Health Care Reform Sandra Gilman My name is Sandra Gilman, I will be doing a seminar on Health Care Reform and the expected effects it will have on the general population, health care workers and health care organizations as a whole. This is a complex issue and there are many aspects of Health Reform that are largely unknown and will remain that until the law is completely in effect. Many studies discussed were simulated studies or focus group quantitative studies. Sandra Gilman

Health Care Reform Outline Overview of Health Care Reform (HCR) The Effect of Health Care Reform on Hospitals and Health Care Workers Nursing and Physician shortage Increased patient population Reimbursements based on patient outcomes Relevant Theories The Point of View of Patient, Physician, and Nurse Health Care Environment Now, and Later Implication of Health Care Reform Recommendations Conclusion My goal of this presentation is to describe the many aspects of health care reform, and the effects it will have on the general population, health care workers, and health care organizations. There will be many changes related to finance, payments and reimbursements which will be discussed. There are many changes that will take place between now and 2019 which is expected to worsen the nursing and physician shortage. I will discuss the interventions placed in an attempt to lessen the burden as well as the various points of view from nurses, physicians, financial officers, and patients. What happens if health care doesn’t change, and what are the recommendations to overcome various barriers related to reforming our countries health care.

Objectives Describe the many aspects of Health Care Reform Identify the impact Health Care Reform will have on the General Population Identify the effects Health Care Reform with have on nursing, physicians, and institutions as a whole. Describe interventions which will lessen the effects of Health Care Reform on Nursing, Physicians, and institutions Recognize the differences in Health Care as it is, and Health Care Reform When choosing this topic I knew it would be difficult, and there were many times I wanted to change subjects. With that being said, I have learned so much useful information which has helped me relate to many changes I have experienced in my own institution. My hope is that I can teach you the many things I have learned throughout this presentation so that you will gain a better understanding of how health reform will effect you, your organization, and your patients.

Terms and Definitions Patient Protection and Affordable Care Act (PPACA) Health Care Reform Accountable Care Organization Medicaid Medicare Bundled Payments Insurance exchanges Integrated Care PPACA is the act that was signed into law which includes all elements of the health care reform. Health Care Reform is an intervention that will take place gradually over a ten year period, there have already been changes as a result of Health Reform. Accountable Care Organizations is essentially an arrangement between providers and suppliers of health care which coordinates services and allows for high quality and effiecient care Medicaid is government assisted insurance for persons under age 65 who are disabled or meet other requirements to obtain services Medicare is Government assisted insurance for persons over age 65 Bundled payments are essentially a payment system which is decided on by an advisory board The provider pays a set amount for most aspects of a patients care Insurance exchanges these are simple an exchange where consumers will be able to shop for affordable insurance which is most right for them Integrated care refers to a more organized, coordinated and consistent care provided to the patient.

Introduction to Health Care Reform Universal Health Coverage for all 32 million uninsured adults will receive insurance Reforming Health Care Payment System Reimbursements based on patient outcomes Achieving Effective and Efficient Health Care Accountable Care Organizations Increasing Access to Quality and Cost information Health Care Reform is directly tied to the Patient Protection and Affordable Care Act which was signed into law by President Barack Obama on March 23rd 2010. It has been a major topic of debate for health care providers, patients and government officials. Health Care Reform will have a significant impact on nurses, physicians and health care organizations as a whole. The primary provision of the law is to require most U.S citizens, and legal residents to have health insurance. Health Insurance exchanges will be created for individuals to shop for the best insurance plan that suits their needs. 16 million of the newly insured 32 million currently uninsured will gain insurance through the Medicaid system. Anyone who does not have qualifying insurance will be subject to a government tax penalty. The law also places pressure on small businesses to offer insurance packages as well. There will be a Medicaid expansion and Medicare growth due to rising amount of Baby boomers which will lead to a significant influx in patients seeking care. There will be a noticeable change in the health care payment system, medical reimbursements will be based on quality patient outcomes and financial penalties will be in place for readmissions. There will also be a focus on wellness and prevention, rather than treatment after a person is ill. In order to provide effective and efficient care the health care team must work in collaboration with each other. Health Reform “encourages the adoption of innovative models of care and payment such as accountable care organizations. Also included in achieving effective and efficient care is providing an adequate work force. Currently there is a purposed shortage in both nursing and physicians. The government has proposed financial assistance specifically for people entering the medical field, as well as accelerated programs, and wage adjustments. Also proposed is for patients to have access to the cost of treatments, and also quality data of institutions prior to seeking treatment. There will be many changes a long the way of Health Reform, I think we can all agree that our current health care system isn't working, but there are definite weakness to the health care reform as it stands now.

