Monday, June 15, 2009

Enough About the Doctors. . . .What Do Nurses Think About Health Care Reform and Why We Should Listen to Their Ideas.

Last week, the media covered with much fanfare the American Medical Association's disagreement with the idea of a federally administered public plan option as a part of health care reform. President Obama promised to implement a public plan during his campaign, but he seemed to back away from the idea earlier this year. Recently, however, the President, backed by many Democrats in Congress, reiterated his support for a public plan.

The AMA's rejection of the public plan puts this powerful doctors' lobby in direct opposition with the President. The AMA, insurance companies and Republicans oppose a public plan. Republicans have waved the red flag of "socialism" in their rhetoric denouncing a public plan. Insurance companies are clearly concerned about having a deep pocket competitor that could reduce costs to plan participants and drive down their own profits. Doctors are also concerned about the bottom line. They believe that a public plan would draw people away from private insurance, and that the plan would offer them lower rates of reimbursement relative to private health insurance.

What About Nurses?
Media outlets have paid very little attention to another important group in the delivery of health care: Nurses. Indeed, nurses probably have more "contact hours" with patients than doctors, and they serve a vital role in the delivery of health care.

Historically, however, nurses have suffered from pernicious societal stereotypes and unequal power, relative to doctors and other professionals. The nursing profession is predominately female. On average, nurses have less educational training and wealth than doctors. These factors undoubtedly cause policy makers and the media to ignore the thoughts of nurses regarding important health care issues.

Although the media have largely overlooked the opinions of nurses regarding health care reform, nursing organizations have proffered reasoned and legitimate positions on the subject that warrant intense consideration. Because nurses have a much smaller pecuniary stake in the outcome of many reform proposals, their positions might reflect patients' and the public's interests more accurately than the views of doctors and insurance companies, which are undoubtedly influenced by personal financial considerations.

Public Plan
There are several unions that cater exclusively to nurses. Nurses are also members of general labor unions. Using the position of these unions as an indication of what nurses favor, it appears that nurses disagree with doctors on the issue of a publicly sponsored health plan.

The California Nurses Association and its national arm, the National Nurses Organizing Committee, represent 80,000 nursing professionals in 50 states. CNA/NNOC will become the nation's largest nurses union, after it merges with with the Massachusetts Nurses Association and United American Nurses. Following the merger, CNA/NNOC will represent 150,000 nurses. The CNA/NNOC supports "universal health care" in the form of a "single-payer style system." CNA/NNOC has been a strong advocate of a single-payer system and recently testified before Congress in support of this policy reform.

The Service Employees International Union is a general labor union that represents 80,000 nurses. Although SEIU and CNA/NNOC have experienced bitter clashes in the past regarding policy, the two organizations have "buried the hatchet" and have agreed to help unionize workers in the nation's largest hospital systems. Under this joint effort, nurses will join CNA/NNOC, while other hospital personnel will join SEIU. The organizations, however, plan to create a "joint union of registered nurses" in Florida.

SEIU, like CNA/NNOC favors a single-payer public plan option. Indeed, SEIU, along with the American Federation of State, County and Municipal Employees, dropped out of government-sponsored health care negotiations because it feared that other members of the consensus group would reject a public plan option.

The American Nurses Association (a professional association -- rather than a union) represents the interests of the nation's 2.9 million registered nurses (RNs). Last week, the ANA responded to the AMA's rejection of a public plan option with a critical press release that includes the following language:
The American Nurses Association . . . believes the best way to achieve its overall health system goal – guaranteed, affordable, high-quality health care for all – is through the inclusion of a public health insurance plan option in any health care reform legislation. ANA is deeply disappointed to learn of the American Medical Association’s position that private health insurance alone should dictate coverage options for all who don’t qualify for existing public plans, such as Medicare . . . .

A public health insurance plan would expand choices and help protect against potential economic calamity for individuals or families who are not satisfied with their current health coverage, have difficulty paying for their health care, or cannot find
affordable coverage. ANA supports President Obama's call for a public plan option, and applauds its inclusion in Senator Kennedy’s comprehensive health reform legislation introduced June 9.
Although the media rushed to cover the AMA's dissent from President Obama's plan, it failed to give equal time to the ANA and to other nurses associations that offer a contrary view among health professionals. The uneven coverage deprives the public of access to diverse viewpoints and important information regarding this critical subject.

Nurse-Patient Ratios
CNA/NNOC has also been instrumental in pressing states to lower the ratio of patients to nurses. CNA fought a tough 12-year battle to legislate reform in this area in the State of California, even suing Governor Schwarzenegger who tried to kill the statutory requirements once he became governor. The California courts, however, ruled that Schwarzenegger exceeded the scope of his authority as governor.

