Issues Update

Quality Managed Care: A Nursing Prespective

An ANA Committee Takes a Holistic Approach to Reforming Managed Care

by Susan Trossman, RN

Once heralded as the cure for out-of-control health care costs, managed care now needs a remedy of its own -- one that raises its consumer consciousness while retaining its cost consciousness.

So far, several legislative, health care, nonprofit, and business groups have offered proposals to fix managed care by guaranteeing consumers a range of protections. None of the proposals, however, so clearly speaks to ensuring quality health care on so many levels as the strategic plan being developed by a group of RNs for the American Nurses Association.

Known as the Managed Care Working Group, 25 registered nurses, along with ANA president and working group chairwoman Beverly L. Malone, PhD, RN, FAAN, developed a set of consumer-sensitive principles that brings nursing's voice to the managed care debate.

Like other managed care proposals, the ANA's principles address such issues as access, quality, cost-effective care, ethics, and confidentiality. But they go further. They promote an environment that offers culturally competent care, makes consumers shareholders in the health system, assures a safe workplace, and values public health services. "Through the principles, we tell the public clearly that we are their number-one advocate and front-line defense in this machine that is health care," said Patty Koenig, RN, a working group member.

The principles are the heart of a larger document, Nursing's Blueprint for Managed Care, which is expected to be completed in October, according to Kammie Monarch, JD, MS, RN, senior policy fellow of the ANA's Department of Health and Economic Policy.

Because They Know

As front-line workers, nurses understand the complexities of delivering care. Working group members drew upon their experiences in fee-for-service and managed care systems.

"We come from a perspective of knowing ... what happens when someone can't get preventive care or access to any care," said Connie Mullinix, PhD, MBA, RN, a working group member and president of a North Carolina-based health care consulting firm. In Koenig's case, she saw a health care environment that "essentially pushed new mothers and babies out the door in 24 hours or less with 'shrink-wrapped' discharge information."

But when the health care pendulum swung toward fee-for-service insurance plans, expensive procedures like surgery often were the treatment of choice for a range of health problems. Mullinix recalled a case in which a physician immediately wanted to remove a child's tonsils because she was complaining of a persistent sore throat in the morning. The child's symptom actually was caused by a limited fluid intake during the evening to prevent bed-wetting. Her throat was simply dry.

What follows are four of the ANA's managed care principles that show nursing's unique perspective on ways to bring the health care pendulum to the center.

The Needs of the Whole

The health care system must address the health of individuals, families, communities, and populations.

This principle goes back to the roots of nursing, a profession that traditionally has looked at health through a wide-angle lens. "The history of nursing is based on prevention," Koenig said. "When the community health nurse went into the home to check Aunt Hattie, she also discussed the importance of proper handwashing with Uncle Ben." Working group members believe nursing's holistic approach is as relevant as ever.

"There's a mistaken perception that in a managed care environment there's a diminished role for public health," said working group member Mary Ann Christopher, MSN, RNCS, FAAN. "Some cite programs like the Kids Care initiative, which results in more children being insured, as a signal that local health departments need no longer offer safety net clinics. This argument overlooks the reality that there are exclusions to participation in the program, and lack of geographic access to approved providers. Nor are managed care organizations monitoring or addressing the needs of populations in geographic areas; they are serving some individuals within those geographic areas," said Christopher, the chief operating officer for the Visiting Nurses Association of Central Jersey. It's an important distinction.

According to Christopher, a key public health role is spotting health trends by focusing on the aggregate. If, for example, 14 managed care providers split the responsibility of meeting the health needs of a specific community of 100,000, each provider has only a limited view of the total population's health based on each small piece of the community. "The significance of any problem, such as the number of tuberculosis or human immunodeficiency virus cases, is reduced," she said. "So we need a public health infrastructure in place from an epidemiologic standpoint alone."

