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In May 2021, the National Academies of Sciences, Engineering, and Medicine released The Future of Nursing 2020-2030: Charting a

Path to Achieve Health Equity. This consensus study from the Committee on the Future of Nursing, 2020- 2030, co-chaired by Mary Wakefield and David R. Williams, builds on earlier work conducted by the National Academy of Medicine and its predecessor, the Institute of Medicine, to study the potential role of nurses in advancing health and health care and the action needed to realize this potential. The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011) and 2016 report assessing progress on the 2011 goals (National Academies of Sciences Engineering and Medicine [National Academies], 2016) focused on identifying expanded roles for nurses and the actions needed to build capacity for nurses to become engaged in and prepare for those roles.

The new report asks, “to what end?” and targets activities and roles for nurses in addressing equity in health care and disparities in outcomes, care, and the upstream sources of disparities. The focus on inequal- ity and equity reflects the increasing attention the National Academy of Medicine has given to health equity and social determinants of health (SDOH), and the Robert Wood Johnson Foundation’s agenda to create a culture of health that provides everyone a “fair and just opportunity for health and well-being,” a plan that has equity at its center (National Academies, 2021, p. 128).

The report embraces a shift from focusing on dis- parities as circumstances requiring downstream reme- diation to having causes that require upstream inter- vention. It identifies inequities in housing, employ-

ment, education, and other precursors to health due to systemic racism and discrimination. It flags inequities associated with socioeconomic status, dis- ability, poverty, limited access to health services, and race, attributing all to systemic and structural causes, not simply individual animus. The report embraces a vision for health systems and healthcare providers to move upstream, to consider how to intervene not just with the patient who presents in the waiting room and while they are in the office or facility, but outside the traditional framework of healthcare delivery, both to prevent illness and disease and treat patients with full consideration of their circumstances.

Tapping Nurses’ Expertise and Experience

Much of the report identifies and discusses pro- grams and activities that can be part of these inter- ventions, both generically and with specific exam- ples. The report notes nurses’ expertise in engaging patients with chronic conditions, coordinating the care of chronically ill patients between the site of care and community and neighborhood resources, leading teams to improve care of high-need, high- cost patients, and working with communities to cre- ate healthy living and work environments. It calls for greater access for populations with complex health and social needs by expanding multiple sources of care and expanded roles of nurses in these settings.

Among the areas for expansion are Federally Qualified Health Centers, retail clinics (often staffed primarily by nurse practitioners), home health and home visiting care services, telehealth services, and school-based health centers (National Academies,

Future of Nursing 2020-2030: Increasing the Focus of Nursing and Health Care on Equity and Discrimination Jack Needleman

The Future of Nursing 2020-2030 report responds to the heightened recognition of systemic racism and discrimination based on ethnicity, gender, and class; the impact of these systemic problems on health and access to health services; and the need for the nursing profession to be deeply involved in addressing these problems.

Economic$ of Health Care and Nursing

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2021). The report identifies school nurses and school nursing as an area of front-line health care, since school nurses help manage chronic conditions and disabilities, address injuries and urgent needs, and provide preventive care and assessments. The report cites the need for improved care management and transitional care. It recognizes care should be customized in collaboration with patients and their families to reflect each patient’s abilities, needs, and preferences, citing research demonstrating the value of person-centered care. And, as in the other areas, the report highlights the role and experience of nurses in providing this care.

Addressing Social Needs

The new Future of Nursing report explicitly dis- cusses how social needs might be addressed in clini- cal and community settings. It calls for increased screening in clinical settings for social conditions, impact of SDOH status, and individual and communi- ty resources that can influence choice of interventions and treatments. It urges more active engagement to address these circumstances through community- based interventions. In the discussion of community- based interventions, the report calls for increases in community and public health nursing and active engagement of nurses and their expertise in interpro- fessional, multisectoral collaborations. Two specific examples of the latter interventions, the Camden Core Model of the Camden Coalition and the American Academy of Nurses’ Edge Runner initiative, are pre- sented.

The Future of Nursing report also discusses the importance of increased engagement of nurses in policy and healthcare governance to increase nurse involvement in effective interventions and to tap nurse expertise in the design and implementation of interventions. But the report is centered on expand- ing interventions to improve equity. A core element of this expansion is assuring these interventions can be paid for and sustained outside of foundation and philanthropic funding models. The issue of funding is addressed in Chapter Six of the report and a com- missioned paper by Needleman (2020). The pay- ment issues discussed can be split into two related but separate questions: What payment models sup- port or facilitate increased health system and nurse engagement in addressing equity and SDOH? What

payment models encourage or create incentives for these interventions?

Payment Systems and Equity

The main form of payment for health services in the United States remains fee-for-service (FFS). Under FFS, revenue is generated through billing for specific services by providers approved to deliver those serv- ices. Concerning the equity agenda, there are multi- ple weaknesses in relying upon payment to support addressing inequity or SDOH. Payment is generally limited to physicians and advanced practice registered nurses (APRNs); billing for services by nurses, social workers, and others for case management and social interventions is minimal. (While some additional billing codes have been created for case management and related services, these services generally cannot be provided by non-physicians/APRNs except when delivered under standard procedures and protocols and when the billing physician/APRN is physically on site.) Billing for telehealth services may similarly be restricted to physicians/APRNs, reducing the potential for follow-up by other care team members. Many key providers in the system, such as school nurses, are not eligible for payment. Community-based outreach and public health nurses may also not be able to bill for services.

