. The primary focus of the Affordable Care Act is access to care; by adding financial coverage the number of those who will have access to treatment will increase significantly. By expanding and requiring insurance coverage for all, an estimated 32 million uninsured Americans will soon have health insurance coverage. Providing this coverage opens up access to care without fear of astronomical out-of-pocket costs. “Lack of health insurance is a major contributor to health disparities.” (Fiscella, 2011) This statement is found in all researchand in articles concerning reform, whatever side of the argument; pro or con, the author is. Without coverage, problems worsen until they reach a serious health crisis or even death, making necessary care complex and exponentially more expensive. To gain access, we also need to improve primary care. In the article Nurses as an Underutilized Resource for Healthcare Reform, by Bauer (2010), it is stated that “The United States simply does not have enough primary care physicians to coordinate patient care.” With the influx of newly insured Americans seeking care and the primary care revival that the reform hopes to have, there is a shortage of providers. Professional nurses can be crucial to filling this gap. Bauer says using nurse practitioners is “one of the most cost-effective and feasible reforms to solve America's serious problems of cost-quality and access to care.” (p. 231). In 1981, the United States Office of Technology Assessment analyzed and published the comparison of care provided by nurses and doctors (Bauer, 2010, p. 229). Since publication it has become a hot topic and has been reinforced by study after study that in comparable settings and within their scopes of practice care outcomes are comparable if not the same. This point should be brought to the forefront of the access to care issue presented by the Affordable Care Act. Nurse practitioners can provide the same services as primary care family physicians at up to a fraction of the cost with comparable outcomes; this would meet the goals of reforming access, improving primary care, and improving disparity. One particular way to do this was through accountable care organizations (ACOs). ACOs would group providers together to provide collaborative care. This would provide providers with “a measurable formula of accountability for providers with respect to the health and well-being of a given patient population they serve” (Barber, 2011). By motivating providers, such as nurses who act as primary care for patients, the idea would be to establish better health throughout the community and provide paid care at an affordable price. This is also a controversial idea as it would change the current primary care model. While media attention has been focused on opposition to the Affordable Care Act, perhaps the focus should be shifted to the positives that some of these changes will bring. According to Healthcare.gov, “chronic diseases, such as heart disease, cancer and diabetes, are responsible for 7 out of 10 deaths among Americans each year and account for up to 75% of national healthcare spending and are often preventable. " This is why reform is so important and should be embraced by the American public, not shunned. If we talk about “reform,” most people seem to focus on a few aspects, namely the feeling of insurance healthcare imposed on them or something else that our country simply cannot afford to support. There is strong evidence that by using primary care, many chronic diseases will be prevented or caught in their early stages, making treatment less costly. expensive. One benefit of the reform already adopted on September 23, 2010 is the provision that evidence-based preventive care is now covered without a deductible, coinsurance or copayment for those who have individual health insurance toward better health for those with insurance who have postponed primary care for fear of high deductibles andcoinsurance (healthcare.gov). For these reasons, reform is necessary; to help Americans, regardless of financial status, race or location, have access to primary and preventative care. It's not about more government control, it's about a healthier America. Nurse practitioners will fill a large gap between providers where there is a shortage of available primary care physicians. This will meet the need for suppliers and financial responsibility; “A study in Tennessee found that costs in nurse-led practices were 23 percent lower than costs of care provided by other primary care providers; hospital admission rates were 21% lower.” (Bauer, 2010, p. 230) The same article states that in over one hundred published reports, in no case was the care received reported as inferior. When it comes to the professional nurse, many confuse or even confuse his role with that of a doctor's assistant role. Both are similar in tasks and schooling, however the practical elements vary, as does their scope. Both roles began at roughly the same time in history, related to the physician shortage and uneven number of primary care physicians across the country (aapa.org). The origins of the nurse practitioner role began in the mid-1960s by Dr. Loretta Ford and Dr. Henry Silver at the University of Colorado. According to Miller, et. al, nurse practitioners are not physician extenders, but counterparts who have expanded nursing roles to include; “promoting health, preventing disease, and providing care to those who have minimal access to healthcare.” They are trained to provide primary care in clinics and have the ability to specialize in various specialties. Scope of practice includes evaluation, diagnosis, test and treatment orders, as well as prescribing privileges. Nurse practitioners can practice mostly without doctor supervision, but their exact scope varies by state; however, many work alongside medical providers and serve as an extension of their care and as peers (Miller, 2005). Nurse practitioners and physician assistants have common duties and tasks; however, physician assistants must practice under the supervision and joint signature of