NN&I asked Donna Bednarski, RN, MSN, ANP-BC, CNN, Kidney Care Partners consultant for the American Nephrology Nurses Association (ANNA), and Robert Blaser, director of public policy for the Renal Physicians Association, for their thoughts on what the next 12 months could look like for health care reform in the United States.

When President Donald J. Trump took office last year, he brought an aggressive agenda to Washington. Among the items on his agenda was reform of the Affordable Care Act.

NN&I : President Trump has nominated Alex Azar II for the next HHS secretary. What can you tell readers about his views on health care?

Robert Blaser : Azar is a conventional Republican choice with previous work history at HHS, which in the current administration makes him a bit of an outlier. He was a deputy secretary of the agency for 2 years in the Bush administration, so he understands the depth and scope of his responsibilities, which is a positive. More recently he was a high-level executive at Eli Lilly, so again his insight into the management of a massive organization, as well as the internal politics associated with developing, selling and implementing a plan for whichever vision he has for HHS should serve him well.

The conventional Republican part of the equation is on the policy side, where by all accounts he is fundamentally opposed to the Affordable Care Act, believes it has been a complete failure and thus supports full repeal of the ACA. Additionally, he reportedly is in favor of converting Medicaid from the current, more open-ended entitlement model to a block grant system that provides a capped, per capita allowance to the states and lets the state governments determine how to administer the funds. It is a policy opposed by most state governments, whether led by Democrats or Republicans, but one that is supported almost across the board by Republicans on Capitol Hill.

As one might expect, Azar is less concerned about the impact of exorbitant drug prices on the American health system than others, having been quoted as saying “A vigorous and profitable drug industry is not a problem to be solved,” and he accordingly is opposed to price controls for the drug sector. He reportedly is more focused on the insurer aspect of the effect of drug prices on consumers and would seek ways to limit out-of-pocket costs rather than the drug prices themselves.

NN&I : In February 2017, legislation in California called for the establishment of patient-to-staff ratios for nurses, patient care technicians, dietitians and social workers. Do you see other states looking at this idea in the future?

Donna Bednarski, RN, MSN, ANP-BC, CNN : There are currently eight states that have staffing ratios for dialysis clinics. Other states have enacted legislation or regulations that address nurse staffing, not necessarily in dialysis clinics. In addition to mandatory staffing ratios, legislation addresses areas, such as reporting staffing levels, mandatory overtime or the development of staffing committees. Based on the robust activity during the past several years, I would anticipate further activity at the state level in this area.

Mandating staffing ratios are an effective way to ensure adequate staffing and thereby recruit and retain nurses. They may attract new students into the profession. They may prevent nursing burnout, decrease work-related injuries and increase time spent with patients. Mandated ratios are opportunities to provide a safer environment for patients by decreasing risks for infectious disease, missed or shortened treatments, needle dislodgements and hospital admissions.

The concern with mandating staffing ratios is the ability to hire sufficient staff. We have seen decreases in days of operation with the current nursing shortage. Dialysis clinics may need to decrease available shifts/days of operation, require the need to alter the length of treatments, and possibly restrict the number of new patients. The unintentional consequences would be limiting patient choice, including the day/shift to accommodate work/home life, access to alternate modalities, and possibly increase distance to a dialysis clinic.

Another controversial issue is the need for continuous coverage and the need to maintain staffing ratios for all breaks, including bathroom breaks. Do staffing ratios regulations require the need for shifts to be covered every minute?

ANNA has not taken a position on mandated staffing ratios due to the complexity of the issue. Traditional approaches for addressing challenges for safe staffing are not always effective in today’s complex health care environment, which is likely why legislative or regulatory initiatives are increasing.

Are there other opportunities for staffing models? Staffing models need to have the ability to create a more flexible workforce, utilizing a collaborative and even multidisciplinary design to achieve improvement in patient outcomes. To budget and plan for adequate staffing models, looking beyond ratios, consideration needs to account for human capital, patient acuity, staff skill level and experience, work flow processes and procedures that determine the availability of resources, including staffing and scheduling practices.

The American Nurses Association (ANA) supports “state and federal regulation and legislation that allows for flexible nurse staffing plans. In addition to promoting flexible staffing plans, ANA and like-minded constituents support public reporting of staffing data to promote transparency and penalizing institutions that fail to comply with minimal safe staffing standards.”


For more information:
Donna Bednarski, RN, MSN, ANP-BC, CNN, is a Kidney Care Partners consultant for the American Nephrology Nurses Association. Robert Blaser, is the director of public policy for the Renal Physicians Association. Disclosures: Bednarski and Blaser report no relevant financial disclosures.