Healthcare Financial and Business Management

Moral Distress and Self-Care

Moral distress can manifest as vomiting, withdrawal, emotional exhaustion, and depersonalization.
The ANA Code of Ethics for Nurses emphasizes the importance of self-care for nurses, including promoting their own health, safety, integrity, competence, and growth.
Strategies to minimize moral distress:
- Express gratitude regularly.
- Contemplate what went well.
- Implement team debriefings.
- Perform a medical pause to appreciate the life of a patient who expired and the care team's efforts.
- Pay attention to body signals of stress, take breaks, eat healthy food, exercise, and get adequate sleep.
Cultivate moral resilience by acknowledging that you did your best.
Utilize organizational resources like employee assistance programs, ethics committees, and chaplains.
DNPs can implement programs to identify and mitigate moral distress.
Nurses must learn to care for themselves to rebound from intense experiences.

Healthcare Financing Policy

Policy defines directives about programs, laws, regulations, or legal directives.
The policymaking process involves legislators, legal professionals, and special interest groups.
Dialogue and negotiation are critical for well-reasoned policy.
The central question in healthcare policy is: "Who, if not you, should sit at the table in the debates over health care policy?"
Public policy is influenced by the economics of constituents.
The process of policy making involves special interests and lobbyist efforts.
The debate continues over whether healthcare is a "right" or a "privilege."
There are fundamental rights to which all individuals are entitled, including healthcare and a life lived with dignity.
Universal healthcare systems ensure that all persons in the country enjoy their right to healthcare.

Healthcare as a Human Right

The U.S. has a market-driven healthcare insurance system that often denies the right to health.
The United States was the driving force behind the international human right to healthcare with the Second Bill of Rights (1944) drafted by Franklin Delano Roosevelt.
Eleanor Roosevelt took it to the United Nations, where it was developed into the Universal Declaration of Human Rights.
The International Covenant on Economic, Social, and Cultural Rights (1966) addressed specific aspects of universal healthcare.
Article 12 of the treaty states on "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health"
All countries ratified this treaty except for Palau, Comoros, and the United States.
The Patient Protection and Affordable Care Act (PPACA; Public Law 111-148), also known as the Affordable Care Act (ACA), is a group of laws concerning health insurance but is far from a law that codifies the universal right to healthcare.

Access to Healthcare

Equal access to a comprehensive set of healthcare services is crucial to maintaining optimal health for everyone.
Nonurgent healthcare is considered a business transaction in a free-enterprise system.
Primary care physicians may limit the number of uninsured patients they accept.
Individuals without healthcare coverage tend to use EDs for nonurgent care.
In March 2010, the PPACA was introduced to provide insurance coverage through the expansion of Medicaid and the establishment of health insurance marketplaces.
The ACA requires participating insurers to accept all applicants, cover specific conditions, and charge the same rates regardless of preexisting conditions or gender (Kaiser Family Foundation [KFF. 2021).
Following the implementation of the ACA, the number of uninsured nonelderly Americans declined.
Between 2016 and 2019, the number of uninsured nonelderly Americans increased from $10.0\%$ in 2016 to $10.9\%$ in 2019.
Many uninsured individuals were able to access the ACA and develop an ongoing relationship with a primary care physician.

Patient-Centered Medical Care Home

Promoting preventive care to reduce acute exacerbation of chronic disease is a vital feature of the ACA and is delivered through the "Patient-Centered Medical Care Home."
The Patient-Centered Medical Care Home model was developed in the 1960s to treat chronic pediatric illnesses.
In 2000, the conceptualization of a medical home became popular in treating chronic diseases.
To qualify as a medical home, a practice must meet specific standards:
- Ongoing communication and collaboration between the patient and the provider and healthcare team.
- Continuity with more than $50\%$ of the patient's medical home visits with the same provider or physician team.
- Comprehensiveness of care that includes preventive as well as end-of-life care.
- A process for quality monitoring based on guidelines and established evidence.
With the advent of the ACA, the number of uninsured persons decreased, and more individuals had insurance and access to medical homes that provided preventive care.
The financial performance of insurers participating in the ACA has risen dramatically to $167 per enrollee in 2018 from an annual low of -$9 in 2015.

