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

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 we are in.

So here are some additional thoughts on their article.

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 tool for this because it promotes the idea 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 health care (fiance) systems, providers increasingly bear the insurance risks associated with their patients’ health care experiences.

This “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 to smaller insurers, 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. Everyone benefits from national health insurance mechanisms. You can even let private insurers manage the claims as long as they do not profit from over-payments or under-payments.

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 very small insurers), and require enormous amounts of idled assets to be properly prepared to meet predictable extremes in operating costs.

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 no matter how the environment has changed around them.

My own analyses 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 transfers of insurance risks to health care providers through capitation contracts. Capitated, risk bearing providers, include hospitals, nursing homes, home health agencies, Physicians, NPs, RNs…

But the same effects play out in the evaluation of individual providers at the level of a single nurse, a nursing unit, a hospital, nursing home, a home health agency, or a physician.

“Professional Caregiver Insurance Risk” also applies in what seem to be “socialized” systems. When insurance risks are de-centralized, such as planned in the Transformation of the NHS, or when Provinces are budgeted and their inadequate budgets are 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, their rights to care, and a provider who acts in their interests and a provider who focuses on their own needs to control costs, settle claims quickly and cheaply, and who acts in their own self-interest, to avoid the adverse consequences of being a very 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 and patient care management. We must understand how these insurance risk transferring mechanisms impact us, our health care systems, and our 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 us. their caregivers, to tell them when they have legitimate claims for our services.

But, if the nurse does advocate for that patient and honors nursing and that patient’s claim for benefits, the burden of the financial consequences of that act of appropriate and professional behavior are all too 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 expenses as well as the lost revenues another patient may have brought.

It is, ultimately, at bedside where the real costs and inefficiencies of transferring insurance risks to health care providers play out. In those seemingly inconsequential, though 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 patients 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. A nurse in a clinic faces far less risk of encountering a “Medical Outlier,” a high cost patient, than a nurse in an ICU, PICU or CCU.

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: We need to do the math. Understand how insurance works, how it exists side by side with us in our workplaces, critique the health care (fiance) system, and arm ourselves with the facts of our new roles.

Ultimately, we need to help our patients understand what is really happening.

Knowledge is what empowers us all.


8 Comments Post a comment
  1. Sam Porter #

    Very interesting post – its main point that we all should care about how our systems are financed is extemely important. Just makes me more convinced that universal health care, funded by progressive taxation, and free at the point if use is by far the most equitable solution. Sam

    April 3, 2011
    • Yes Sam,

      If I understand the White Paper on transforming the NHS – the ultimate impact will be to de-centralize risk management and leave Trusts to make decisions about how to allocate resources that are going to be both difficult to agree on and hard to implement. Not to say that it won’t proceed – just that patients, nurses and doctors will feel the pain very quickly and once you head down that slope I am not sure how you crawl back.

      The beneficiaries of local control and risk management – whether patients, providers, or profit making entities will fight hard to maintain their advantage, while those harmed will face a stiff challenge in turning back the hands of time.

      April 3, 2011
  2. Robert Newsom #

    HOWDY, BEAR! So this is where to find you these days! I am blogging in other venues besides the Nursing Philosophy Listserv also. Recognize the handsome country gent below, straightening out everyone over the ethics of the “Ashley X treatment ?

    This is a great post!


    July 12, 2012
  3. Hi Bob,

    What a pleasure to read your piece.

    and you are absolutely right, I have never seen a more dignified professor of philosophy save perhaps for Bertie.

    I miss our lively and spirited discourse on the nursing philosophy listserver. It sometimes seems that if you and I aren’t embroiled in a debate there just isn’t any discussion – just posts without responses.

    But no, there isn’t much happening here either. A lot like nursing philosophy, the maximum number of interchanges between specific posters seems to have some sort of cap at about 2-3. 🙂

    But so much for lamentations about deficient interaction.

    I think that on an infinitely long chain of individual instances I would, as you, conclude that individual attention and respect for the differently abled is critical. Unlike you I don’t have the same sort of personal concern though I do certainly have my own selfish concern and a “herd” concern. You have exquisitely addressed the considerations – personal, philosophical, medical, ethical of the individual situation, so I will simply say that by and large I agree.

