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The Enforcers

August 31, 2005 -- Today the Boston Globe published an op-ed by journalist Suzanne Gordon about the Tufts Health Plan's apparent return to the health care "micromanagement" of the 1990's, including placing nurses in Massachusetts hospitals to "patrol" treatment and patient stays. Gordon argues that this poisons nurses' relations with physicians and patients, exacerbates the nursing crisis, and does not even result in the cost savings that are its goal. Instead, she contends, only the kind of universal health care system that prevails in other industrialized nations will be able to contain the runaway expenses of the private insurance industry, prescription drug costs, and other wasteful features of the current system.

Gordon reports that the Tufts plan is reinstating 1990's-style "1-800-mother-may-I" care review "[i]n an effort to stem escalating health insurance premiums." She argues that this move to "mangled care," and especially the enforcer roles that nurses themselves will be asked to play in it, will harm nurses. She notes that in the 1990's, insurance companies tried unsuccessfully to reduce costs by micromanaging physician practice and hospitalizations. She points out that a lot of this was implemented by nurses "paid to sit in front of video screens flashing insurance company algorithms that dictated length of hospital stay and permissible treatments," as well as the bedside nurses "who enforce hospital 'throughput' by sending sick patients home where ill-prepared family members are usually asked to provide professional-level nursing services." Gordon explains that this causes great harm to nurses' relations with physicians and patients, while failing to reduce overall costs. She notes that when nurses, whose relations with physicians have long been troubled, are "hired to tell doctors 'No!'" and are "viewed as HMO handmaidens, doctors will not be encouraged to consider them to be partners who have important insights and information about patient care." Moreover, nurses' relations with patients suffer because it is the nurses, not insurers or hospital administrators, who have to "prowl[] the halls of hospitals" looking for "outliers" who have stayed past the pre-determined length of stay. Gordon asserts that these measures will be no more successful now than they have been in the last decade, and that they will only exacerbate the nursing shortage that they helped cause in the first place.

Gordon argues that only a taxpayer-funded universal health care system, like those that "exist[], in some form, in every other industrialized country," will be able to "squeeze out the billions of dollars we now waste on insurance company administration, marketing, and profiteering, the most expensive prescription drug costs in the world, unnecessary clinical care, and fraud and abuse." She notes that such a system would also provide the stability in hospital budgets that would allow administrators to focus on issues beyond institutional survival and short-term profit. And she urges patients to join the many Massachusetts nurses now fighting for universal health care.

On the whole this is an effective piece of health care advocacy. Gordon acknowledges that runaway health costs are a problem, but persuasively argues that based on the experience of the last decade, the Tufts solution will only make things worse, especially for the nurses who are already in the midst of a crisis. She might have also noted that such measures--in addition to hurting nurses' relations with others, exacerbating the shortage and failing to cut costs--would appear to have had a significant negative effect on patient outcomes. When patients cannot get the nursing and physician care they need, outcomes suffer and costs actually rise, in the form of costs to treat conditions that could have been prevented or caught earlier, to say nothing of malpractice costs. Moreover, the strain such micromanagement has placed on nursing practice is a powerful independent factor in the nursing shortage. Unwarranted cost-cutting exacts a terrible psychic toll on nurses who want to provide good care, and it is a major factor in nurse burnout, as Gordon shows in her book, "Nursing Against the Odds" (2005). Of course, Tufts can't establish universal care by itself, but Massachusetts citizens can work for that change, and in the meantime try to contain costs through a focus on preventative care and adequate nurse staffing, which actually costs less in the long run because of reduced turnover and better patient outcomes.

See the op-ed by Suzanne Gordon in the August 31, 2005 edition of the Boston Globe "Micromanaging healthcare."

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