Faye Abdellah’s Nursing Theory in relation to Health Care Reform Abdellah’s Nursing Responsibilities Patient Centered Approach Effective Communication Relieve pain, and provide continuous security for the patient Plan for optimum health at local, state and national level Continuous research and evaluation of nursing practice Goal of Health Care Reform Reimbursements are tied to quality outcomes Development of new models of care Community heath needs appraisal by not for profit hospitals Affordable Quality care for all Faye Abdellah’s nursing theory relates very well to Health Care Reform. Abdellah’s model of care is patient centered, she stresses the importance of providing patients with optimal care, and continuing to provide optimal care over time. She also acknowledges the need for nursing research to improve nursing models of care to meet the needs of patients. One of Abdellah’s nursing responsibilities is to plan for optimum care at the local, state and national level, which is the exact goal of Health Care Reform. Health Reform encompasses providing quality patient care to all United States Citizens, quality of care includes providing positive patient outcomes, developing evidence based models of care to deliver care to a diverse patient population. Current Nursing: A portals for Nursing Professionals; Nursing Theories Kaiser Family Foundation: Summary of New Health Reform Law

The Current Health Care System Many Working American’s Lack Medical Insurance Health disparities exist Poor management of chronic disease Lack of providers who except Medicaid Rising health care costs Fragmented Care Strict Medicaid eligibility Life time dollar limit on health plans I think we can all agree that there are many flaws in our current health care system. We have all cared for a patient who was unable to get the quality of health care they deserved due to lack of financial assistance which may be related to unemployment or their employer not offering health insurance. This gap in health insurance causes many disparities to exist. There are many people who fit under the umbrella of low socioeconomic status, especially with the current recession that our country is in. What many don’t know is that in order to financially qualify for Medicaid under current legislation the income for a family of three will need to be within 50-100% of the federal poverty level. According to the Kaiser Family Foundation 50-100% of the poverty level is an income of between 9,265-18,830 for a family of three. So lets pretend that your neighbor Joe who lives down the street, who is a hard worker, but due to the economic downturn he has experienced several job cuts and he is now only bringing home $19,000 a year, his employer doesn’t offer insurance and he just misses the cut off for insurance. He holds his breath and prays that nothing happens to him or his family because he certainly cant afford to buy his own insurance only making $19000 a year. Unfortunately, Joe hasn’t been feeling well, he was in a snowmobile accident a few days ago, he is barely able to walk due to the pain in his back. He doesn’t have a doctor so he has no other choice but to go to the ER for treatment. He gets pain meds and is sent home, it isnt until his third visit that studies are done showing that Joe has a fracture in his back which may require surgery. This type of scenario happens often. Which is Health Care burden number 1. Joe has went to the ER 3 times for pain meds which is a huge financial burden on him and the institution because he will likely not be able to make the payments. He now has a condition which may help him qualify for Medicaid, but good luck trying to find a physician who will accept new Medicaid patients that isn't already full. So now Joe has insurance but still no doctor which will lead to further use of the Emergency room for general treatment he could otherwise receive in a doctors office. “The United States Ranks in first among nations in annual per capital health care spending with an average of $7960 per capita”, yet many Americans aren’t even insured. Musanti, R., et al.(2012) Partners in Caring Kaiser Family Foundation, (2012), Kaiser commission on key facts Medicaid and the uninsured