ACA and Healthcare Reform

Congressional efforts to repeal portions of the ACA reveal the breadth and scope of the national debate on our healthcare social contract.
In March of 2017, the Republicans introduced the American Health Care Act (AHCA).
This bill kept many of the features of the ACA, including the ACA exchanges, protections for those with preexisting conditions, and the provision that parents could continue to keep their children under 26 years of age on their health insurance.
The individual and employer mandates in the ACA were kept intact, although the AHCA canceled the penalties for the individual mandate (KFF, 2021).
The AHCA repealed certain features of the ACA, including taxes imposed on healthcare insurance providers, makers of prescription drugs and medical devices, and a surtax of high-income Americans making more than $250,000 a year.
The bill planned to end the requirement that insurers offer plans with specific levels of coverage and left the level of coverage up to the insurer's discretion.
The AHCA also included a repeal of the Medicaid expansion program, which was delayed to 2020.
Individuals in the expansion plan before 2020 were to be allowed to keep their Medicaid coverage as long as they qualify under the AHCA.

Congressional Budget Office (CBO) Report on AHCA

Federal funding for Medicaid would be reduced by $880$ billion over 10 years.
The plan would partially replace that with $100$ billion to help states pay for healthcare.
There would be a significant move to curb the federal deficit by transferring the responsibility for healthcare costs to the states.

Failure of AHCA and Ongoing Challenges to ACA

The news of the transfer of costs to the state was controversial, and 18 days after its introduction, the Republicans pulled the bill due to lack of support.
This failed attempt to change the ACA demonstrates our nation's conflicting ethics related to healthcare, particularly regarding who can access healthcare and who is responsible for paying for healthcare.
The debate about the ACA continues to generate multiple legal actions in federal courts to challenge the constitutionality of the legislation.
The legal activities include challenges by states, legal experts, and independent businesses.

Supreme Court Cases and the ACA

In November 2020, the Supreme Court heard arguments in California v. Texas that raised new questions about the survival of the entire ACA.
The case challenged the ACA's minimum essential coverage provision, also known as the individual mandate.
In 2012, the individual mandate was upheld as Congress's constitutional power to tax at the U.S. Court of Appeals (Eleventh Circuit).
Included in this ruling was a finding that reversed the lower court's position that the individual mandate could be severed without invalidating the remainder of the ACA (Fiedler, 2020).
The individual mandate was essentially repealed in 2017 through tax legislation that eliminated the tax penalty associated with the mandate (KFF, 2021).
The ACA made comprehensive healthcare coverage changes that decreased the uninsured by 18.6 million from 2010 to 2018 (KFF, 2021).
Many modifications to the individual insurance market were made, such as requiring acceptance of people with preexisting conditions, creating insurance marketplaces, and authorizing premium subsidies for people with low and modest incomes.

Potential Consequences of Overturning the ACA

Additional changes to the healthcare system, in general, include expansion of Medicare and Medicaid eligibility for low-income adults, coverage of preventive services free of patient cost-sharing, phasing out the coverage gap of the Medicare prescription drug doughnut hole, reducing the growth of Medicare payments to healthcare providers and insurers, and establishing new national initiatives to promote public health.
These provisions could have been overturned if the Supreme Court struck down portions of the ACA.
It would be challenging to extend coverage if the ACA provisions were separated from the current healthcare system.

Supreme Court Decision in California v. Texas

In June 2021, the Supreme Court announced its decision that, by a vote of 7-2, it would not examine the merits of the California v. Texas case.
Instead, the court ruled that the plaintiffs did not have the standing to bring the case to court.
Standing would have been developed if the plaintiffs had effectively shown that they have or could suffer injury due to the legislation.
The failure to establish standing leaves the ACA intact for 31 million U.S. citizens.

The Role of Nurses and the Importance of Policy Knowledge

Milstead and Short (2019) suggest that as healthcare costs increase, efforts to improve both the quality and efficiency of healthcare delivery rest on the shoulders of professional nurses.
Having an understanding of the policy and legal aspects that guide professional practice is to realize that these are defined mainly by managing the financial affairs of populations and systems.
Laws are political entities designed and shaped by the will of society.
Seminal questions must be asked: Who should pay? How should the "marginalized populations: be supported?" Can the law be fair to both the rich and the poor?

