January-February 1999, VOLUME 25, NUMBER 1
Graduate Nursing Education: The Continuing Challenge
by
Deborah B. Gardner PhD, RN, CS
Assistant Director for
Education and Policy
For over ten years, AACN has fought to establish Medicare support for the clinical education of graduate nurses, but now support for graduate nursing education (GNE) funding is in jeopardy. This is due to increasing pressures to slow the rate of growth in Medicare spending, which includes limiting graduate medical education (GME) funding. To effectively obtain legislative support for GNE, the larger political context surrounding Medicare policy decisions must be understood. The nursing community needs to revise expectations and strategies to leverage this political context.
Congressional Motivations for Medicare Reform
Medicare means many things to many people, such as financial security against acute illness, an income stream that keeps rural hospitals alive, and funding to sustain graduate medical clinical education and nursing clinical education. Medicare spends more than $200 billion a year. Much of the motivation for reform has been financial, as Medicare supports the costs of training resident physicians with GME funds amounting to over $7 billion per year. In 1997, an estimated $290 million supported clinical nursing training. Although future Medicare costs are highly uncertain, experts project a major financing problem.
Short-term reform for Medicare was provided in the Balanced Budget Act (BBA) of 1997, which mandated both federal spending reductions and tax cuts over five years (1998-2002). In the process, Medicare funding was cut and GME was one of the chief targets. A projected oversupply of physicians led to the recommendation of decreased GME funding to reduce this growth. However, the BBA of 1997 also changed GME reimbursement to include non-hospital providers for graduate medical education.
This education policy change acknowledged the shift in health care delivery from the traditional medical model to community and prevention-focused systems of health care delivery. Unfortunately, the new GME policy had the unintended consequence of creating a financial incentive to train physicians rather than advanced practice nurses (APNs). Primary care-oriented APN programs receive most of their clinical education in non-hospital sites. An increasing number of schools of nursing who educate APNs have reported decreased access to community sites.
Current Reform Efforts: The "Premium Support" Model
On January 26, 1999, the National Bipartisan Commission on the Future of Medicare formally unveiled the "premium support" model. Due to the fact that Republicans and Democrats have very different views on how to "fix" Medicare, this premium support model will be used to establish a bipartisan approach for Medicare issues. It is based on a system patterned after the Federal Employee Health Benefits Program. Theoretically, the model would allow for a blend of existing government protections and market-based competition, as well as guarantee financial protection for low-income beneficiaries.
The premium support model also incorporates other ideas that have attracted interest: improvements in the traditional Medicare fee-for-service program, Medigap reform, an expanded Medicare drug benefit, and an increase in the eligibility age for the program. These changes would "modernize" Medicare by providing beneficiaries with more choices of care plans and broader coverage. As consumer advocates for the elderly, the nursing profession is excited over these proposed changes. However, the proposed changes in GME are of great concern.
A separate study group within the Bipartisan Commission focused on GME and proposed that payment for direct medical education (DME) be carved out of the Medicare program. Medicare recognizes the costs of education in two ways: It provides direct medical education payments (DME) to hospitals, faculty salaries and administrative expense, and it provides an indirect medical education (IME) adjustment that reflects the added costs of patient care associated with the operation of teaching programs. Currently, nursing clinical education (entry-level) is funded through DME.
GME costs continue to be a budgetary target. The premium support model would fund DME through the annual appropriations process. If DME is carved out from Medicare, a potential new and stable source of funding for the clinical education of advanced practice nurses would be unavailable. By moving DME into annual appropriations funding, nursing would need to lobby each year for funding that also would compete with the nurse education act (NEA) and NIH funding. Regardless of payer source (Medicare or all-payer pool), federal funding for GME should be made available to support the training of advanced-practice nurses.
Political Competition
Medicare has an unparalleled constituency base, spending money in just about every city, town, and congressional district in the United States. Because Medicare is linked to the larger political process and the stakes are high for everyone, finding common bipartisan agreement to change the structure of Medicare will likely mean delays and slow movement, with perhaps some "pulses" of action to avoid financial crises.
Bruce Vladeck, writing in Health Affairs (January, 1999), describes Medicare as an enormous aggregate of smaller prizes in which the Medicare-Industrial complex politics revolve around very narrow interests. The fact that Medicare makes payments to providers of services, not directly to beneficiaries, creates political power of classic dimensions for Medicare suppliers. Medicare is the largest single source of income for the nation's hospitals, physicians, home care agencies, and clinical laboratories, among others. All of those groups work as energetically as nursing to protect and advance their interests through the political process.
Reframing and Leveraging
Another issue potentially inhibiting support for GNE is workforce projections. For example, in a recent JAMA article (September 2, 1998) is the depiction of an "explosion" of nonphysician clinicians (which includes APNs) as potential competitors in the supply stream of a budget-limited system. This is a similar workforce scenario to that which preceded the reductions for GME in the BBA of 1997. The innovative ability of schools of nursing to produce high quality advanced nurse practitioners cannot be sustained without direct support from Medicare GME.
Currently only six percent of all registered nurses are APNs. The complex needs of Medicare beneficiaries require sophisticated health care providers who can offer preventive and long-term care that is cost effective and complementary to the care provided by physicians. Research that supports the identification of "value-added" skills that APNs provide to consumers is critical to pursue in terms of their contributions to Medicare cost control, patient satisfaction, and clinical outcomes.
It is critical to reframe the increase of nonphysician clinicians from an "explosion in competition" to a scenario that promotes the need for a multidisciplinary primary care workforce. Different types of practitioners can fill different ecological niches in the health care system. Overlapping skills and role boundaries are viewed as necessary t o improve health care access and to avoid serious gaps in quality care. Thus, there is a need to develop GME policy recommendations from a multidisciplinary perspective.
Nursing organizations have made strong efforts in the past to gain support for GNE. Once again, defining areas of common agreement within the larger nursing community is needed. Consensus recommendations on key issues that must be linked to GNE policy are: the nursing workforce, the need for a stable source of funding for clinical education, and access to health services provided by APNs to Medicare clients, especially those who reside in underserved areas.
Finally, Medicare reform is critical to nursing on both a personal and professional level. Efforts to move policy that supports the clinical education of graduate nursing education is embedded in broader Medicare policy issues. The time and effort required to move this agenda may depend on the larger political movement of action on the global issues related to Medicare. As the 106th Congress begins, there is work to be done in educating new and old members and sharing concerns from a nursing perspective. AACN remains committed to the GNE issue. Persistent political efforts by AACN members and other nursing organizations to present the GNE issue and recommendations are required to create an opportunity for successful policy change.
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