I was surprised when I returned to graduate school in nursing after 6 years at the bedside to find that my classmates were often fresh out of undergraduate nursing school with no work experience. Aside from feeling like an old lady, I wondered how they would define the nurse practitioner role without having worked as Registered Nurses. In addition, I felt that my experience shaped my desire to work as a nurse practitioner and gave me a strong background in basic assessment and treatment.

The biggest thing that I learned working as a nurse was just how much I didn’t know. And that was a good thing, because I learned that I needed to ask a lot of questions. I also learned that being aware of the limits of your knowledge made you a great nurse. Sometimes I still drive my coworkers crazy with questions about orders, medications, and treatments. But the truth is that there is so much that is not taught in school. Even if one works their whole life at the bedside, one will still not know everything. That is why you have to be able to think critically and ask questions to be an excellent nurse. It is not always what you know that makes you excellent, it is asking about the things you do not know.

Bedside nursing is hard work and many people who choose nursing as a career do not want to do bedside nursing. I understand that, but sometimes my fellow students seem to think they know everything they need to know. Sometimes a lack of respect for experience comes across. I think it is unintentional, but it sure ruffles my feathers. This is what was innocently said to me one day: “I think it will be harder for you to be a nurse practitioner because you will not be able to break out of your RN mindset. Since I never worked as an RN, I will not have that problem and will adapt better to the Nurse Practitioner role.”

We had some nurse executives speak to our class about leadership, ethics, and other current issues in nursing. One student expressed frustration that no one wanted to hire her as an advanced practice nurse because she did not have any nursing experience. She wanted to know why so many employers wanted experience when she felt her education gave her all the qualifications necessary to do the job.  This individual felt that as a nurse practitioner there was no difference in skill between herself and people who have worked previously as registered nurses.  The nurse leaders responded by saying they understood her frustration, but that in advanced nursing roles one needs credibility and that credibility comes from experience.

The ripple of ghastly exclamations practically reverberated through the class. While I empathize with my classmates’ frustrations, I do see the credibility issue present in nursing today. I think there should be opportunities for people who go straight through undergraduate to graduate programs. On the other hand, my experience working also indicates that many registered nurses are very aware of nurse practitioner experience levels. Many nurses say that they can see a big difference between the skills of nurse practitioners who have worked at the bedside and those who have not. I’ve heard nurses who feel that experience at the bedside makes nurse practitioners better also say that it doesn’t take many years of experience to make the difference. One or two years working as a nurse is usually enough for them to see increased competency in nurse practitioners. Whether all nurses agree with that in an idealistic sense, that reality of the credibility conundrum exists. Credibility from experience matters to many nurses and prospective employers. There are many new graduate nurse practitioners who will demonstrate advanced critical thinking skills despite less direct care experience. On the flip side, there are many experienced Registered Nurses who will struggle with the demands of advanced practice nursing. Even with this in mind there is a credibility issue that a lack of experience presents in many clinical settings.

This issue is magnified when new nurse practitioners with no nursing experience do not seem to understand the value of experience.  To express frustration with the challenge of finding a job is one thing, but to state that there is no difference between yourself and a new nurse practitioner with years of experience is another matter.  At times this failure to understand and respect that credibility from experience can be misconstrued as arrogance by other health care providers.

Even if you choose not to get experience before obtaining an advanced degree, I would encourage you to think about the importance of respecting experience. Recognizing that nurses with experience might know and understand things that you do not will go a long way towards those nurses wanting to work with you.  they will also give you respect for knowing the boundaries of your own experience and not equating education with experience.