Legal Liability and Nurses

The Nurses Service Organization and Continental National American Group (2020) provide malpractice insurance to over 500,000 nurses. In 2020 they issued a report on 5-years of malpractice claims and license defense claims.
The report found 455 legal claims with costs over $10,000 that involved registered nurses, licensed vocational nurses, and nursing students between 2015 through 2019.
Of these cases, nursing liability claims had an average cost of $210,513$ per claim, increasing $4\%$ over the last report in 2015.
Claims that were ultimately dropped, defeated, or dismissed still incurred legal administrative costs and were paid at an average of more than $20,000$ .
Over half the malpractice allegations were for improper care or treatment.
Nurses' malpractice claims dropped from $20.2\%$ of total claims in 2011 to $6.6\%$ in 2015 as patient care moved away from inpatient facilities.
Nurses' malpractice claims in patients' homes rose from $8.9\%$ of total claims to $21.8\%$ .

Malpractice Claims and Injuries

Malpractice claims against obstetrics nurses had an average cost of $558,007$ .
The next highest nurse malpractice claims occurred in postanesthesia care ( $384,912$ ), behavioral health ( $228,518$ ), and correctional health ( $219,924$ ).
The most common injury resulting in litigation is patient death, which accounted for $40.9\%$ of the malpractice lawsuits against nurses.
The cause of death in $47.3\%$ of these cases was cardiopulmonary arrest.

Licensing Board Complaints

Any public member can make a licensing board complaint against a nurse, even the nurse's employer.
A patient injury is not required for a complaint, and it does not have to be associated with professional duties.
Unprofessional conduct was the most common licensing complaint ( $32.5\%$ ), followed by nursing practice ( $25\%$ ), and documentation errors and improper treatment (19\%$).
Around 55\% of licensing board complaints filed against nurses result in an action taken by the State Board of Nursing.
Nurses tend to overestimate the risk of liability claims, but as the report shows that liability claims are relatively rare.
The nurses included in this report were 3 times more likely to defend themselves against a licensing complaint than a malpractice claim.

Healthcare Malpractice Claims

The average cost of healthcare malpractice claims in healthcare facilities has been rising at an alarming rate.
The number of verdicts that exceeded 25 million more than tripled between 2014 to 2018.
The average cost of each claim has risen 50\%.
The increase in the average cost of healthcare malpractice claims adds to healthcare costs, which already account for 17.7\% of our gross national product (Centers for Medicare & Medicaid Services, 2020).

Law and Ethics

The relationship between law and ethics is the difference between what we ought to do and what we are expected to do.
Ethical decisions are made based on a person's moral sense of what we ought to do because it is the right thing.
Laws codify societal behaviors and specify what we are expected to do.
The codified behaviors we are legally obliged to follow are based on moral principles accepted by society, so in essence, laws extend societal moral principles into formalized rules.
Two ethical principles that have been codified into healthcare malpractice law are nonmaleficence and duty.
When patients believe they have been harmed by a healthcare provider who did not follow the standard of care, they can seek a reward for damages and obtain a remedy through the court.