    I cannot entirely avoid the question of the benefit the Ashleys of the world derive from care. I am sure that it exists and I would go so far as to agree that it is measurable, important, perhaps even crucial to our notions of ourselves as human beings and in this particular case, as nurses. Nurses often treat patients about whom it might be said, they receive no benefit from this care and these resources are better devoted to others. So comatose patients, brain-injured patients, quadralegic patients, the severely and persistently mentally ill who live in a state of constant confusion or delusion…

    As individual situations we can always rise to their care but this often comes about because we focus on these individuals, not herds. Here, just to head off objection to the use of the word herd as though I am applying some lower status to Ashley I am thinking specifically of the term in such epidemiological contexts as “Herd Immunity.”

    Of course we both know from our past discussion of male gentital mutilation [I know you were just waiting for this one :-)], that we disagree about whether non-consenting patients should be operated on, for any reason, when there is a not an absolutely clear, well articulated personal benefit for them, as opposed to only some thin “possible” future benefit for them, or even less acceptable, someone else. You will recall that this was the position that you championed as regards the “possible” future exposure to an STD for an uncertain future female sex partner of a non-genitally mutilated male.

    But, having gotten that off my chest, I will turn away from the consideration of an individual and address some of the issues with regard to “herd” ethics.

    The problem I have, and no I have not figured out a solution for it, though I certainly know one supposed solution that is unacceptable, is that there is another view entirely that is not based on an infinitely long chain of individual instances. It is the view that in a social domain, where resources are scarce, and the care needs of community’s rather than individuals are the focus, one arrives at very different sets of standards.

    This is, of course, of particular interest to me in the realm of capitation – doesn’t the entire universe revolve around capitation?

    Let us advance a few years forward when Kenneth J. Arrow and other luminaries achieve their goal of extending capitation to everyone: Hospitals, Physicians, Nursing homes, Home Health agencies, RNs. LPNs, CNAs, RTs, Psych personnel, etc. A bold time when every health provider and every patient is capitated.

    We no longer have the great spigot in the sky that douses the differently abled with manna from heaven. Instead we have the harried, under-compensated health care providers who labor day in and day out, compromising themselves and their patients.

    Instead of risk management by companies with tens of billions in assets and highly predictable costs, we have a health care provider with a roster of 10,000 – 25,000 patients, operating on the basis of daily cash flows and with virtually no ability to manage higher than average costs for the entire collection of health insurance risks manifest by their patients.

    This provider is doing pretty well, treating the usual assortment of sniffles, sneezes, colds, flus, pneumonias, broken bones and minor surgeries.

    Then out of the blue, our harried provider encounters their Ashley. Since meeting Ashley is an exceptionally rare event for any health care provider, our capitated health care provider has virtually no idea how to proceed. Nor does our health care provider have the inclination, time, talent or ability to learn how to deal with Ashley.

    Our harried, capitated health provider picks up the most obvious information off the first couple of websites that pop up. Some of these are done by real doctors with a variety of perspectives on treatment, some are done by real parents facing the trauma of overwhelming need and inadequate assistance, some are done by predators out to scam Ashley’s family with bogus cures and treatments for whatever ails their Ashley.

    If we put some numbers on this it might make it easier. Let’s suppose that our harried provider’s average patient incurs costs of about $3,000 per year. Some never show up and cost virtually nothing. A few really high cost patients require $50,000 – $250,000.

    Ashley is neither of these. The costs to provde the highest recommended level of care for Ashley exceed $1,000,000 per year. Home care assistants, hospital based care, medications, tube-feeding, durable medical equipment, respiratory therapy, “patterning,” physical therapy, vocational (?) training, relief for over-stressed family members, psychotherapy…

    The costs to provde the lowest recommended level of care for Ashley are close to $0. Do nothing and Ashley will die.

    More to the point, this provider has a total operating budget of $30,000,000 – $75,000,000 per year. In the best case scenario Ashley’s treatment costs are 1/75th of the total resources for all the provider’s patients.

    The more care the provider furnishes to Ashley the less care they can provide to 9,999 – 24,999 other patients. These other patients each have a legitimate claim for an average of $3,000 worth of medical care. If the provider provides the highest level of care to Ashley, each of the other patient’s benefits are now capped at an average of $2,900 – $2,960.

    If the provider provides the lowest level of care to Ashley, allowing Ashley to die, either through willful action or neglect, each of the other patient’s benefits are now capped at an average of $3,040 – $3,100.