Another weakness of FFS is its incentive to increase the volume of billable services provided. Efforts to modify FFS created incentives to reduce total costs per patient. These incentives may encour- age providers to stint care, so they are often coupled with additional incentives to deliver appropriate care. This combination of incentives for cost containment and improved quality form the core of value-based payment, an essential modification of FFS.

The size of the incentives compared to the rev- enue that can be realized from increasing FFS vol- ume will determine whether the net motivation is to reduce cost and improve care or continue to increase volume. The measures in these systems shape provider behavior. There are examples of pri- mary care practices using registered nurses and other case managers to reduce hospital readmissions and other acute services. But the initiatives adopted are often specific to which incentives can be earned, such as reduced hospital readmissions or quality measures tied to particular diseases.

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One program designed to create population-level incentives within FFS is the Accountable Care Organization (ACO) model created by the Centers for Medicare & Medicaid. An Oregon ACO addressing SDOH and health equity is highlighted. But ACOs have weak incentives to promote such policies in general. Entry into the program has not been ran- dom. ACOs serving a higher proportion of racial and ethnic minorities have had lower scores on quality measures. Because the ACO accountability structure is grafted onto the FFS payment system, internal incentives through bonus sharing and coordination can also limit the ability of ACO providers to address the equity plan. The size of the bonuses themselves is a constraint on the resources available outside of the FFS system for program initiatives.

Capitation, per-patient payments, offers robust support for provision of non-billable services or non- billing staff to provide services that can reduce cost or increase quality. Capitation provides the greatest flexibility for health systems to design care processes that reduce high-cost care since actions that fall out- side of traditional billable services can be implement- ed if they will lower costs or promote other organiza- tional goals. Capitation also offers the greatest incen- tives to avoid enrolling high-cost or high-risk patients and stint care, subject only to discouraging healthier patients from enrolling due to a poor reputation. This outcome has led to risk adjustment in setting capita- tion rates to reduce incentives to avoid high-cost patients and value-based payment or incentive approaches to encourage delivering high-cost care. But capitation will address equity and disparities only if it also lowers net costs.

Value-based payment systems, or systems with incentives and rewards, base incentives and rewards on specific measures. Measures define the expecta- tions of care and determine the provider’s focus. If the efforts focus narrowly on standard quality meas- ures such as diabetes control or the patient care experience, other considerations associated with improved population health or reduced disparities in care may not receive attention. None of the current major initiatives encourage or create incentives for interventions to improve equity and address social determinants of care.

Near universal features of the bonuses or pay- ments for high-quality care among the FFS or alterna- tive payment systems are the comparison of quality

across providers and limited social-demographic adjustment for risk factors, particularly community and neighborhood effects. Missing in these systems are adequate assessments of the social determinants of poor health or access to health care, payment adjust- ments to allow more intensive care to these popula- tions, and reviews of performance or rewards based on improvements over time in outcomes for socially disadvantaged people or reducing disparities in care and outcomes.

Given the quality metrics used to direct and incentivize behavior, current alternative payment methods are not well constructed to encourage improving population health, equity, and disparities. While there are actions that can address these issues, some proven, some still being trialed, a payment sys- tem that will support implementation of programs to address disparities and equity should be developed from the inside out, starting with the programs and actions that will improve equity and reduce dispari- ties, and then designing payment methods and incen- tives that will encourage and support implementing these programs and activities. Such programs should recognize the vital role nurses play in implementing actions to respond to incentives and assure payment for engaging nurses and other non-physicians/APRNs in this work.

The Future of Nursing report recognizes current payment limitations and calls for including metrics on equity and reducing disparities in payment systems. It also highlights the importance of expanded funding for school nurses and public health nurses and build- ing payment and programmatic linkages between health and social service providers.

Conclusion

Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity responds to the heightened recognition of systemic racism and systemic discrim- ination based on ethnicity, gender, and class. The report recognizes the impact of these systemic prob- lems on health and access to health services and the need for the nursing profession to be deeply involved in addressing these problems. These prob- lems cannot be addressed without understanding how the economics of care delivery influence behavior. Payment must be changed to create strong incentives and rewards for actions and activities that

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address disparities and promote equity in health and health care. $

Jack Needleman, PhD, FAAN Fred W. and Pamela K. Wasserman Professor Chair, Department of Health Policy and Management UCLA Fielding School of Public Health Los Angeles, CA Nursing Economic$ Editorial Board Member References Institute of Medicine. (2011). The future of nursing: Leading change,

advancing health. The National Academies Press. https://doi. org/doi:10.17226/12956

National Academies of Sciences, Engineering, and Medicine. (2016). Assessing progress on the Institute of Medicine report the future of nursing. The National Academies Press. https://doi.org/ doi:10.17226/21838

National Academies of Sciences, Engineering, and Medicine (National Academies). (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. The National Academies Press. https://doi.org/doi:10.17226/25982

Needleman, J. (2020). Paying for nursing care in fee-for-service and value-based systems [White paper]. https://www.nap.edu/ resource/25982/Needleman%20Commissioned%20Paper.pdf

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