New Face of Health Care Affordable insurance for all Insurance Exchanges Higher quality care New regulations on private insurance companies Increase in physicians accepting Medicaid/Medicare Bundled Payments Accountable Care Organizations’ With that being said, the goal of Health Care Reform is to ensure quality affordable insurance for all. It is projected that 32 million Americans will gain health insurance benefits as a result of health reform. Of those 32 million people, 16 million will join through Medicaid Services as a result of increasing eligibility to Americans whose incomes are with in 138% of the Federal poverty level, which is equal to $26,344 for a family of 3. The other 16 million Americans will obtain insurance by shopping the state regulated insurances exchanges to find a plan that is affordable and meets their needs. The government has also placed restrictions on insurance companies which restrict them from dropping individuals insurance, and denying coverage due to pre-existing conditions. The Medicare population continues to grow as baby boomers age, the people seeking treatment from Medicare services will be on the rise, in addition Medicaid will be taking on an additional 16 million people. It is obvious that changes will occur in order for the Center of Medicare and Medicaid services to remain fiscally responsible. In an effort to save money CMS has instituted more stringent requirements for reimbursements to institutions for the care they deliver. Reimbursements are based on positive patient outcomes, there are penalties in place for re-admissions, as well as rewards for high performance. Essentially hospitals, physicians and nurses will be trying to deliver positive outcomes to a rapidly growing patient population. In order to aid in the delivery in a cost effective manner the law encourages health care organizations to create innovative models of care and payment. An example of this being The Accountable Care organizations and the Bundling of payments. The Accountable Care Organization is a collaborative group of health care providers in an array of different settings which assume care and delivery of service for the whole patient and a crossed the continuum of care. This type of organization prevents fragmented, inconsistent quality care because each provider of care in the organization is taking responsibility for the patients care and outcomes. The ACO’s back up the principals to Health Care Reform as their goals are “to provide high-quality, cost-effective health care with providers reward for delivering excellent care” (Hart, 2012, p. 23). Bundled Payments are the piece to the puzzle that has many physicians grumbling, however may prove to be beneficial to the consumer. Currently providers are reimbursed for treatment and services even if the treatment isnt necessary. Under Bundled payments, an advisory board will determine the cost of a service or treatment which will be expected to cover most aspects of the patients care. I would say that each of us know a person or many people for that matter who will greatly benefit from Health Reform, the largest unknown with Health Reform is the impact it will have on Health Care Professionals. McNeilly, L. 2012, Accountable care, value based purchasing, outcomes measurement Kaiser Family Foundation (2010) Summary of new health reform law Hart, M. (2012) Accountable Care Organizations, the future of care delivery?

Barriers to Change Increased health care worker shortages Many physicians threatening to leave practice Older nurse population close to retirement Therapy Services Financial Implications Deliver more with Less Resources Cost of Health Reform Influx in patients seeking care There are several barriers to consider in order to successfully reform Health Care. There is already a shortage of nurses and primary care physicians this will likely increase as 32 million Americans gain access to treatment. Perhaps the largest barrier will be that health care providers will be expected to provide higher quality care with less resources to provide the care due to shortages of Health Care Professionals. There are many financial implications which will effect organizations and physicians, the financial implications are largely unknown however, speculations can be made. There have also been changes to the reimbursements related to therapy services. More sufficient documentation will need to be done with specific goals and outcomes, and how long it will take to reach the goals in order for reimbursement. In a survey study conducted at a Medicare home health agencies, many administrators felt that the therapy changes would result in a loss of revenue at least in the initially. And Lastly, many Americans are concerned about the cost burden of Reforming Health Care on the United States and individual states as well. Cabin, W.D. (2011) Doing more with less McNeilly, L. (2012) Accountable care, value based purchasing, outcome measurement