Presently, bills are pending in both the House and the Senate which would enact new staffing ratios throughout the nation's hospitals. Representative Jan Schakowsky introduced the House measure (as she did in previous years), while Senator Barbara Boxer sponsored the Senate bill. In addition to mandating a reduction in staffing ratios, the proposed legislation contains "whistleblower" provisions that would protect nurses who report noncomplying facilities.

Nurses stand to gain more from the reduction of staffing ratios than from other issues related to health care reform. Thus, they are not exactly "unbiased" parties to this subject. Nevertheless, the staffing ratio issue raises interesting questions that should inform the broader topic of health care reform.

Much of the debate over health care reform has centered around the need for cost reductions. Hospitals, understandably, oppose reducing staffing ratios on the grounds that this will increase their costs. CNA/NNOC, however, cites to several studies (in a neatly prepared brochure), which indicate that reforming staffing ratios by reducing the number of patients per nurse will ultimately decrease costs.

The research concludes that the present ratios overburden nurses and lead to costly medical mistakes. If nurses could spend more time in direct contact with individual patients, they could diagnose and treat (or seek treatment for) conditions in their patients, which would reduce preventable deaths, the need for return visits, and the expense of subsequent treatment. The research also links high turnover rates among nurses to high patient loads. Reforming staffing ratios could reduce the costs that hospitals spend to replace nurses, pay existing staff overtime, or to hire temporary nurses to cover shortages. Nursing professionals, however, do not hold uniform positions on the benefits of mandatory national staffing ratios (See: American Nurses Association - Mandatory Hospital Nurse to Patient Staffing Ratios: Time to Take a Different Approach).

Closing Thoughts
Although this essay finds substantial disagreement among leading nurses unions and doctors' representatives, exceptions to this general pattern exist. Physicians for a National Plan and Doctors for America, for example, support universal health care and a public plan, but these groups are much smaller and probably less powerful than the AMA. Some opinion polls, however, indicate that the majority of doctors and the American public favor a government-sponsored insurance plan.

The public plan opposition legitimately questions the impact of such a plan on the quality of care. This question seems relevant to and appropriate for every health care reform issue. But arguments related to the loss of profits for insurance companies ring hollow. Health care costs represent an enormous drain on individuals, business and society. If competition generated by a public plan could reduce these costs, then, as a matter of a longterm investment in society, a public plan seems like a valid and sensible policy.

If Congress creates a new public plan, insurers will have to lower their own costs, face reduced profits and adjust like every other sector in this changing economy. The nation should not compromise its economic and medical health in order to fatten the coffers of insurance companies and doctors. The country can and should ask the same of insurance companies that it has demanded of General Motors, Chrysler, and American consumers.

Update: This article was edited to include the views of the American Nurses Association regarding the "public plan" debate.


Calif. Nurse said...

Thanks, Professor Hutchinson for thinking about nurses. There is a lot of information on the web about patient ratios. This is a necessary investment in the future of our nation. Also, I agree that it is bogus for companies to resist a public plan because of competition. We have public schools. Health care is just as important. We must do better as a nation. Thanks.

Doctor Feel Good said...

I am a doctor, but I am one of those doctors who support the public plan. I work in an inner-city hospital, and I do this for public service, not for money (although I am fairly well off). It is vital for the country that everyone have access to health care, including poor people of all races and rural communities. We cannot let this opportunity escape us.

PS: Thanks for giving kudos to nurses. They are essential to health care.

Darren Lenard Hutchinson said...

Calif. Nurse and Dr. FG: Thanks for your replies. I am very committed to this issue, and I learned a lot researching it. I hope you will return to make additional comments.

FLRN said...

Darren - Your analysis is correct - nurses have very little financial stake in the decision making process so it would be wise to look at motivation - the desire to "care" for the patient. We spend 12 + hours a day seven days a week with our patients, providing care to the most vulnerable members of our society - those that seek tertiary care. To understand the vista without $$ clouding the issue ask those doing the work and benefiting the least- the RN. Single payer systems already exist - VHA is a cornerstone example of socialized medicine.