Elements of Negligence Required for Malpractice

The legal system has established four elements that must be satisfied to prove the negligence required for a malpractice action.
Medical negligence is one element required to prove a malpractice case, whereas medical malpractice refers to the entirety of the claim.
The plaintiff (patient) must compel the court that all elements of negligence have been satisfied before a case can be adjudicated.
The first element is the duty to care, which is the established obligation to conform to a recognized standard of care.
The plaintiff must show that a caregiver-patient relationship was in effect at the time the alleged injury occurred.
In general, the delivery of services within a healthcare organization, such as a hospital or clinic, establishes the duty to care.
The breach of obligation is the second element needed to prove malpractice.
It is established by proving that the nurse did not follow the recognized standard of care.
The standard of care is the behavior expected of a reasonably prudent person under the same or similar circumstances.
The court hears testimony from nursing experts who attest to the standard of care for nurses working in similar facilities.
The focus is on the community standards, which are the unique standards used by nurses working in similar settings.
The third element that a plaintiff must prove is that there was injury or harm.
The plaintiff must establish the nature and extent of actual damages.
If there are no injuries or monetary costs, the plaintiff will not show damages and will not get an award.
The fourth element of malpractice is causation.
The plaintiff has an obligation to prove that the injury was caused by the departure from the standard of care and not from another cause.
Part of the discussion regarding causation is the question of foreseeability.
The plaintiff must show, usually through expert testimony, that a reasonable person with similar training would have anticipated injury.
An example of this might be a nurse working with a faulty piece of equipment that causes harm to a patient.
The nurse's defense might be that the standard of care was followed, and it would have been impossible to foresee the injury.
This defense may help the nurse reduce culpability, but the plaintiff's attorney will press on other factors that require examination, such as the organization's guidelines for preventive maintenance and routine checks of operability.

Litigation and Justice

Satisfying the burden of proof for the court can be quite challenging, and plaintiffs often file cases and subsequently drop them when it becomes apparent that it will be difficult to prove negligence.
The legal system in our country developed around the ethical principle of justice regarding all parties involved in legal disputes, including the defendants.
The act of taking legal action helps patients who have suffered harm seek compensation.
Many plaintiffs say their interest in legal action goes beyond compensation and is focused on seeking justice for the general public.
Many plaintiffs believe taking legal action causes healthcare professionals to accept the liability of their actions and to change their practices to improve the safety of future patients.

Essential Pillars of Ethical Healthcare Policy

A critical framework that can serve as a foundation for an ethical, lawful, and cost-effective healthcare policy relies on three essential pillars: (a) quality and safety of care, (b) access to care, and (c) cost.
Studies continue to demonstrate that simply increasing spending does not influence population mortality.
Infrastructure that includes environmental health, vaccinations, and clean air and water has significantly impacted population health.
The United States spends twice the amount for fewer years of life.

DNP Role in Healthcare

In 2004, the AACN made a determined effort to move toward acceptance of a DNP degree as the primary advanced nursing practice qualification to take leadership and organizational roles in healthcare organizations (AACN, 2020).
In 2019, there were 7,944 U.S. graduates of DNP programs.
The DNP graduate is trained to implement evidence-based practice, quality improvement, and system leadership to improve patient care outcomes, focusing on efficiency and efficacy.
The AACN provides guidance on the 10 essential domains of all nursing practice in The Essentials: Core Competencies for Professional Nursing Education (2021), advising that the DNP be trained at the highest level, Level II.

The 10 AACN Domains:

Knowledge for Nursing Practice
Person-Centered Care
Population Health
Scholarship for Nursing Practice
Quality and Safety
Interprofessional Partnerships
Systems-Based Practice
Information and Healthcare Technologies
Professionalism
Personal, Professional, and Leadership Development

DNP Graduates and Their Impact

The graduates of DNP programs work in various settings to implement projects, design systems, and take the leadership role in practice improvement through innovation, testing of interventions, and evaluation of healthcare outcomes.
Their training provides them with a high level of knowledge in the latest developments and best practices in keeping with AACN domains 1 $and$ 4.
DNPs develop their colleagues' respect and trust, which is a requirement for interprofessional practice (Domain 6) due to their high level of clinical and systems knowledge (Domains 6 and 7).
DNPs use these tools to lead effective and efficient teams to improve service delivery based on the values and ethics of the nursing profession.

Translation of Research and Policy

The main work of the DNP is to translate research evidence and health policy into clinical practice to improve the quality and safety of care as well as reduce unnecessary healthcare costs.
This goal is accomplished by implementing evidence-based practice change projects with a primary focus on improving the quality of care.
The changes made were primarily implemented out of respect for the beneficence of improving patient care; it also focused on efficiency.
There was a vital concern for resource stewardship and accountability.

