Assigment .Apa seven . All instructions attached.

1

Policy Literature Review: Impact and Advocacy in Healthcare Legislature

Student Name

Miami Regional University

MSN5400

Dr. Suarez

Date

Policy Literature Review: Impact and Advocacy in Healthcare Legislature

Healthcare legislation is a major component of the effort to address system issues, build the system, and improve patient outcomes. In the last decade, escalating costs of healthcare and surprise billing have been the forces driving change. This paper aims to assess the No Surprises Act (NSA), which was signed into law in December 2020, and whose main aim is to protect patients from balance billing from out-of-network services in emergencies or at in-network facilities. The NSA not only bans balance billing but also requires additional reporting of the healthcare costs. The review includes articles, statistics, and the primary responsibilities of nurses in promoting and implementing this revolutionary policy.

Overview of the No Surprises Act (NSA)

The NSA addresses a pressing issue in the U.S. healthcare system: surprise medical billing. The shock bills arise when an insured patient seeks medical attention from a health care provider that is not in the insurance network and the patient is charged highly. It protects patients from shocking bills from out-of-network providers when they are encountered in the course of emergencies, or even when confined to in-network hospitals. It prohibits balance billing on the covered service; ensuring that patients only pay for cost-sharing for in-network services. The Act also establishes an independent payment dispute resolution between the providers and the insurers. It requires that healthcare providers give consumers cost estimates before services and insurers to explain policy benefits and costs to consumers.

Literature Review

In his article, Colla (2021) examines the essence of surprise billing based on issues of cost to patients and the issue of pricing. The article shows how these issues are addressed by the No Surprises Act, which prohibits bills for emergency and in-network services and adds arbitration of the provider-insurer disputes. Colla also notes that, cost control, patient safety, and provider independence are not easy to achieve. Despite the advances, the article cites issues in its enforcement and stakeholder consistency, arguing that on-going assessment is critical to effectiveness in enhancing patient outcomes (Colla, 2021).

Hoadley et al. (2022) evaluates the impact of the No Surprises Act mostly concentrating on the enforcement to protect the patient from balance billing. In their article, they assessed an extent to which the act has raised the consciousness of cost by patients and financial viability of emergency and in-network facility care. The authors also pointed out difficulties connected with the act, such as difficulties with arbitration and possible disadvantages, which are higher premiums or deterioration of the relation between providers and insurers. But, their research affirms that policies like the NSA are useful in reducing the gap of the cost of healthcare by establishing a more certain cost.

Lieneck et al. (2023) performed a systematic review of the studies on the views of the stakeholders and their concerns related to “No Surprise” billing in the United States before and after the implementation of the No Surprises Act. The study also highlights on the efficiency of the Act in dealing with matters concerning out of network charges, financial responsibility as well as patient trust in the health systems. Nevertheless, the authors pay attention to problems such as time consuming, administrative procedures, the growth of the complexity of arbitration, and the on-going battle between the providers and insurers (Lieneck et al., 2023). Several stakeholders raised their concerns on the compliance cost and on possible side effects, including rising of premiums (Lieneck et al. 2023). The review finds that, although the No Surprises Act targets important patient protections, sustained engagement of the relevant stakeholders and policy updating are needed to reassure proper functioning of the new legislation.

Long et al. (2022) investigates the occurrence of surprise out-of-network billing in hand and upper extremity trauma patients. They found out that the majority of such patients receive unexpected charges from out-of-network practitioners even if they are admitted in in-network hospitals. The authors describe the issue of high costs and the lack of clarity in the financial aspect for patients. Their findings stressed on the importance of the legislations like No surprises act in safeguarding the patients against surprise billing as well as guaranteeing that patients have predictable charges in the emergency and in specialty care.

Statistical Data and Health Outcomes

Surprise billing impacts about 20% of emergency department encounters and 16% of in-network hospitalizations with an average out-of-pocket cost of $750 to $2,600 per patient per year (CMS, 2022). These bills especially affect the uninsured and patients in rural communities whereby patients are restricted to the providers’ in-network. According to the data, after the NSA enactment, there is a 27% decrease in a patient’s self-reported surprise bills in the first year (Hoadley et al., 2023). Also, the study established that low-income families had improved timely care-seeking behaviors by 15% in terms of improved financial status and access. Minority groups were more likely to find themselves in the situation of receiving surprise bills before the involvement of the NSA, because of their use of emergency services and their underinsurance. But data collected after implementation reveal a sharp decrease in the financial complaints of these groups, thus suggesting that the disparities have decreased.