Which Comes First, Health Care Cost Containment or Access:

Comparing the Health Plan Policies of John McCain and Barack Obama

Either John McCain or Barack Obama will become the next president of the United States in January 2009. According to a recent poll by the Kaiser Family Foundation, “one in four Americans cite paying for health care as a serious problem.” (Kaiser Family Foundation, 2008) Beyond the challenges of American individuals struggling to manage rising health care costs, insurance companies, hospitals, and employers continue to adapt their policies to attempt to decrease the economic burdens of health care. As these stakeholders have responded to rising costs by attempting to shift the cost burden to other stakeholders, the burden that is shifted back on the individual has contributed to increases in the number of uninsured Americans. The recent economic downturn and associated rise in the unemployment rate is associated with an increase in the number of uninsured individuals by a factor of 1.1 million new uninsured for every 1% rise in the unemployment rate. (Kaiser Family Foundation, 2008) The presidential candidates have both articulated health care plans and policies that address health care reform in terms of cost, quality, and access to varying degrees.

Barack Obama and John McCain’s foundational philosophies about health care reform are vastly different. Where Barack Obama aims to reform health care and create affordable, quality health insurance accessible to all Americans, John McCain’s approach is to reform health care by focusing on cost containment measures that will be market driven. While Obama does not articulate his plan as a plan for universal health care, the idea that health care is a human right appears to be the foundation of his plan. Obama’s rhetoric focuses on increasing access through increasing the role of the government in providing insurance along with investments in research, technology, and public health. McCain articulates a philosophy of change that emphasizes shifting control of the system to the individual consumer. In McCain’s health care reform paradigm, shifting control and cost burden to the individual consumer will optimize cost containment. According to McCain’s plan, the notion of moral hazard in our current health care system, where the consumer is shielded from the cost and therefore has no incentive to be cautious in their utilization of services, is a contributor to rising healthcare costs. In comparing the underlying principles without reference to the specifics, one must evaluate whether reform of health care is best accomplished by increasing access or containing costs first. Where Obama’s plan lacks clarity on cost containment, McCain’s plan does not significantly address the issue of access. In terms of the many details of their plans for increasing quality, the candidates are in agreement.

Access

The road to increasing access to insurance for all people is clearly defined in Barack Obama’s plan. Obama’s plan will create a national health plan that people who do not have access to insurance through their employer, cannot afford private insurance, or have not been eligible for coverage can purchase. Obama’s outline indicates that all premiums, co-pays, and deductibles will be “affordable.” According to the outline, those individuals who do not qualify for Medicaid or SCHIP but cannot afford the premiums of the national plan will be eligible for subsidies to offset individual costs. Other aspects of Obama’s plan that are designed to increase access include expansion of eligibility for Medicaid and SCHIP, mandatory coverage for children, creation of the National Health Insurance Exchange as a means of regulating the private insurance market, and inclusion of portability as a component of the national health plan.

While Obama’s plan does not mandate coverage for adults, it does appear that more Americans would have access to insurance through the creation of the national health insurance plan. One area that seems unclear is how well the subsidies would offset costs for families that would qualify. Obama does not dismantle the private insurance system, but would require employers to either provide insurance or contribute towards the costs of the national health insurance plan. The integration of public and private insurance under Obama’s plan makes it appealing, and less likely to evoke strong resistance on the part of big business than a true universal health care plan. In terms of access, Obama’s plan appears to be a true reform, but the implications of this plan for cost control in health care are problematic.

McCain contrasts sharply with Obama over the issue of increasing access to healthcare for Americans, though he has never articulated commitment to universal health care. McCain’s plan does state that they will make insurance more available to individual Americans by lowering costs and increasing portability. According to his outline, he will use tax credits to make insurance more affordable. He will eliminate the employer tax exemption on health care and provide families with direct tax credits they can use to pay for insurance. The idea here is that families will search for the lowest cost plans and this will drive competition in the industry. Employer-based plans are still an option, though. Bob Lazewski has analyzed McCain’s plan and notes, “With the average cost of employer-provided family health insurance at $12,000 a year, a $5,000 tax credit will often come up way short—especially for higher age people and those who don’t have the benefit of an employer contribution.” (Lazewski, 2008) In addition, if an employer pays a portion of the costs, families would now pay taxes on that benefit. In this sense, McCain’s tenet is that he will make health insurance more affordable, which will give more people access. The challenge here is that it is not clear who will benefit from this plan. It depends on how much one earns and the ability to find coverage. (Kaiser Family Foundation, 2008) In addition, there is no requirement of coverage. The McCain plan also emphasizes the use of Heath Savings Accounts, national plans that are portable, and a Guaranteed Access Plan for people who are otherwise ineligible for insurance. The mechanism of the GAP is not well-defined.