What it means for society Nursing Shortage Estimated shortage Causes of the shortage What it means for society How do we fix it? Nursing contribution In the late 1990’s talk of the nursing shortage was quite popular. More people began to apply for nursing school and accelerated nursing programs started popping up to help with the shortage. It is the perception of many that the nursing shortage is better right? Wrong! Nursing is merely experiencing a slight reprieve. Due to the falling economy many Americans are only receiving necessary treatment. Elective surgeries are on hold for many who cant afford to be off work or make medical payments. Therefore as many Americans gain medical insurance, and care becomes more affordable, the nursing shortage will become more noticeable. In addition there is a rapidly aging population as many baby boomers are reaching retirement age. It is estimated that by 2025 nursing will experience a shortage of nearly 300,000 nurses. This is startling given the evidence which proves that higher level of nurse staffing results in approximately 25% fewer negative outcomes. Nursing shortages have been proven to be a threat to society due to increased fatigue and understaffing. Many may wonder why the nursing shortage problem hasn’t been addressed more aggressively. Part of the problem is the decreased amount of nursing faculty to teach the amount of student who wish to enter the programs. IN the 2007/2008 school year it was estimated that colleges turned away more than 30,000 qualified applicant for the nursing program due in part to lack of faculty. Unfortunately becoming a nursing instructor doesn’t look very attractive, the wages are comparable to other entities such as bedside nursing yet a high level of education is The necessary to be an nursing instructor. In addition the funding to increase nurse faculty is inconsistent and insufficient. The government is attempting to take steps to rectify this problem by offering an education reimbursement of up to 85% of the cost of education in exchange for faculty service for 3 years are more. In a time of a significant nursing shortage which may lead to many nurses working overtime with inadequate staffing. recommendations have been made for nursing to contribute more. Expected contributions include increasing and implementing EBP, involvement in inter-professional teams, involvement in community and public health, care coordination, transitional care all in an attempt to improve quality cost effective care. Once again it is expected that nurses provide a higher level of care with less resources to deliver that care, which could have significant implications for institutions as reimbursements are based on quality rather than quantity. Studies have shown that patient outcomes have suffered as a result of inadequate staffing levels. In a study conducted at the Columbia University school of nursing it was determined that area’s of higher staffing resulted in better patient outcomes. ICU’s with higher staffing had a lower incidence of CLBSI, Ventilator associated Pneumonia, 30 day mortality and hospital acquired pressure ulcers. The study consisted of 15846 patients in 51 adult intensive care units. Cleary, B., Wilmoth, P. (2011) The Affordable Care Act Dick et al (2007) Nurse working conditions and patient safety outcomes Lavizzo-Mourey, R., Rother, J. (2009) Addressing the nursing workforce

Nursing Wage by Specialty As mentioned the nursing shortage is in part a result of a nursing faculty shortage. This chart indicates the salary of nurse faculty versus MSN NP and a Bedside nurse. According to the American Association of Colleges of Nursing, a Masters prepared Nurse Practitioner makes approximately 91,310 a year, where as a Masters prepared nursing professor makes approximately 72,028. Which is just over the national average salary of a bedside nurse which is 69,110 annually. Keep in mind that the faculty nurse educator has a masters degree yet makes only 3,000 more than a bedside nurse. The salary of nursing faculty has been identified as a potential cause of the nurse faculty shortage. I can honestly say it would be really hard to further my education to a masters degree to make an extra $3000 a year. American Association of Colleges of Nursing (2012)

Physician Shortage As of 2014 the projected physician shortage is estimated at 62,900. Shortage projected to increase to nearly 140,000 physicians by 2025 Lack of providers who accept Medicaid Simulated Study projected the need of 4,500-12,100 new physicians by 2019 New physicians choosing specialties to make more money A simulated Study completed by Public Health Professors at Harvard University estimates that there will be a need for anywhere from 4,500 to 12,100 new physicians. In order to determine this the professors created a simulation model that helped them determine how many people would be eligible for Medicaid, and how many of them would actually enroll. Surveys used to determine the amount of enrollees included the “current population survey” from 2009 and the income and program participation from 2008. This study did not however account for the role of Nurse Practitioners and Physician Assistants The Final results were that 17.3 million people would be newly enrolled in Medicaid by 2019 which will require an additional 7,400 physicians to provide care. According to the American Academy of Family Practice Physicians The Primary Care Physician Shortage will exceed to nearly 140,000 by 2025. The Primary Care Physician Shortage is partly due to the fact that Medical students and residents are choosing to specialize in area’s partly because of the increased wages of specialty physicians. The average college debt of a new physician is $130,000 which is the approximate yearly income of a Primary Care Physician. Where as a Surgeon or other specialty makes double or even triple, depending on specialty. Lastly, Many physicians have stopped accepting Medicaid patients due to the poor reimbursements for care provided as well as the time it takes to be reimbursed. Cleary, B. (2011) The Affordable care act- what it means for the future of nursing. Epstein, A. Et al. (2011), Policy makers should prepare for major uncertainty in Medicaid enrollment, costs, and needs for physicians under Health Reform Sanchez, C. (2010) Health law may worsen family doctor shortage.