a physician. According to the American Academy of Physician Assistants, the practice of physician assistant also began in the mid-1960s to try to alleviate the same physician shortage. The idea of ​​the medical assistant was to be a partner or supervised by the doctor, but also be able to evaluate and diagnose. Physician assistants are not necessarily trained as nurses first, as they may typically hold a bachelor's degree in science prior to the physician assistant program and closely follow the medical model similar to medical school and residencies. Historical Perspectives Since their beginnings in the 1960s, both the nurse practitioner and physician assistant have become vital roles in the medical field. Today, as then, there are gaps in coverage of primary care areas and a shortage of primary care physicians. With healthcare reform focused on primary preventative care and universal access for Americans, both professions will help provide care to a larger and growing population of patients who will require primary care. As the focus shifts from health care to preventative care in the United States, the number of providers needed will only increase. A barrier according to Miller et. al., if the scope and training of professional nurses is not well known, cites a study conducted in Minnesota; “33% of people in rural areas ofMinnesota did not know the role [of the professional nurse]” (p. 167). By increasing public knowledge of both the scope and availability of professional nurses, perhaps some of the patient's limitations would naturally be alleviated by physicians. The article Reflections on Independence in Nurse Practitioner Practice (Weiland, 2008), provides an excellent description of the struggles of the nursing profession since its inception. Because the profession is intended to create independence, it has also naturally created competition and conflict between nurses and doctors in similar practices. Weiland states in relation to natural competition “whereby movement in any direction of a given profession inevitably influences other professions” (2008, p. 347). While physicians closely follow the medical model, nurse practitioners are nurses first and have the unique ability to see the patient from both a nursing and professional provider perspective, paralleling nursing values. Using this model developed the need not only for a “filler” provider, but for a new specialty as a mid-level provider with the ability to work independently from clinics to inpatient hospitals. Nurse practitioners and physician assistants are both considered mid-level providers. Nurses' autonomy, however, allows them to more easily and independently bridge the gap in the provider/patient relationship. While it is likely that more people will seek care under the new reform, it is more than likely that they will not want to wait a long time for an appointment. Unlike waiting for an appointment, the number of providers currently available will not be able to accommodate even the likely number of potential patients. As more people seek care, current providers' ability to accept new patients will decline. Each healthcare worker can care for a limited number of patients; this is where the need for more primary care providers in this country comes into play. Role Implementation To increase the number of providers in this country, physicians are not the only answer. Many studies have shown that the number of doctors focusing on primary care or family practice has declined in favor of more lucrative specialties. Having specialists is a necessary option for quality care; however, primary care is a necessity and will receive even greater attention with the current reform. “Nurses can be the primary care providers of the future. They have the education, training and guidance needed to change their system to address true “health care” rather than “disease” treatment. (Counts, p. 13). Being nurses before being professionals, the bedside manner and attention of professional nurses are unique. The attention tends to be preventive, focusing on "health", as Conti says. While many doctors focus on the problem at hand, nursing care tends to be more holistic. This comes into play with the new healthcare reform laws, as they focus heavily on preventative care, the area in which many nurses specialize. As Buerhaus states, "As millions of Americans are expected to gain health insurance in the coming years, media interest in health care workers has increased and has even focused on whether restrictive state laws are limiting opportunities for nurses to bridge the gap." in primary care” (2010, p. 346). The scope of practical skills of nurses varies from state to state; to meet the number of suppliers needed, perhaps some statesthey should become less restrictive and allow independent practices. As access to care and a focus on primary prevention become the norm, more providers will be needed, thus building their own patient bases separate from physicians in the same geographic area. Additionally, with lower costs, the ability to place nurse practitioners throughout the community and in schools to serve vulnerable populations who are generally underserved is a viable option to improve access. The Affordable Care Act also contains provisions to allow reimbursement for the services of professional nurses at the same rates as doctors are paid. As more nurse-led clinics develop, the right to higher reimbursements will develop. This is at odds with the question of reform in terms of cost-effectiveness; however, the number of available care providers increases. The Affordable Care Act will provide bonuses to primary care physicians to eliminate payment differences between Medicare and Medicaid; it is not clear whether this will also be transferred to nurses (Fiscella, 2010). This is where there is a gray area with the reform, as professional nurses are not specifically mentioned in many publications. Some assume they fall under primary care providers, but their scope varies from state to state. The cost of underutilizing nurses costs billions every year; “denial of