Example of DNP Impact

Dr. Rosalie Geronimo (2019) identified a potential opportunity for increasing the number of MRI placements of cardiovascular implantable electronic devices by establishing more nurse practitioner's support.
This process change would reduce patient safety concerns and align the facility with best practices.
Leadership was required to enhance the role of the nurse practitioner with a keen focus on beneficence and respect for patient safety (nonmaleficence; AACN, Domain 10).
It also supported the ANA Code of Ethics because it formalized the standards nurse practitioners apply for ethical decision-making regarding these types of patients.
The project would not produce a net gain until the second year after implementation when it is expected to have a net gain of around $200,000 due to improved service availability.

Accountability and Fraud Prevention

To carefully control the resources for vulnerable patients within complex systems depends on a robust ethical framework that provides for the high level of accountability necessary to avoid the commission of fraud.
Recent coordinated efforts through the administration of policy, law, and ethics have been focused on fraudulent billing issues.
The complex billing system that exists under multiple reimbursement structures ranging from public and private insurances depends on the provider and billers' ethics in interpreting the regulations and laws that guide the practice of coding and billing.
It is no longer adequate to rely on the insurance entity's process for monitoring each payment for adherence to billing regulation.
Today healthcare systems must check their billing to verify that it meets regulatory requirements.
Therefore, the DNP needs to understand the regulation, law, and ethical frameworks that apply to our social contract to pay for healthcare services.

Ethical Principles and Legal Code

DNP education includes a solid commitment to using ethical principles to improve patient care with accountability for practice, including understanding how the legal code defines fraud.
To be specific, in the U.S. legal code, Title 18 Part I Chapter 63 § $1347$ healthcare fraud is defined as:

Definition of Healthcare Fraud

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice-

To defraud any health care benefit program
To obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than ten years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned for not more than 20 years, or both. If the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or life, or both (U.S. legal code, Title 18 Part I Chapter 63 § $1347$§ $1347$).

Efforts to Combat Healthcare Fraud

In 2009, the Department of Health and Human Services and the Department of Justice established the Health Care Fraud Prevention and Enforcement Action Team.
With this move, Medicare fraud became a Cabinet-level priority.
The Secretary of Health and Human Services and the Attorney General direct the work of the team.
A year later, the PPACA passage enhanced language about healthcare provider overpayments.
The new language clarified that liability for overpayments, accidental or otherwise, was with the provider.
Overpayments must be reported within 60 days of discovery, and failure to return an overpayment within the time frame exposes the provider to action through the False Claims Act.
The Act also encouraged support from the public to report fraud through an 800 number (PPACA; Public Law 111-148).
In 2012, the administration announced an enhanced antifraud public-private partnership to prevent healthcare fraud.
This partnership shares information and best practices in the detection and prevention of fraudulent healthcare billings.
Insurers and patients trust care providers to be accurate in their billing practices and reject fraudulent billing, intentional or inadvertent (Pozgar, 2019).

Government Audits and Investigations

The government has used its authority and power to audit and investigate potential fraud, and the effort has been increasingly efficacious.
The report showed that the Medicare Fraud Strike Force resulted in 301 criminal and civil charges against physicians, nurses, and other licensed medical professionals, for alleged participation in healthcare fraud schemes.
The schemes involved around 900 million in false billings.

Vigilance Against Inadvertent Fraud

Healthcare organizations must be vigilant to avoid inadvertent fraud and maintain accurate billing practices to prevent inaccurate billing, such as overcharges or claims for services that are not documented or delivered.
In response, healthcare organizations have developed processes to do prebilling checks for accuracy using specially trained medical records coders, information technology professionals, and nurses.
Case Management and utilization review nurses play a prominent role in verifying that the documentation supports the diagnostic and procedure coding.
These nurses use their analytical skills to identify potential fraud and waste before billing the federal government.

DNP's Role in Safe and Efficient Healthcare

The DNP, who has the highest level of training in the AACN Essentials, understands how the appropriate use of information, communication, and informatics technology makes decisions to provide "safe, high-quality, and efficient healthcare services following best practice and professional and regulatory standards."
The AACN Essentials focuses on quality and efficiency (AACN, Domain 5 Quality and Safety, p. 40), which is essential to avoiding violations of the False Claims Act or ACA.
In conducting this work, DNPs also rely on their professionalism and the accountability inherent in the professional role (AACN, Domain 7, Systems-Based Practice, p. 45).