Nursing Role in the Legislature

Advanced practice nurses (APNs) and nursing organizations have been at the forefront in advocating for, and supporting healthcare legislation. For example, APNs who have more profound clinical experience and knowledge of the healthcare system were instrumental in demanding the No Surprises Act. They explained how balance billing during emergencies is prejudicial to the patients, especially the critical ones (La Forgia et al., 2021). The APNs have also been engaged in the provision of information to the policymakers on the effects of out-of-pocket expenses on the health of patients and care. Because of direct patient care and advocacy, APNs have been able to educate the legislators on the need to protect the financial aspect of a patient.

Moreover, professional nursing associations including the ANA and NNU have been leading the campaign for patient directed legislation. Such organisations joined other health care stakeholders and patients’ advocacy groups to advocate for the enactment of the No Surprises Act (La Forgia et al., 2021). Also, through mobilizing the nurses’ constituency with lobbying campaigns, organizing and testifying before legislative bodies, these organizations have enshrined policy influence for the nursing profession. They were able to shed light on how much those surprise bills have cost patients financially and advocate for the laws that would protect consumers.

Nursing leadership has played a major role in the development of the formulation of health policy through advocacy and participation in policy making processes. Nurse leaders used their expert opinion and contacts with lawmakers to support the provisions of patient safeguards in the No Surprises Act (Inayat et al., 2023). In this regard, they encouraged the important conversations in reference to health care accessibility, which costs the marginalized part of the society heavily. Nursing leadership has also strived to make the implementation of the legislation to meet the care delivery needs so that the patient’s protection is well implemented across the contexts.

Conclusion

The No Surprises Act has been an important step toward addressing disparities and financial cliffs providing crucial consumer safeguards from unexpected out-of-network bills. Drawing from empirical literature, it can be clearly ascertained that this legislation has brought about improvement of patient health by decreasing the out-of-pocket expenses hence enhancing trust and stability in health systems. The active participation of nurses in this policy, especially advanced practice nurses, insists on the importance of the nursing profession in current health care reform. Nursing leadership must continue its role as advocator and policy maker to ensure that legislation remains accountable, fair, transparent, and patient-centered to meet the needs of health consumers especially the vulnerable ones.

References

Centers for Medicare & Medicaid Services (CMS). (2022). Millions of People Shielded From Surprise Medical Bills in 2022. Retrieved from https://www.hmpgloballearningnetwork.com/site/frmc/news/millions-people-shielded-surprise-medical-bills-2022?amp=

Colla, C. (2021). Surprise billing—a flashpoint for major policy issues in health care.  JAMA,  325(8), 715-716. https://jamanetwork.com/journals/jama/article-abstract/2776697

Hoadley, J., & Lucia, K. (2022). The No Surprises Act: a bipartisan achievement to protect consumers from unexpected medical bills.  Journal of Health Politics, Policy and Law,  47(1), 93-109. https://read.dukeupress.edu/jhppl/article-abstract/47/1/93/174073

Hoadley, J., Lucia, K., Volk, J., Walsh-Alker, E., Swindle, R., & Wengle, E. (2023, April). No Surprises Act: Impact and implications. Center on Health Insurance Reforms, Urban Institute. https://www.urban.org/sites/default/files/2023-04/No%20Surprises%20Act%20Perspectives%20on%20the%20Status%20of%20the%20Consumer%20Protections%20Against%20Balance%20Billing.pdf

Inayat, S., Younas, A., Andleeb, S., Rasheed, S. P., & Ali, P. (2023). Enhancing nurses’ involvement in policy making: A qualitative study of nurse leaders.  International Nursing Review,  70(3), 297-306. https://onlinelibrary.wiley.com/doi/abs/10.1111/inr.12828

La Forgia, A., Bond, A. M., Braun, R. T., Kjaer, K., Zhang, M., & Casalino, L. P. (2021). Association of surprise-billing legislation with prices paid to in-network and out-of-network anesthesiologists in California, Florida, and New York: an economic analysis.  JAMA Internal Medicine,  181(10), 1324-1331. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2782816

Lieneck, C., Gallegos, M., Ebner, M., Drake, H., Mole, E., & Lucio, K. (2023, March). Rapid review of “No surprise” medical billing in the United States: Stakeholder perceptions and challenges. In  Healthcare (Vol. 11, No. 5, p. 761). MDPI. https://www.mdpi.com/2227-9032/11/5/761

Long, C., Zhang, G., Sanghavi, K. K., Qiu, C., Means Jr, K. R., & Giladi, A. M. (2022). Surprise out-of-network bills for hand and upper extremity trauma patients.  The Journal of Hand Surgery,  47(12), 1230-e1.