McCain’s plan may make health insurance more affordable for some, but the shift from the employer-based system to an individual purchaser system will undoubtedly be a bumpy road. The plan does not address how the uninsured poor will have more access to insurance, especially since the degree to which the costs will be driven down is unknown.

Cost

McCain’s plan is rooted in cost containment. In this sense, his plan does not require significant new expenditures that need to be funded by tax increases. His tax credit will essentially be funded by ending the tax exemption on health insurance benefits. Looking at how his plan impacts stakeholders, it appears as though his plan to drive down costs through competition would decrease costs for some stakeholders to some extent. By placing the burden on individuals, there would be some relief of cost burden for employers who may stop providing insurance and subsidize their employees’ individual purchases. At the same time, McCain’s plan does not articulate a clear mechanism to deal with the impact of the uninsured on hospitals and providers, who then pass the cost of providing care of the uninsured to private insurers. Unless there is flow of new capital into the system by way of more purchasers of insurance or some other means, the cost burden on the private insurers may increase, and then increase costs to individuals whose salaries do not rise at an equal rate. McCain does articulate other cost containment strategies such as: lowering drug prices through reimportation and increased generic availability, emphasizing preventive care and disease management strategies, greater use of information technology as a cost-saving measure, increased use of walk-in clinics in retail outlets, tort reform, and Medicaid and Medicare payment reform. In terms of cost containment, McCain’s plan does have a cost benefit in so far as the implementation of the plan will not produce significant new government expenditure; however, it does not clearly articulate who will have lower heath care costs and to what extent the costs will be lower. The extent to which low-income uninsured will benefit from tax credits depends on several specific details about tax credits that are not stated in McCain’s Plan. (Kaiser Network, 2001) McCain’s plan also does not demonstrate that the cost containment strategies he will implement will be equal or greater to the cost burden of 47 million uninsured on the system.

With respect to cost, Obama’s plan requires extensive government spending to be implemented, estimated at 50 to 65 billion dollars per year according to his campaign website. This cost will be passed on to individuals through the repealing of Bush’s tax cuts. In all fairness, those tax cuts have been noted to primarily benefit the wealthiest Americans. Essentially his plan will infuse cash into the system that will cover many uninsured and increase the number of insured. On the other hand, his other cost containment strategies are not well-defined and are similar to the McCain plan. Obama’s plan also emphasizes cost control through use of information technology and lower drug costs, though he does briefly discuss regulation of unjustified price increases by big business. Ultimately, if the cost of health care itself cannot be reduced through decreased utilization of the system and reduction of administrative costs, covering the uninsured will not be feasible in the long run with tax increases. The bottom line is that Obama’s plan will cover the uninsured which will help reduce the cost burden on hospitals, providers, private insurance companies, and the privately insured, but does not provide well-articulated strategies for controlling costs within the system.

Quality

There are few significant differences between Obama and McCain’s ideas about improving the quality of health care aside from the implications of access or as quality indicators. Both support initiative for preventive care, public health, research, increased use of information technology, and federally supported outcome measurement initiatives. Obama provides more specific examples of the types of quality initiatives he supports, but they are really not espousing vastly different quality improvement strategies other than the ways they relate reform of access and cost issues to issues of quality in health care.

Nurse Practitioners and the McCain and Obama Plans

McCain is the only candidate that gives some reference to utilization of nurse practitioners as a mechanism of improving access and quality when he discusses the use of walk-in and retail clinics, though he does not explicitly state that nurse practitioners constitute a component of the approach. The physician lobby is fairly powerful and both candidates are most likely aware that if they want support of their plans, they will need the blessing of the physician lobby. Even though increased use of nurse practitioners as providers has the potential to decrease costs for Medicare, Medicaid, and the insurance companies, McCain and Obama are not likely to state this in their plans.