Physician Pay As you can see from this chart there is a significant difference in the wage of a primary care physician who makes approximately 130,000/year where as a Radiologist makes 350,000/year. With the amount of education required many physicians enter practice with more than 130,000 in student loans. As doctors are entering the work force they are often choose to specialize, which is also contributing to the primary care physician shortage Sanchez, C. (2010) Health law may worsen family doctor shortage.

Hear it from the Doctor

Financial Implications Financial impact is unknown Medicare and Medicaid Service payment reductions Changing payer mix Budget cuts Lost revenue if outcomes aren't met What is known about Health Reform is that there will be a change in payer mix as there will be an increase in the amount of health care that is paid for by Medicaid and Medicare services. In addition, the reimbursements will be tied to quality outcomes which may be difficult to meet as a result of the workforce shortage. I am guessing most of us have experienced budget cuts in the institutions or environment in which we work. Many organizations are looking for ways to remain financially sound and be somewhat prepared for what Health Reform may bring. In an effort to learn how organizations leaders are preparing for health reform 123 health care executives were interviewed. Several of the CEO’s expressed the importance of maintaining a collaborative relationship with physicians especially as budget cuts are considered as the cuts will have implications for physicians. Executives report that they are working on strategies to make the changes that will be necessary in the face of reform. Most executives recognize the need to identify the systems strengths and weaknesses in the current model of care, and create models that are more efficient, accessible and cost effective. The Financial impact that health reform will have on institutions and providers is unknown, many health care providers and executives are trying to prepare for the worst case scenario. Schmidt, R. (2010) Reshaping the healthcare delivery network

Theory of Microeconomics as it Relates to Health Reform Aspects of Micro Economics Economic Changes in the face of Health Reform Evaluates Supply and demand Studies individual purchasing Flow of economic resources Helps determine costs Value Based Purchasing Bundled Payments Increase in Baby Boomer population Accountable Care Organizations Micro Economics can apply to just about anything as that principals primarily focus on supply and demand, flow of economic resources, studies individual pricing which all help to determine the costs of the provided service. In Health Care Reform there it is mandatory that there is a shift in the cost of care and reimbursements. The Demand of health Care is projected to have a large increase due to the amount of baby boomers who will be obtaining medicare services between 2000 and 2050, reaching a high of 87 million people. Suppliers of the increase demand will be scarce. It is also projected that we will continue to experience a shortage of healthcare workers and it is expected to continually get worse. There will be a change in the costs of care, the amount of reimbursements organizations and physicians receive, and the economics of health reform will push provider rates down. Value based purchasing refers to quality driven reimbursement. Micro economics is also used to determine the costs of certain procedures or treatments. A board will determine the amount of money that will be reimbursed to health care providers. The flow of economic resources includes the Accountable Care Organizations we it is a way for health care workers to collaboratively work together to provide care and essentially keep the equity within the ACO. This is a complex issue and it is not yet known how much health reform will effect institutions financially, but there is a lot of preparation taking place between Chief Financial Officers of many organizations. Hart, M.A. (2012) Accountable Care Organizations Hussain, A., Rivers, H. (2009) Confronting the challenge of Long Term Health Care Crisis in the United States MBA Knowledge Base, Micro Economics and Macro Economics 2012