Policy Literature Review Rubric

1

Policy Literature Review: Impact and Advocacy in Healthcare Legislature

Student Name

Miami Regional University

MSN5400

Dr. Suarez

Date

Policy Literature Review: Impact and Advocacy in Healthcare Legislature

Healthcare legislation is a major component of the effort to address system issues, build the system, and improve patient outcomes. In the last decade, escalating costs of healthcare and surprise billing have been the forces driving change. This paper aims to assess the No Surprises Act (NSA), which was signed into law in December 2020, and whose main aim is to protect patients from balance billing from out-of-network services in emergencies or at in-network facilities. The NSA not only bans balance billing but also requires additional reporting of the healthcare costs. The review includes articles, statistics, and the primary responsibilities of nurses in promoting and implementing this revolutionary policy.

Overview of the No Surprises Act (NSA)

The NSA addresses a pressing issue in the U.S. healthcare system: surprise medical billing. The shock bills arise when an insured patient seeks medical attention from a health care provider that is not in the insurance network and the patient is charged highly. It protects patients from shocking bills from out-of-network providers when they are encountered in the course of emergencies, or even when confined to in-network hospitals. It prohibits balance billing on the covered service; ensuring that patients only pay for cost-sharing for in-network services. The Act also establishes an independent payment dispute resolution between the providers and the insurers. It requires that healthcare providers give consumers cost estimates before services and insurers to explain policy benefits and costs to consumers.

Literature Review

In his article, Colla (2021) examines the essence of surprise billing based on issues of cost to patients and the issue of pricing. The article shows how these issues are addressed by the No Surprises Act, which prohibits bills for emergency and in-network services and adds arbitration of the provider-insurer disputes. Colla also notes that, cost control, patient safety, and provider independence are not easy to achieve. Despite the advances, the article cites issues in its enforcement and stakeholder consistency, arguing that on-going assessment is critical to effectiveness in enhancing patient outcomes (Colla, 2021).

Hoadley et al. (2022) evaluates the impact of the No Surprises Act mostly concentrating on the enforcement to protect the patient from balance billing. In their article, they assessed an extent to which the act has raised the consciousness of cost by patients and financial viability of emergency and in-network facility care. The authors also pointed out difficulties connected with the act, such as difficulties with arbitration and possible disadvantages, which are higher premiums or deterioration of the relation between providers and insurers. But, their research affirms that policies like the NSA are useful in reducing the gap of the cost of healthcare by establishing a more certain cost.

Lieneck et al. (2023) performed a systematic review of the studies on the views of the stakeholders and their concerns related to “No Surprise” billing in the United States before and after the implementation of the No Surprises Act. The study also highlights on the efficiency of the Act in dealing with matters concerning out of network charges, financial responsibility as well as patient trust in the health systems. Nevertheless, the authors pay attention to problems such as time consuming, administrative procedures, the growth of the complexity of arbitration, and the on-going battle between the providers and insurers (Lieneck et al., 2023). Several stakeholders raised their concerns on the compliance cost and on possible side effects, including rising of premiums (Lieneck et al. 2023). The review finds that, although the No Surprises Act targets important patient protections, sustained engagement of the relevant stakeholders and policy updating are needed to reassure proper functioning of the new legislation.

Long et al. (2022) investigates the occurrence of surprise out-of-network billing in hand and upper extremity trauma patients. They found out that the majority of such patients receive unexpected charges from out-of-network practitioners even if they are admitted in in-network hospitals. The authors describe the issue of high costs and the lack of clarity in the financial aspect for patients. Their findings stressed on the importance of the legislations like No surprises act in safeguarding the patients against surprise billing as well as guaranteeing that patients have predictable charges in the emergency and in specialty care.

Statistical Data and Health Outcomes

Surprise billing impacts about 20% of emergency department encounters and 16% of in-network hospitalizations with an average out-of-pocket cost of $750 to $2,600 per patient per year (CMS, 2022). These bills especially affect the uninsured and patients in rural communities whereby patients are restricted to the providers’ in-network. According to the data, after the NSA enactment, there is a 27% decrease in a patient’s self-reported surprise bills in the first year (Hoadley et al., 2023). Also, the study established that low-income families had improved timely care-seeking behaviors by 15% in terms of improved financial status and access. Minority groups were more likely to find themselves in the situation of receiving surprise bills before the involvement of the NSA, because of their use of emergency services and their underinsurance. But data collected after implementation reveal a sharp decrease in the financial complaints of these groups, thus suggesting that the disparities have decreased.