Examples of DNP Contributions

An example of how DNP-prepared nurses use their focus on quality and efficiency to avoid violations of the ACA can be seen in the work of Dr. Emily Trefethen (2020).
Section 3025 of the ACA established a process for the Secretary of the U.S. Department of Health and Human Services to deny payments to Inpatient Prospective Payment System hospitals for excess readmissions.
Dr. Trefethen implemented a program to reduce avoidable heart failure readmissions through an interprofessional training program for novice nurses.
After the training was implemented, heart failure readmissions decreased by 12\%.

Focus on Healthcare Providers Well-Being

Most DNP implementations are focused on improving patient care, but some focus on the healthcare providers' well-being.
Dr. Melinda Furrer, a nursing staff educator, implemented one such project to reduce moral distress in new nurse graduates (Furrer, 2020).
Her work is consistent with Domain 10 of the AACN Essentials, which centers on nurses' self-reflection, resilience, and well-being.
Dr. Furrer's search of the evidence showed a 27.7\% turnover rate of new nurse graduates less than 1 year after beginning practice was often the result of moral distress.
The cost of turnover can be high, with an average cost of 56,000 for each one.
Dr. Furrer developed a program to train new graduate nurses who were starting their first job at a healthcare facility on the signs of moral distress.
The new graduates were given tools to build moral courage, moral clarity, and self-confidence.
Her work showed that 40\% $of the new nurses reported an increased ability to face and resolve moral distress when situations arise, and$ 60\% agreed that the information on moral courage would improve their ongoing practice.

Policy and Nursing Professionalism

Dr. Marketa Houskova, a DNP with an avid interest in policy and the advancement of nursing professionalism, questioned why only 5\% of RNs serve on hospital boards when nursing has the number one rank as the most trusted and ethical profession for the past 18 years (Gallup, 2021).
She implemented an online public policy and advocacy toolkit to respect nursing as a profession (Houskova, 2019).
An evaluation of the nurses' reaction to the online policy toolkit was to increase their knowledge of the nurses' role in policy development and advocacy by 36\%$$.

California AB 890

In September 2020, Governor Newson signed California AB 890, which amends the Business and Professions Code to expand independent practice for nurses.
There has never been a greater need for nursing involvement in policy making than the discussions about the nurse practitioner scope of practice at the California state level.
In 2015, the California legislature rejected SB 323 when it faced vocal opposition from the California Medical Association, claiming that nurse practitioner independent practice would cause patient harm due to lack of oversight.
Twenty-two states already grant nurse practitioners full practice authority, and 40 others provide some level of independence.
Support for AB 890 was the result of a compromise initiated when evidence showed a scarcity of primary care providers during the COVID pandemic.
The bill provides two restricted routes for nurse practitioners to obtain independent practice.
In 2021, nurse practitioners can take a route which does not require direct physician supervision, but nurse practitioner practice settings are limited to a location with a physician in that same practice for 3 years.
By 2023, the Board of Registered Nursing will issue additional regulations regarding a genuinely independent nurse practitioner role.
Routes 103 and 104 require nurse practitioners to have a minimum of 4,600 hours of clinical practicum experience.

Conclusion DNP and The US Healthcare System

DNPs are educated to be keenly aware of how to use the ethical principle of justice, beneficence, and stewardship of resources to deliver patient-centered care.
The U.S. healthcare system is based on business principles and corporate interests, and these factors can distract focus from the need for patient-centered quality healthcare.
Cost-effectiveness in healthcare is essential, and so is adherence to ethical and legal standards.
DNPs have the ability to develop innovative solutions for patients in need.
They are visionaries who understand what makes good healthcare practice.
Using the ANA (2015) Code of Ethics for Nurses and trained in the 10 AACN nursing domains, DNPs understand the complexities of the healthcare system, including how to influence healthcare policy, design aligned work environments, and keep a sustained focus on optimal patient care.
Armed with a thorough understanding of current evidence, awareness of complex adaptive systems, and a deep understanding of ethics, DNPs help others see the value of patient-centered care delivered with fiscal accountability.