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Was just reading: “Bringing Values Back Into Evidence-Based Nursing: The Role of Patients in Resisting Empiricism” by Porter, O’Halloran, and Morrow.

What a great article. Nails a number of things that I have been tangentially interested in. Without in any way suggesting a deficit it was interesting to me that little attention seemed to be given to “how” and “why” we got here: How and why we have slipped up and where we must go to get out of the hole so many of us feel.

So here are some additions to their piece.

In our health care (finance) systems here in the US, in Canadian systems, and increasingly in the NHS there is an over-riding issue that propels all care toward the average, or lower. EBN is the perfect manifestation because it suggests that average levels of care are appropriate.

In domestic programs: Managed Care and Capitation, DRGs, the Prospective Payment Systems and in the Canadian and British systems, providers increasingly bear the insurance risks associated with their patients’ health care experiences. The “localization” of decision-making, far from empowering providers or patients, does exactly the opposite, compelling inadequate care and deception in relationships of trust between doctors , nurses, and patients. I call all this “stuff” “Professional Caregiver Insurance Risk.”

But I get ahead of myself. First we must understand what these programs really do and how they affect providers and patients. The key to it all would make Nightingale proud: It is about the mathematics and statistics of health care finance. Large insurers, national health insurers being the best possible example, are incredibly efficient risk managers. Transfer all the insurance risks associated with patient care to national health insurers, along with the premiums paid by patients, and you increase the probabilities that the national health insurer will: Earn profits, Avoid losses, and Avoid insolvency compared with any smaller insurer. Because they are so efficient, national health insurers can also provide higher levels of patient benefits, higher payments to providers, and they require virtually no idled surplus funds.

These things are all important because smaller insurers have much lower probabilities of: Earning profits, Avoiding losses, and Avoiding insolvency, must cut benefits dramatically (On the scale of 50 – 100% for much smaller insurers), and require enormous amounts of idled assets to be properly prepared to meet predictable extremes in operating losses. Of course most insurance risk assuming health care providers are not prepared for anything other than “Average” demands. They cut their costs to the bone, overwork their staff, have no reserves for an epidemic or natural or (wo)man-made disaster. They operate on shoe strings as though that is as much as they ought to be prepared, or asked, to do.

My own analysis focus on the impact of capitation on these operating consequences of “Professional Caregiver Insurance Risk” and the impact inefficient insurance operations have on health care providers, especially nursing.

First, I use “capitation” generically for DRGs, capitation contracting, the Medicare and Medicaid managed care and Prospective Payment Systems, as well as direct capitation transfers insurance risks to health care providers, including hospitals, nursing homes, home health cagencies, Physicians, NPs, RNs… But it also plays out in the evaluation of individual providers at the level of a single nurse, a nursing unit, a hospital, nursing home, home health agency.

“Professional Caregiver Insurance Risk” also applies in “socialized” systems. When insurance risks are de-centralized, such as planned in the Transformation of the NHS, when Provinces are budgeted and their inadequate budgets transferred to collections of providers, it is the “insurance risk transfers” that matter most. All these mechanisms create small, inefficient insurance operations with the problems listed above.

The most egregious aspect of this is that patients do not understand this at all. They feel it – All patients hate managed care. But patients do not realize that their insurance claims agents are the health care providers in front of them. How can patients be “Empowered” in a system based on misrepresenting their experiences as patients – as they are treated as claimants rather than recipients of caring?

If providers obfuscate and patients do not understand that their providers are trying to settle their claims for care, at the lowest possible cost, as any insurance claims agent will try to do, they cannot understand the subtle differences between a relationship with a provider who focuses on their needs, rights, and acts in their interests and a provider who focuses on their own needs to control costs, settle claims, and who is acting in their own self-interest to avoid the negative consequences of being a terribly inefficient insurer?

Providers, especially nurses, must understand the mathematics of health care finance and patient care, the impact of probability and statistics on insurance operations and nursing unit management, and the way these insurance risk transferring mechanisms impact health care systems, themselves and their patients, because in so many cases it is we nurses that make, and communicate, these claim settlement decisions.

If a nurse fails to advocate for a patient who needs to stay an extra day or two, or requires more than average clinical care, or needs to move from a home health setting to a higher level of care, the nurse has denied the patient’s legitimate claim for those benefits. The patient may never even know they had a legitimate claim because patients rely on their caregivers to tell them they have claims.

But, if the nurse does advocate for that patient, honors that claim for benefits, the burden of the financial consequences of that act of appropriate and professional behavior are often borne alone by that nurse. That nurse’s “Costs” are out of control, that nurse provides excessive and wasteful services, that nurse cost the facility thousands of dollars a day in costs and lost revenues.

It is ultimately at bedside where the real costs and inefficiencies of transferring insurance risks to health care providers plays out. In those dramatic decisions: Honoring and paying patients’ claims or not, providing the best care for individual patients, or viewing the average level of care as the highest level of care the patient ought to expect. When our new roles as insurers are understood, everything else falls in to place. EBN is the mechanism of choice to limit patient costs and settle patient claims on the cheap.

Health insurers try to settle all their claims at, or below, average – their own form of EBN. Small insurers expend more effort in this than large insurers because a single large claim, for a small insurer, may mean a year of operating losses, or worse still, insolvency and closure. It is no different when health care providers are their patient’s insurers. A single decision to advocate for a patient may “cost” a nurse and his/her facility tens of thousands of dollars/euros. In a worst case scenario the nurse is held accountable, fired or transferred to an area where they won’t be such a problem.

So, what does one do? We in nursing need to do as Nightingale would do for anything that interferes with our care of our patients and the promotion of their well being and healing: Do the math. Understand how insurance works, how it exists side by side with us in our workplaces, critique the system, and arm ourselves with the facts of our new roles and, ultimately, help our patients understand what is really happening. Knowledge is what empowers us.

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