Obama’s plan has potential to impact Nurse Practitioners favorably by virtue of increasing the flow of revenue into the system in the form of more insured patients. If nurse practitioners can position themselves as lower cost yet effective providers, they have the opportunity to create jobs for more nurse practitioners and have more money flowing into their pockets. Many nurse practitioners feel that the health of the population is adversely affected by the number of uninsured individuals.

Conclusion

While the lack of cost containment policies in Barack Obama’s plan is a concern, the expanded access that it will provide to uninsured Americans makes it a better plan than John McCain’s plan. I do not think the shift towards a consumer driven insurance market is going to aid the uninsured or be a real cost containment measure unless the shift is coupled to heavy regulation of the insurance industry. Given John McCain’s principles, it is unlikely that he would support increased regulation. Even though Obama’s plan is more costly, I support the repeal of the Bush tax cuts to pay for it and also believe that decreasing the numbers of uninsured will serve as a cost containment measure. Once access is expended, efforts to contain costs can be more focused and refined with the removal of the financial cost of caring for the uninsured. Without expanding access, I do not believe costs will be contained. While expanding access has a cost, it is a cost that also serves the health of the population, which is important. I also happen to support the idea that health care is a human right. Given the current state of the economy, I fear that McCain’s plan will only increase the numbers of uninsured as individuals struggling to make ends meet will be forced to use any tax credits to offset other necessary costs. If that were to happen, the cost burden could continue to be shifted back on the insured anyway. In do not believe the net cost effect on the average insured American differs that greatly between the two candidate health plans. While we may pay in the form of taxes for Obama’s plan, I believe McCain’s plan will probably cost us some employer-provided benefits that will not be made up by increased wages as well us cause increases in hospital costs to cover the uninsured. By failing to address the access issue for uninsured Americans, I believe hospitals and private insurance companies will continue to deflect the cost of care to the uninsured onto the privately insured. The costs associated with either plan are essentially equal in that I believe any health reform will cost me. But my belief that health care is a human right leads me to support Obama’s plan.

References

1. Bodenheimer, T. S. & Grumbach. (2005). Understanding health policy: A clinical approach. Stanford, CT: Appleton& Lange.

2. Kaiser Family Foundation (2008) New Analysis Shows Effect of Rising Unemployment on Health Coverage, Medicaid and SCHIP Spending and Enrollment. Retrieved on 7/13/08 from http://www.kff.org/medicaid/kcmu042808pkg.cfm

3. Kaiser Family Foundation (2008) Tax Subsidies for Health Insurance: An Issue Brief. Retrieved on 7/16/08 from http://www.kff.org/insurance/upload/7779.pdf

4. Kaiser Network. (2001) Presentation Transcript from 4/6/2001: A Briefing on Extending Health Coverage- Tax Credits, Public Program Expansion and Combination Approaches. Retrieved on 7/17/08 from http://www.kaisernetwork.org/health_cast/uploaded_files/kff040601.pdf

5. Lazewski, Bob. (2008) A Detailed Analysis of Senator John McCains’s Health Care Reform Plan. Retrived on 7/12/08 from http://healthpolicyandmarket.blogspot.com/search/label/McCain%20Health%20Plan%20Analysis

6. McCain, John. (2008) Straight talk on health Care System Reform. Retrieved on 7/10/08 from http://www.johnmccain.com/Informing/Issues/19BA2F1C-C03F-4AC2-8CD5-5CF2EDB527CF.htm

7. Obama, Barack. (2008) Plan for a healthy America. Retrieved on 7/10/08 from http://www.barackobama.com/issues/healthcare/

This essay originally written for my advanced practice nursing class on Health Policy and Finance July 23, 2008 at Emory University.