primary care status” is among these underutilizations (Weiland, 2008). Only time will tell how professional nurses will be recognized through the reform process and its implementation. Again, by educating the public about scope of practice and nurse training, utilization rates will increase resulting in improved overall public health. In almost every context in which doctors and nurses practice, there is some sort of overlap. “With projections of a doctor deficit hovering around 63,000 by 2015, the promise of 32 million more Americans gaining health insurance, and a rapidly aging patient population burdened by chronic diseases, hospitals they are rushing to deploy health workers” (Frellick, 2011). Mid-level providers, nurse practitioners and physician assistants will increasingly fill the gaps. From another perspective, the same article states that this will free up doctors with more medical training for higher risk procedures. When comparing professional nurses and family doctors there is a big difference in the level of education; classroom hours versus clinical hours, physicians have more in each area. However, to be accepted into the master's degree in nursing to earn your bachelor's degree in nursing; years of nursing experience are typically required, which can fill this educational gap with real-world experience. For both professions, continuing education requirements vary by state. Each is a licensed provider and must continue to practice and keep up with continuing education credits each year or retake a licensing exam. Although doctors are paid higher, patients' experience with nurses is an attraction and a skill to use in negotiations. "Of more than 100 published, post-US Office of Technology Assessment (OTA) reports on the quality of care provided by both nurse practitioners and physicians, not a single study found that nurses provide inferior services within the overlapping scopes of licensing practice.” (Bauer, 2010) The above statement refers to studies that attempt to find differences in the quality of care between doctors and nursespublic education about the lack of difference is a necessity. Since studies show the parallel in care, it should be fair that the two are considered equal and reimbursed and considered as such. Naturally, some doctors felt threatened by nurses' ability to overlap their jobs in some way. Once a graduate nurse passes the certification test, he or she can take the DEA exam for prescription services. Despite the possible duplication of services; the cost of nursing services is lower than the same services provided by a doctor. “A study in Tennessee found that costs in nurse-led practices were 23 percent lower than costs of care provided by other primary care providers; hospitalization rates were 21% lower” (Bauer, 2010, p. 230). When nurse practitioners provide cost-effective care with lower hospital admission rates, patient satisfaction scores increase not only because of these factors, but patient satisfaction scores are generally higher overall with nurse practitioners in the outpatient setting ( August, 2009). The lower cost of professional nurses has also made them more available to practice in a variety of settings, from working on-site with employers, to schools, to health clubs. The exact privileges of various nurse specialties vary depending on status, organization, and personal trust level. . Nurses who practice independently are typically permitted to admit themselves into hospitals, write prescriptions up to and including controlled substances, and also bill for all services rendered under their care. They are all parallel services to traditional doctors, but with a different profession. It is hoped that the new health care reform laws will “eliminate outdated variations in scope of practice and reform advanced nursing practice by disseminating best practices throughout the country and creating incentives for their adoption” (Frellick, 2011, p. 49) . The same article makes a very good point that no one model will work across the board; each health system and each state varies in what they allow within the scope of practice. With a reform that potentially provides incentives to providers for primary care goals, overall health improvement across the population will potentially be achieved through ACOs and changes in standards of care will become uniform. Personal Perspectives The lure of independence is what drives many nurses to further their training as professional nurses. “Nurses define independence as being free from the regulation imposed by another profession” (Buerhaus, 2010, p. 346). This speaks to the level of autonomy and independence that professional nurses can have. The ability to practice as a provider and maintain nursing skills is attractive to current nurses seeking to advance their education. Of course, they can always work in collaboration with a doctor and other healthcare professionals, but this is not an obligation. Nurse-led clinics are becoming more common and represent a cost-effective solution to reform legislation where cost assessment and financial accountability are placed at the forefront of quality care. In a time of healthcare reform and financial instability, a nurse-led clinic is a viable and attractive option for increasing the number of primary care providers available to the public. In a Nursing Economics interview it was stated that professional nurses have taken over rural practicesof retired family doctors and are well received in the community. The percentage of insurance companies paying nurses as primary care providers is increasing over time; in 2004, 20% of insurances included covered nurse practitioners as primary care providers, and in 2009 the percentage rose to 52% (Buerhaus, 2010, p. 347). As the reform goes into effect, coverage for nurse practitioners is expected to increase as they are a cost-effective option, and study after study has found that nurse practitioners and physicians of the same specialty have the same outcomes. results and recoveries (Bauer, 2010). Using this reasoning, insurance company reimbursement