What happens with out Health Care Reform Amount of Americans without insurance will increase Rising healthcare costs Rapid increase in Federal debt Bankrupt Medicare Even with the possible financial burden that Health Reform may have on health care providers and institutions the evidence shows that reform is necessary. We as americans and health care providers can no longer ignore the fact that there are at least 32 million US citizens lacking insurance, people live in fear that their insurance company may drop them in the middle of a medical disaster, there are many uninsured children, and rather than focusing on prevention, many focus on treatment after the illness. It is projected that if Health Reform doesn’t happen that The amount of Americans who are uninsured may soar to 72 million by 2040, which would place a greater financial burden on hospitals and clinics due to delivery of uncompensated care. According to Hussain and Rivers, Medicaid spending would increased to 800 billion and as uncompensated care would increase to 250 billion in the absence of reform. Lastly Hussain and Rivers state that failure to reform HC could bankrupt Medicare with in the next 9 years, which will nearly double the nations 2 trillion debt with in 10 yrs. As all systems begin to fail this will ultimately lead to higher out of pocket costs to the general population, and increased insurance premiums. Due to the needs of our health system, and the benefits, Health Reform must happen to ensure safe, quality and affordable care for all. As we continue on the journey of health reform, we must due any interventions in our power to conserve resources in order to ensure a smooth transition with out significant shortages which may lead to serious medical errors. Nurses must work together in the event of a nursing and all members of the health care team must work together to create the best quality outcomes possible. Hussain, Et al. (2009) Confronting the challenges

Critical Steps to Ensure Success Transform the workplace to focus on Quality Support Nursing School Advancement Implementation of innovative models of care There are critical steps which must be taken in order to be successful with our changing environment. Health Care organizations must use creativity to implement systems to conserve revenue, create a collaborative approach with physicians, nurses and other members of the health care team to ensure quality of care delivery and seek feedback in regards to budget cuts. Institutions and nurses must be proactive in identifying areas of weakness within their current system and brainstorm ideas to rectify them. Steps must be taken in order to retain and recruit nurses and physicians to provide adequate staff to deliver care. Nurses should seek involvement in inter-proffesional teams and look for ways to build on evidenced based practice. Health Reform will focus on transitional care which involves nurse follow up in the home to decrease readmission rates. Advanced practice nurses are in high demand therefore, qualified nurses should seek oppurtunities to continue to a higher level of education to lessen the burden of the physician shortage and provide more access to primary and preventative care. The ACA authorizes financial reimbursements for student loans for nurses who obtain advanced degrees and committ to working in shortage area’s such as nursing education for at least 3 years.

ANA Standards Quality of Practice Ethics Collaboration Environmental Health Quality of practice Uses creativity and innovation to enhance nursing care. Participates in quality improvement activities, using indicators to monitor quality, safety and effectiveness of nursing practice. Implementing activities to enhance the quality of nursing practice Participating in or leading efforts to minimize costs and unnecessary duplication. Analyzing organizational systems for barriers to quality healthcare consumer outcomes. Nurse will use both the ANA standards of Quality of Practice and Collaboration inorder to implement innovative models of care. Through collaboration with all members of the health care team and patients the nurses will ensure positive outcomes for the patient and engage in activities to improve in current processes to create a unified working environment Ethics. Advocates for equitable healthcare consumer care. As a nurse we should want to provide the best outcomes possible to as many people as possible. This support the efforts of Health Care reform and nurses should remain positive and encourage and educate co workers and patients about the changes in our system Collaboration: Partners with others to effect change and produce positive outcomes through the sharing of knowledge of the health care consumer and/or situation. Cooperates in creating a documented plan focused on outcomes and decisions related to care and delivery of services that indicates communication with healthcare consumers, families, and others. Engages in teamwork and team building process Environmental Health: Attains knowledge of environmental health concepts such as implementation of environmental health strategies. Promotes a practice environment that reduces environmental health risks for workers and healthcare consumers. Nurses will engage in services which promote prevention and wellness to the entire population. The health system will likely see a more diverse group of patients to provide care to which will require creative ways to ensure education is delivered and needs are met to prevent readmissions to in patient care facilities. American Nurses Association (2010)

