Nurse As Nexus

A More Effective Strategy For Managing Health Care Costs?

In talking with nurses, one of the most frequent concerns they voiced was the feeling of being in a double bind between doing what’s best for their patient and doing what third party payers require to approve reimbursement. They say that rather than cutting costs, some of these measures turn out to be counterproductive and drive costs higher.

“We’re under pressure to send patients home quickly. Even if we have doubts that they are ready to go home, if reviewers decide the criteria wasn’t enough for another day, they cut reimbursement. But, if we send patients home to meet criteria before they are actually ready and they are readmitted within 30 days, reimbursement is cut there, too,” one nurse said.

Another told the story of flying home on a Thursday night because her mother was on a ventilator and her survival was in doubt.

“They removed the ventilator on Friday and told us late Friday evening they were sending her home Saturday morning. We didn’t have medical equipment in place and she was terrified, being so close to death and suddenly being dumped out. But since she was no longer on a vent, they didn’t think another day would be reimbursed. I was a nurse, and scrambled to do what I could. But what do people do if they aren’t nurses?”

Yet another nurse said, “It’s always hard to decide what to do about diabetics who have bladder control problems. If they don’t report that they have a UTI or other condition and are later found to have it, reimbursement can be reduced. You start second guessing yourself. Normally, you’d use a catheter. But diabetics have a high risk of developing UTIs with a catheter. But, if you don’t use one on someone who has bladder control problems, they are miserable, especially since budget cuts have made it harder for fewer nurses to respond to their call bell in time. You have more accidents, more linen expenses, more staff time tied up changing beds, and skin issues start to develop, which can be dangerous in diabetics.”

Measures linking quality of care to reimbursement are now being implemented, and a big part of that is HCAHP scores (Hospital Consumer Assessment of Healthcare Providers and Systems).  Telephone surveys of patients after discharge ask questions like “Did someone always respond to your call button promptly? Was your pain always controlled? Were your medications always explained to you?

“Quality is important, and we want patients to feel they are getting quality care. But if patients don’t report 75% “always,” reimbursements are going to be cut,” one nurse said. “How do we score 75% always when patients may have memory problems, were on medication, have cognitive problems, or are just having a bad day when the interviewer calls?”

Joyce Varner, BSN, DNP, president of the Alabama State Nurses Association, said, “Payers are looking at quality and paying for quality. If we can’t get those HCAHP scores up, smaller hospitals are not going to be able to afford the loss in revenue. Nurses spend more hours in direct contact with patients, and we need to give them more training in leadership and a greater voice is identifying areas that could be better and allow them more initiative in improving quality.”

The association will be offering a leadership camp for nurses to prepare them to take on the expanded roles they will be called on to play in a rapidly changing health care system.

To a great degree, nurses already handle much of the coordination between members of the care team. By upgrading their management skills so they can be the “go to” source for coordinating care, communication can become more efficient and expensive repetition can be reduced.

Nurses already help to prepare patients for discharge and educate them and their families on after care at home. Upgrading this function could help reduce readmissions, reducing costs, preventing loss of reimbursement, and saving patients discomfort and risk.

Nurses are out in the community in schools, work sites and clinics. Increasing their training and competencies in preventive medicine and wellness could help to prevent many costly illnesses or identify them while they are more treatable and less expensive. More advance practice nurses could do the same for underserved communities and bring primary care to millions who do not presently have access. This would help to relieve some of the shortage of and time stress on primary care physicians, expanding the capacity of the health care system to meet the surge in demand over the next few years.

With deficit reduction proposals calling for drastic cuts in Medicare, a recommendation in the Institute of Medicine’s report on nursing is very timely. The health care system should “enable the full economic value of nurses’ contributions across practice settings.”