Nursing Role in the Legislature

Advanced practice nurses (APNs) and nursing organizations have been at the forefront in advocating for, and supporting healthcare legislation. For example, APNs who have more profound clinical experience and knowledge of the healthcare system were instrumental in demanding the No Surprises Act. They explained how balance billing during emergencies is prejudicial to the patients, especially the critical ones (La Forgia et al., 2021). The APNs have also been engaged in the provision of information to the policymakers on the effects of out-of-pocket expenses on the health of patients and care. Because of direct patient care and advocacy, APNs have been able to educate the legislators on the need to protect the financial aspect of a patient.

Moreover, professional nursing associations including the ANA and NNU have been leading the campaign for patient directed legislation. Such organisations joined other health care stakeholders and patients’ advocacy groups to advocate for the enactment of the No Surprises Act (La Forgia et al., 2021). Also, through mobilizing the nurses’ constituency with lobbying campaigns, organizing and testifying before legislative bodies, these organizations have enshrined policy influence for the nursing profession. They were able to shed light on how much those surprise bills have cost patients financially and advocate for the laws that would protect consumers.

Nursing leadership has played a major role in the development of the formulation of health policy through advocacy and participation in policy making processes. Nurse leaders used their expert opinion and contacts with lawmakers to support the provisions of patient safeguards in the No Surprises Act (Inayat et al., 2023). In this regard, they encouraged the important conversations in reference to health care accessibility, which costs the marginalized part of the society heavily. Nursing leadership has also strived to make the implementation of the legislation to meet the care delivery needs so that the patient’s protection is well implemented across the contexts.

Conclusion

The No Surprises Act has been an important step toward addressing disparities and financial cliffs providing crucial consumer safeguards from unexpected out-of-network bills. Drawing from empirical literature, it can be clearly ascertained that this legislation has brought about improvement of patient health by decreasing the out-of-pocket expenses hence enhancing trust and stability in health systems. The active participation of nurses in this policy, especially advanced practice nurses, insists on the importance of the nursing profession in current health care reform. Nursing leadership must continue its role as advocator and policy maker to ensure that legislation remains accountable, fair, transparent, and patient-centered to meet the needs of health consumers especially the vulnerable ones.

References

Centers for Medicare & Medicaid Services (CMS). (2022). Millions of People Shielded From Surprise Medical Bills in 2022. Retrieved from https://www.hmpgloballearningnetwork.com/site/frmc/news/millions-people-shielded-surprise-medical-bills-2022?amp=

Colla, C. (2021). Surprise billing—a flashpoint for major policy issues in health care.  JAMA,  325(8), 715-716. https://jamanetwork.com/journals/jama/article-abstract/2776697

Hoadley, J., & Lucia, K. (2022). The No Surprises Act: a bipartisan achievement to protect consumers from unexpected medical bills.  Journal of Health Politics, Policy and Law,  47(1), 93-109. https://read.dukeupress.edu/jhppl/article-abstract/47/1/93/174073

Hoadley, J., Lucia, K., Volk, J., Walsh-Alker, E., Swindle, R., & Wengle, E. (2023, April). No Surprises Act: Impact and implications. Center on Health Insurance Reforms, Urban Institute. https://www.urban.org/sites/default/files/2023-04/No%20Surprises%20Act%20Perspectives%20on%20the%20Status%20of%20the%20Consumer%20Protections%20Against%20Balance%20Billing.pdf

Inayat, S., Younas, A., Andleeb, S., Rasheed, S. P., & Ali, P. (2023). Enhancing nurses’ involvement in policy making: A qualitative study of nurse leaders.  International Nursing Review,  70(3), 297-306. https://onlinelibrary.wiley.com/doi/abs/10.1111/inr.12828

La Forgia, A., Bond, A. M., Braun, R. T., Kjaer, K., Zhang, M., & Casalino, L. P. (2021). Association of surprise-billing legislation with prices paid to in-network and out-of-network anesthesiologists in California, Florida, and New York: an economic analysis.  JAMA Internal Medicine,  181(10), 1324-1331. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2782816

Lieneck, C., Gallegos, M., Ebner, M., Drake, H., Mole, E., & Lucio, K. (2023, March). Rapid review of “No surprise” medical billing in the United States: Stakeholder perceptions and challenges. In  Healthcare (Vol. 11, No. 5, p. 761). MDPI. https://www.mdpi.com/2227-9032/11/5/761

Long, C., Zhang, G., Sanghavi, K. K., Qiu, C., Means Jr, K. R., & Giladi, A. M. (2022). Surprise out-of-network bills for hand and upper extremity trauma patients.  The Journal of Hand Surgery,  47(12), 1230-e1.