rates and coverage will start to be on par with doctors, in proportion to the level of expertise, in my opinion. Nurse practitioners must begin to fight current billing practices that deem an “incident to” medical care; and bill separately as a supplier to ensure independence (Counts, p. 14). This way, not only will the reimbursement for their services be fair, but it will also strengthen their independence and difference from traditional doctors. As the playing field becomes more level, doctors who have fought progress and nurse autonomy will be overtaken by those who believe this is the answer to future healthcare. There is a sense of competition between these two groups for clientele in areas that have practices in close proximity. Like any business, it is a free market and I believe that ultimately people will make their own decisions, but with reform, nurse skills training should be made known to the public. Some believe that politically, through recent changes and very public debates, the professional nurse has been considered a “replacement” for traditional doctors, but this is not the case at all (Weiland, 2008). Like any free market, healthcare will always be a source of innovation, competition and income. Using this free market to improve community health should be in the foresight of all providers. As people choose products that fit their family's needs, they will soon be able to do so with healthcare due to increased access; some will choose the more expensive “name brand” option, i.e. traditional doctors, and some will choose something comfortable, but affordable, and can continue to buy it, professional nurses. Some people prefer to see their doctor once a year and get everything treated, no matter what. Others prefer to see their doctor more often and build a working relationship because they can afford it. This is where nurses have the advantage and it has been found that nurse visits are typically longer; with greater patient satisfaction afterwards, as well as patients feeling they could go more often, for the little things, to keep up with their health because it's convenient (Agosta, 2009). Keep all these points of autonomy, convenience and high patient satisfaction in mind; Why not become a professional nurse? While working in an inpatient hospital unit, following doctors' orders, day after day, it starts to feel like an assembly line. Repetitive tasks are a common nursing practice, while caring for different patients and occasionally a different diagnosis. The patient care aspect is what I love about nursing; including building new relationships, getting to know people and helping them improve their conditions through holistic care.What I didn't like was having to ask for an order for extra blood sugar because something was wrong, or calling the doctor in the middle of the night because someone had low production, knowing full well they just needed more IV fluids. I wanted autonomy. Being able to use my bedside nursing skills when diagnosing and treating my patients, as well as being their primary care provider, is what I have always wanted to do. I feel that this class of nurse practitioners currently studying will enter the field at a very critical inflection point. I will graduate in 2014; this is the moment when the reform is expected to become law and become fully effective. Being in school during the initiation phases gives us the ability to have access to the most current research, be in class to discuss as things happen, and learn from changes as they occur. As more nurses enter the market with this background thinking they are the path to changing primary care delivery in the United States, I think the stronger the movement will become. The greatest advertising is word of mouth. I believe that the more people use mid-level providers as a primary care resource, the more the idea will catch on and therefore become a norm. My goal as a nurse practitioner is to educate the public about our capabilities and provide access to those who previously did not even have the ability to have a primary care provider. By providing quality primary care to more people, the healthier the general population will potentially become. Ensuring access is my main goal as a future supplier. No one should go without healthcare due to cost. Health is a right, not something afforded only to the rich or employed. Right now a lot of the literature seems to focus on providing care to rural areas, but I really think the focus should be universal. Rural people are disadvantaged simply because of distance, but so are those living in a suburb without public transport to the local clinic. Again, access to care is a very important part of the reform laws that we need to advocate for and educate our patients on. Many people will hear about access and simply think of physical location, but the number of available providers and a diverse field of providers also speaks to access. Finding a doctor or primary care physician is not a one-size-fits-all solution. Matching people with a provider that fits their personality and needs is also a must. I feel that nurses tend to be more attuned to the holistic needs of their patients; such as psychological needs and social health in addition to physiological health simply because of their initial nursing background. Focusing on family-centered primary care is important to me as a future nurse practitioner. Once people have access to care; whether physical or financial, the next major focus is on the importance of the primary care that people will now have access to. By focusing on the entire family, not just the individual, health behaviors and problem areas can be addressed more effectively. Having children as well as their parents under one's health care providers provide insight into family health and dynamics. Furthermore, by treating and following the family as a unit, I believe that a better relationship can be achieved and support systems within a family can be improved. Relationships between suppliers are also important within a community. “The expectations are that nurses and