The alternative has been less than appealing. In the 1990's The Medicare Prospective Payment System and DRG reimbursement process, blind to the work of the nurses, cut revenue payment to the facility and the doctor, making a decreased length of stay the focus of acute care. What is the real impact of private insurance plans on patient safety? - Nurses will tell you private insurance can be a threat to patient safety and survival in the acute care setting as patients are pushed to transition before they are ready to move to lower levels of care then to home. Yes it does inspire competition, but sick patients have no benefit in this situation as hospital industry also responds to the PPS by reducing staffing and replacing professional nurses with unlicensed personal - illustrating the industry itself did not recognize the crucial function of nursing role in acute care.

Few ask nurses for their opinion because they are unsure how to process the reality of our perspective. Nurses are the largest group of healthcare professionals and until lately we have had the quietest voice. Every American at some point in their lives has received care by NURSE. We are the common denominator and health care hinges on nursing intervention. From our perspective the American Healthcare system is broken in many different directions and will require a collaborative effort to rebuild an industry that today offers high cost health care with no assurance of quality or safety.

Nurses have watched as adverse events, medical errors and more than 7,000 preventable deaths occur each year. Unsafe staffing levels and inadequate ancillary support in the care environment leaves the patient's family filling the gap. Nurses have been forced to take unsafe assignments, work long hours and find themselves in impossible and abusive situations daily. Patient safety has taken a backseat to length of stay and rising costs that have hospitals scrambling to address liability and containment as a business plan, all the while paying lip service to quality and patient safety. We watch as patients struggle to afford their medications and neglect costly interventions as they balance feeding their families against paying for private health insurance plans that do not ensure access to care.

The American consumer pays the bill today for a health care system crumbling under the largest and longest nursing shortage in our history. Perhaps no one has asked the nurse because they can't find them as across the country nurses, forgotten by the safety net, have voted with their feet and have left the bedside.

Any healthcare reform must address all the issues - the most successful plan will be that which protects the patient, provides safety and addresses the role of the nurse to provide care assessment, intervention and advocacy for the patients and their families by ensuring access to care for every American citizen

Darren Lenard Hutchinson said...

Go, FLRN! We are all paying for a system that does not provide preventive care to all people, covers many people in expensive emergency room settings, and which fails to connect patient to family/friends and community. I agree with your assessment that nurses have a lot to say and do on this issue. I am happy to see nurses participate in the debates, but I hope that their contribution will last beyond this year's discussions. These are ongoing issues!

Nurses For Change said...

Thank you for this article. Nurses have a range of opinions on the issue of health care reform, however, most nurses feel that they want a system that best serves the needs of patients.

Our system today serves corporate greed. The system can be designed to profit from illness.

The system must address disparities in outcomes along the lines of race and class.

Stray Yellar Dawg? said...

Thanks for this. I had, somehow, missed it.

My own opinion... as a nurse... is not far from the ANA's. I recently wrote about it in my blog.

I believe that there should be a basic level of care afforded all American's. And that we, the taxpayers, should be willing to pick up that tab.

I also believe there can be "free market" health care.... to the extent that folks wish to pay for care over and above that which is considered "basic."

The devil is in the details.... What *is* basic care? And what is above and beyond "basic care." If we allow nurses at the decision table ... we can remove a whole lot of ulterior motive and behind the scenes dealing. Why? Nurses are, by and large, not paid based upon what is "covered" and what is not. (As are physicians and pharmaceuticals companies.)


Alas, we are heading down just the wrong path, IMO. When you have Big Pharma running ads in favor of a plan.... that can't be good.

Baby Doctor said...

Professor Hutchinson,

As a practicing primary care physician for almost two decades, I feel compelled to correct some of your misstatements.

First, the American Nursing Association does not "represent the interests of the nations 2.9 million registered nurses...". This is patently false and, unfortunately, a myth that President Obama continues to propagate (see any of his recent speeches). The ANA has a relatively small membership, only ~ 180,000 according to themselves, and this number is likely overstated. Likewise, the American Medical Association has a membership that is a fraction of the total physicians in this country (~ 200,000 and falling fast.)

When President Obama says the AMA and ANA are "onboard" with his plan for health care reform, and that they represent "millions" of doctors and nurses, this is an outright fabrication.

By the way, a huge problem for physicians in primary care is the lousy reimbursement we receive from Medicaid or Medicare. My practice is 60% Medicaid and I only get ~ 40 cents on the dollar versus those evil insurance companies. If I open my practice to more medicaid-style reimbursement, I wouldn't be able to afford my exceptional nurse (they are the hardest working parts of the health care system, BTW). Although I am not involved in Medicare patients, no adult PCP in my town is taking new Medicare due to lousy reimbursement.

If "health care reform" involves more Medicaid/Medicare levels of reimbursement, patient access to doctors will plummet.



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