    What is the most appropriate course of action for the provider? Should the provider deprive 9,999 – 24,999 other patients of their entitlements to respond to Ashley’s needs? Is there even an ethical scale imaginable that says that each of the non-Ashleys should suffer harm so that Ashley may benefit no matter how great her benefit may be and when you have acknowledged that this benefit is in fact a murky area?

    From the vantage point of herd ethics is it ever justifiable to sacrifice the well-being of most of the individual members, and arguably to sacrifice the well-being of the herd to marginally benefit just one member?

    So, for example, let’s assume a worst case scenario because in the end ethics is never about averages – it is always about what to do when faced with extremes. The lost medical care for the rest of the herd means some services are not provided.

    We could provide Ashley’s care and minimize the impact on the herd and its members, by withdrawing care from say 2-10 other, less seriously ill people, but then we have simply increased the number of people deprived of a significant amount of care.

    So, I would argue, the better alternative is to spread the loss over the entire herd by eliminating some inexpensive services for everyone and my fear is that…


    we are about to get to “Herd Immunity.”

    We may decide that immunization programs are the best place to cut costs.

    Now, if we cut immunizations, or for that matter, almost any other service that might fall under the categories: Public health or Prevention we do so at the peril of the entire herd. Eliminating pneumonia shots for senior citizens and early childhood immunizations expose the individuals who go without to the diseases intended to be prevented and they also open the door to epidemic levels of preventable diease, debility and death.

    So, while I would not want to have to make this decision, as you appear to have to, I would, in my more lucid moments assert that in the final analysis it is the well-being of the herd that is most important and that if a choice must be made between an individual’s well being and the herd’s well being, the good for the individual is overweighed by the collective good for the herd. I would even go further and assert that this is always the case (See below) and unavoidable and we are severely deluding ourselves if we pretend that it is not.

    Yes, it may appear to diminish us for our lack of regard for the humanity of an individual – but the baldest truth is that over any finite period of time there are real constraints on the amount of care available. Unless your nursing home is overstaffed, patients wait to have nurses care for them. The time you spend consoling Ms. Jones for the loss of her husband is balanced by the delay in caring for Mr. Smith who has repeated episodes of fecal incontinence across the hall.

    In long term care these compromises occur a thousand times a day – so frequently that most nurses do not even consider these individual situations as individual ethical choices – it is just “Nursing and patient care as usual” in a busy, long term care setting.

    But if you apply all the same thought and attention to each of these individual situations as you do with regard to Ashley you will see that it is really only how much attention we focus on an individual ethical dilemma – not whether or not we encounter them routinely – that lies at the heart of your argument.

    Substitute any common patient need for the profound needs of an Ashley and attend to it with the attention, insight, compassion, conviction and moral concern you raise with regard to Ashley’s care and you will see that the same applies to withholding the most basic, comfort instilling, anxiety reducing, tender, compassionate, caring for myriad Mr. Smiths.

    IF we lived in a world with infinite resources and we NEVER had to make choices about who to care for and who not to care for I would side with you absolutely – but we do not live in that world and while it is good for us to once in a while stop for a moment, focus on an individual in need, and wrap our brains and souls about what to do next for this individual without letting the needs of others intrude, what we choose to ignore concerns me far more than what we choose to attend to….

    Now, as I say, I have no answer for resource scarcity. We have all gone through a period in which it seemed that almost everyone in the country could have what they wanted: Big houses, big cars, consumer durables and disposables. But this was a shared delusion as we have since come to learn.

    So the one thing we can do, something that every nurse in the world ought to be doing, is rail against the insanity of the capitation system that exacerbates the situation. We, as health care providers have a duty to our profession, to ourselves and to our patients to put our feet down and say: “No, provider risk bearing is unacceptable. No more capitation.”

    I won’t be holding my breath for nurses to actually do this because there is little to suggest that most would care all that much if they did understand what they were doing, and even more are perfectly satisfied to remain ignorant as though it were someone else’s responsibility to bring them up to speed.


    July 13, 2012
  4. melissa ravello #


    September 27, 2012
    • Hi Melissa,

      Might be easier to do so if you explain what you mean. Giving examples of situations in which you think change is needed could be helpful in getting feedback.

      September 27, 2012
      • Thanks for continuing this discussion! I agree, examples of situations is where we have to start in making change.

        September 27, 2012
  5. 🙂

    September 27, 2012

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