Registered nurses also want a health care delivery system that will tackle social and environmental issues. "As nurses, we have the responsibility to make sure that public health services are in place to deal not only with communicable diseases, but also social issues such as domestic violence, tobacco use, and alcohol abuse," said Jessie M. Colin, MSN, RN, assistant professor of nursing at Barry University in Florida and practicing home health nurse who helped craft this principle. "If we want a healthy population by the next millennium, we need to make addressing these social issues a priority."

With this principle, nurses also are asking clinicians to take actions to protect the environment, such as reducing the amount of medical waste they produce.

Meaningful Care

Health care services must be provided in a culturally competent and linguistically appropriate manner.

Several managed care proposals, such as U.S. Representative Charles Norwood's (R-GA) Patient Access to Responsible Care Act of 1997, address the issue of nondiscriminatory care, particularly in terms of access. Through this managed care principle, the ANA makes clear that clinicians must be able to communicate effectively with their patients and understand their cultures.

"Nursing is moving this issue to the front of the line," Malone said. "This principle also fits so well with President Clinton's emphasis on eliminating the great disparity between minority and nonminority health." Added Koenig, "The health care industry still has a tendency to back up teaching with printed materials, such as consumer guides to improving health. But what happens when those materials are sent to a Sudanese family who can't read English?"

Working group nurses already have some strategies in mind to achieve culturally competent health care. "This principle doesn't mean that everybody has to begin speaking another language," Colin said. "But health care professionals need to become culturally sensitive. When nurses are culturally sensitive, they take the time to listen and to frame their plan of care in a way that makes it more meaningful for their patients."

Then there is the other side of the equation. "We are also looking to increase the number of minority nurses." Malone said. "Most groups addressing managed care reform don't talk about changing the provider group." To accomplish this goal, the ANA wants greater effort placed on developing more links between academic institutions and health care settings to bolster recruitment, retention, and promotion of registered nurses from "emerging majorities."

Consumers as Stakeholders

Accountability for quality, cost-effective health care must be shared among health plans, health systems providers, and consumers.

Viewing consumers as partners is another nursing approach steeped in tradition. With managed care under scrutiny, many groups are calling for heightened accountability on the part of providers. "But prevention requires accountability on the consumer's part, as well as the provider and the purchaser," Malone said.

Nurses also need to educate consumers about their role in using the health care system effectively. "As home health nurses, we need to work together with patients and their families to make the system financially viable, while providing the maximum level of quality care," Colin said. "But when patients refuse to take some responsibility for their care, this leads to an increased burden on the entire system."

Malone said the real key to this ANA principle is partnership. "How can consumers be partners unless I, as a health care professional, respect them enough to hold them accountable?" she said. But some working group nurses offered this caution: A true partnership needs to exist. "Often health care providers want to force accountability on consumers without looking at them as equals," Christopher said.

Mullinix agrees. "The arrangement of giving care is often a dialogue between the health care professional and managed care provider," she said. "The consumer needs to be included in the dialogue."

A `Safe' Pursuit

While pursuing the reduction of costs in the health care system, the right to a safe and healthful work environment for all health care providers must not be compromised.

"The ANA has been a leader in making sure the work environment is safe," Monarch said. Nurse members already have taken on issues, such as latex allergy, surgical smoke, and workplace violence.

This principle expresses another nursing value, according to Monarch. "Having an adequate number of RNs promotes safety, so patients receive quality care," she said. Statistics bear this out. In 1995 to 1996, hospitals decreased their RNs by 20,000 full-time equivalents, Monarch said. With that reduction, studies show there's been an increase in medication errors, falls, fractures, and waiting time for routine care.

"The notion of what constitutes a workplace needs to be put in a broader context," Christopher added. "In community nursing, many are going into areas where even the police don't want to go." Managed care has looked at ways to reduce direct care costs, she said. Yet insurance providers don't seem to be aware of other costs associated with community nursing, such as the need for beepers, access to portable phones, and, in some cases, escorts. "We need to set up a framework that sets safeguards for our expanded roles in the community," Koenig said. "This is new territory for many of us."

Susan Trossman is senior report for The American Nurse at the ANA.