I’m worried about what will happen when one aspect pay for performance in Medicare and Medicaid is implemented this fall. The need for effective cost containment strategies in health care is evident. Neither hospitals, providers, consumers or public and private insurers can afford to continue shifting costs around the system in a financial game of Russian roulette. The government as a public payor via Medicare and Medicaid plans to cut costs by stopping payment to hospitals and providers for treating conditions deemed “reasonably preventable.” Sounds like a good idea, right?

When you read the fine print and then look at it in context with the state of our health care system today, this is another health care cost containment measure that will not really contain costs and will potentially result in hospitals losing money to the extent that they will close. My primary concern is that the hospitals that will not be able to meet these standards are those operating in areas with limited resources, such as those in medically underserved areas.

The six conditions included in the list of reasonably preventable conditions are:

1. Pressure ulcers

2. Catheter-associated urinary tract infections.

3. Staphylococcus Aureus septicemia (really hospital acquired venous access infections)

4. Air embolism

5. Blood incompatibility

6. Object left in patient after surgery

I think that some of these are no brainers. If you have a hospital whose surgical staff has problem leaving objects in patients, they need a serious wake-up call. Likewise, if the hospital continual gives patients the wrong blood type, theses are safety standards that MUST be met at a minimal level and no one but the hospital should pay the bill resulting from that error.

On the other hand, probably more morbidity is associated with catheter associated urinary infections, pressure ulcers, and line infections, but they are harder to prevent. It is also hard to prove causality for these events. Any patient with an indwelling catheter is at high risk for getting an infection, even if the staff does everything within their power to prevent infection. Hospitals will test patients for the presence of these conditions on admission and if any of these conditions are present on admission Medicare and Medicaid will pay for the treatment. If a patient did not have a UTI on admit and gets one during the course of treatment, Medicare and Medicaid would not pay.

This concept is great from the standpoint of the need for quality improvement in care to reduce risks for these conditions. There is not greater incentive for the hospital to get busy with their staff to reduce these theoretically preventable conditions than hitting them with a financial consequence. At the same time the a nursing shortage and a primary care physician shortage make it very difficult for hospitals to reach levels of quality that depend on their staff being able to do everything they should do to provide the best quality care.

Pressure ulcers are preventable when nurses and auxillary staff turn at-risk patients every two hours and ensure that nutritional intake is optimized. When I work as a bedside nurse I am obsessed with turning my patient every two hours to prevent pressure ulcers. But I’d be lying if I said there were not times when staffing was so low or other types of care had to be prioritized first that I was not able to do this on every patient every two hours. Is that my fault? Yes and no. If I have 6 patients to care for that all require a high level of care and the auxillary staff called in, I am forced to prioritize care and do the things that are most important first. Now working under those conditions and not being physically able to do everything I want to do for my patients feels horrible. But what other choice do i have? If I have four patients and have support from other nurses with similar patient loads and support staff, I can provide the best care. I feel great when that happens. The reality is that there is a nursing shortage. Nurses will tell you over and over again that they are so short-staffed that they cannot do everything they need to do. Nurses in this situation will also tell you that they ask for help from their administrations constantly. Some hospitals deal with the shortage better than others, but in some geographic areas there is no relief. Will those hospitals be able to meet the quality standards at the same level as other hospitals? Is a hospital in New Orleans suffering from a severe loss of staff and an increase in patients after Katrina be able to make quality improvement at a high enough rate to prevent loss of revenue from treating these catheter-associated infections without reimbursement?

If they cannot, and they have to close, how will that serve the New Orleans community? If you think about the types of hospitals that will have more trouble with this mandate it is important to realize that hospitals with lower quality are often hospitals that serve in areas of high need with few economic resources.

I know that there are many errors that are unacceptable, including some on this list. There are some errors on this list that are less black and white. Preventing those errors falls heavily on the nursing staff that is already overtaxed with responsibility. In areas faced with high shortages and other barriers to making the desired improvements, these mandates will potentially have a large financial impact. I have great concern about the who and where of this financial impact as an indicator of vast disparities in health care along socio-economic lines.