QSEN Standards Patient-Centered Care: Teamwork and Collaboration Safety Evidence Based Practice Quality Care Several QSEN competencies will be utilized as well in order to ensure a smooth transition to health reform. Nurses must engage in patient centered care to ensure positive outcomes. This includes forming an interpersonal relationship with out patients, providing resources necessary for them to be successful and preventing hospital acquired illnesses and exacerbation of chronic diseases such as CHF and HTN to name a few. Nurses must use teamwork and collaboration with their coworkers in order to meet these standards. In addition nurses must create a safe environment by utilizing evidence based practice when delivering everyday nursing care, this will help meet the outcomes desirable for reimbursement for care provided. Quality and Safety Education for Nursing (2012)

Conclusion American’s deserve equal treatment Will produce good quality outcomes May worsen nursing and physician shortage Financial burden on organizations Once reform complete will likely have more positive than negative In a time when our economy is in a recession it is especially important to ensure adequate care for all US citizens. There are many people who are not able to get the medical treatment that they desperately need. The influx in patients will likely worsen the shortage of nurses and physicians but I believe that we as nurses will be able to band together and create the quality outcomes even in area’s that are short staffed. It is rare that I interact with a nurse who comes to work just to work. Most of us put our patients first even if it means we will be getting out late. Some adverse events will be more likely to happen such as med errors due to nurses being in a hurry, however with appropriate interventions this will likely get better. Many organizations are preparing for the initiation, and will likely be more ready for the transformation that we expect. Regardless of the concerns, Health Reform must happen inorder to stop the burden of increased debt and soaring healthcare costs.

References American Association of Colleges of Nursing (2012) Nursing Faculty Shortage retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-faculty-shortage American Nurses Association (2010) Scope and Standards of Practice Nursing (2nd ed.) Silver Springs: MD Cabin, W.D. (2011) Doing more with less. Home Health Care Management and Practice 23(4) 266-270 Cleary, B., Wilmoth, P. (2011) The Affordable Care Act- what it means for the future of nursing. Tar Heel Nurse 8-12. Current Nursing: A portals for Nursing Professionals; Nursing Theories: A companion to nursing theories and models(2011). Retrieved October 11, 2012, from http://currentnursing.com/nursing_theory/Abdellah.htm Dick, A. W., Glance, L.G., Horan, T., Larson, E. L., Mooney-Kane, C., Stone, P.W., Zwanziger, J. (2007) Nursing working conditions and patient safety outcomes. Med Care 45(6) 571-578. Epstein, A., Sommers, B.D., Swartz, K. (2011). Policy makers should prepare for major uncertainties in Medicaid enrollment, costs, and needs for physicians under health reform. Health Affairs 30(11) 2186-2193 Hart, M.A. (2012) Accountable care organizations: the future of care delivery? American Journal of Nursing 112(2) 23-26 Hussain, A., Rivers, P.A. (2009) Confronting the challenges of long-term health care crisis in the united states. Journal of Health Care Finance 36(2) 71-82 Kaiser Family Foundation (2010). Summary of New Health Reform Law. Focus on Health Reform . Retrieved October 11, 2012 from http://www.kff.org/healthreform/8061.cfm Kaiser Family Foundation (2012, July). Kaiser Commission on Key Facts Medicaid and the uninsured. Retrieved from http://www.kff.org/medicaid/upload/8338.pdf Lavizzo-Mourey, R., Rother, J. (2009) Addressing the nursing workforce: a critical element for health reform. Health Affairs 28(4) 620-624 MBA Knowledge Base (2012). The micro economics and macro economics. Retrieved from http://www.mbaknol.com/managerial-economics/the-micro-economics-and-macro economics

References Mcneilly, L., Sutherland-Cornett, B. (2012) Accountable care, value based purchasing outcomes measurement. American Speech Language Hearing Association Leader 10-13. Musanti, R., O’Keefe, T., Silverstein, W. (2012) Partners in caring, an innovative nursing model of care delivery. Nursing Administration 36(3) 217-224 Sanchez, C. (2010). Health law may worsen family doctor shortage. The Tennessean a Gannett Company Schmidt, R., Altus, G. (2010) Reshaping the healthcare delivery network. Health Care Financial Management 64(1) 100-104 Quality and Safety Education for Nurses (2012) Quality and Safety Competencies. Retrieved from http://www.qsen.org/