Vital Signs

Overcoming Managed Care's Quick Fix

by Sara McComber, RN,C

Managed care's impact in acute care has been widely chronicled in reports on such practices as discharging mastectomy patients within a few hours of surgery. Though less publicized, managed care's reach beyond the hospital walls is also of concern. Public health nurses are well aware of the link between individual health and societal concerns. In public health, treating the "disease" can be futile if the underlying causes are ignored.

For example, in my work with adolescents and young adults, I often encounter youths with mental health problems. When a teenager threatens suicide, we all spring into action, desperately seeking to save a young life. The managed care solution is often to place the teen in a facility for one night or to prescribe medication. If longer therapy is approved, it's often delayed for six weeks. Though we may save a child for one night, without addressing the depression that sparked the crisis we may only be postponing a tragedy.

Another clear example of managed care's shortsightedness in public health can be found in its approach to care of pregnant adolescents. While it's commendable and cost-effective for insurance companies to pay for prenatal care for this group, this has only the potential to ensure a healthy birth. It does nothing to prevent future health and social problems for mother and child that could be avoided by nurse visits focused on parenting skills. Teens would benefit for years to come from such help in parenting their children.

In both these instances, public health nurses are hard-pressed to meet the needs of their clients. Managed care tends to look for the "quick fix" instead of the long-term solution, leaving registered nurses with little teaching time for their clients. Staff nurses in hospitals and public health nurses in the community all share in the struggle to provide high-quality care in the face of limited resources. Patients are sicker and they're being sent home earlier. Yet instead of adding RN resources to cope with the mammoth educational needs resulting from early discharges, nurses are having their ranks thinned. Who among us hasn't felt frustrated and alarmed about a patient sent home two hours after a mastectomy who won't be able to drain her wound, or a depressed 15-year-old who might succeed in his next suicide attempt?

For registered nurses nationwide, the solution is clear but far from easy. If we could s omehow summon the energy needed to fight this tremendous undermining of safe, quality care, many of us could face personal sacrifice -- particularly those not protected by collective bargaining contracts -- in our attempts to humanize the corporatization of health care.

Belonging to a professional association has aided me in coping with and addressing the dangerous changes in health care. In fact, the partnership between my state nurses association and the ANA has assisted me in advocating for patients by providing crucial information regarding practice, policy, legislation, and the workplace. This partnership goes a step further by actually advocating on my behalf and on behalf of registered nurses nationwide -- on Capitol Hill, in state legislatures, in the media, and with other professional groups.

My professional association has helped me to analyze the impact of managed care and separate the good from the bad. I've come to believe that managed care can strengthen the nursing role, often making the RN a pivotal person in the health care system. It also has benefited the profession by requiring us to be more engaged in health care delivery beyond our clinical role and to seek to understand the impact of business and policy on our practice. As a result, many of us are effecting positive change in managed care practices.

Yet a lot more must be done. To that end, I have worked as an ANA board member and on the ANA's Managed Care Blueprint Task Force to position nursing as a strong voice in health care. The task force recently completed Managed Care: Nursing's Blueprint for Action, which provides direction for changes in the health care delivery system. (See Issues Update, page 56.)

The understanding and acknowledgment of this blueprint throughout the health care industry will ultimately affect the daily practice of us all. Our goal is to change the course of care for our clients, ensuring that treatment addresses both their problems and the causes behind them. By building a solid foundation on what works in managed care and replacing what doesn't, we may ultimately create a health care structure that meets the needs of all patients. Perhaps in the future none of us will have to choose between what insurance will cover and what a client really needs.

Sara McCumber is a staff nurse at the Arrowhead Juvenile Center, Duluth, MN, and a member of the Minnesota Nurses Association. She serves on the ANA Board of Directors and is a member of the ANA's Managed Care Blueprint Task Force.