Balancing Quality Care and Efficiency in Healthcare

Introduction
As rising health care costs continue to pose problems for stakeholders in the health care industry, the question of just how to solve this dilemma remains an elusive one. The trouble is that it is not just a question of cost—but also a question of how to balance quality care with efficiency of care in an industry where for-profit facilities seem more and more to put profits before people, as opposed to putting people before profits (a concept that might naturally find expression in a profession so inherently oriented to helping those in need). While stakeholders understand that in order for professionals to provide quality care and for patients to receive it there must be some cost and some efficient system in place to expedite delivery, they must also realize that a balance of quality and cost-efficiency must be acquired in order for the industry to remain operable over the long run (Sikka, Morath & Leape, 2015). This paper will discuss the problem of the health care as an industry whose services have become almost too expensive to be obtained by the people who need them most.
Background of the Key Ethical Issue and Its Relevance
Provision 1 of the ANA Code of Ethics states that “the nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.” As this is the first provision of the ANA Code of Ethics, it is worth focusing on, especially in the light of the problem identified in this paper. It must be noticed that the provision does not include a stipulation regarding cost of care—i.e., something like “so long as the patient can afford the expenses associated with the care received.” No, the nurse’s most prized and pronounced ethic within the Code is to demonstrate respect for every patient and to practice the art of nursing for every patient who comes for care. This ethical principle is critical to the nurse’s sense of mission, self and vision. Within it are the seeds of the Code’s second and third provisions—namely that “the nurse’s primary commitment is to the patient, whether an individual, family, group, or community” and that “the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (ANA, 2010).
The relevance of these three provisions within the ANA Code of Ethics to the issue of balancing quality care with efficiency of care is that each serves as a guide for how health care should be directed. Each puts the person at the center of the care giving process. Not one of them mentions the for-profit nature of the industry today—mainly because the profit side of the business is not the nurse’s concern. The concern of the nurse is to provide quality care for every patient. The nurse’s concern is to put people before profits. This must be kept in mind by all stakeholders, for if the nurse is unable to fulfill this ethical provision for whatever reason—whether it is because health care costs have skyrocketed to the point where patients do not feel comfortable seeking care or whether it is because health care facility administrators want care to be provided in a way that emphasizes maximizing profits instead of maximizing quality of care—the nurse and all other health care providers are very likely to experience a very low sense of job satisfaction, as Sikka et al. (2015) point out in their study on the experience of providing care. The ethical issue at play in the health care industry today is this all-important question of which should come first—the people or the profits? Understandably, the latter should flow from an appropriate level of attention given to the former—but in the highly corporatized business world of health care today, what gets deemed an “appropriate level of care” does not always correlate with the ethical provisions provided to nurses in the ANA Code of Ethics—primarily because effecting correlation might cut into profits. However, if there is no correlation, the health care provider is more than likely to feel dissatisfied in the job because the aim of the provider has been corrupted. This is the essence of the ethical problem underlying the issue.
Scholarly Literature
Bodenheimer and Sinsky (2014) note that the Triple Aim of health care—“enhancing patient experience, improving population health, and reducing cost”—is a commonly accepted standard among health care practitioners, yet low patient satisfaction, poor health outcomes and increased costs all appear to be the product of the current health care system (p. 573). In other words, far from achieving the aims that health care providers have in mind, the industry is actually seeing the exact opposite of what it intends to achieve come to fruition. Sikka et al. (2015) provide a fourth aim: “improving the experience of providing care” (p. 608). This fourth aim is helpful in providing context for the troubling situation in which the health care industry finds itself today: the experience of providing care has fallen to a standard below where it should be. Access to care is minimal for a substantial population of patients; quality care is marred by nurse error, unaffordable care, high cost prescriptions, prescriptions that lead to addictions, and so on (Kolodny, Courtwright, Hwang et al., 2015). The experience of providing care is falling short of what stakeholders expect.
Sikka et al. (2015) show that experience is not just bad for patients—it is also bad for providers: “the evidence that the healthcare workforce finds joy and meaning in work is not encouraging. In a recent physician survey in the USA, 60% of respondents indicated they were considering leaving practice; 70% of surveyed physicians knew at least one colleague who left their practice due to poor morale” (p. 609). The issue of low morale among health care providers stems from poor experience of providing care; and that poor experience is related to the problem of balancing quality care with cost efficient delivery. In an industry that is increasingly focusing on profits and costs, the question of care and the importance of the patient-provider relationship is getting lost in the mix (Dowsett & Dowsett, 2015; Jennings, Clifford, Fox, O’Connell & Gardner, 2015; Baummer-Carr & Nicolau, 2017). In order to provide an ethical solution that can help to restore the balance between quality care and cost-efficiency so as to help the industry to obtain all of its objectives, the research shows that health care providers must be willing to put people before
Ethical Principles That Guide This Issue
The ethical principles that guide this issue are that health care providers and specifically nurses are bound to provide quality care for every patient who comes to them, without regard for socioeconomic status. Implicit in this principle, which is explicitly stated in the ANA Code of Ethics’ first three Provisions, is the notion that nurses must give quality care wherever it is needed; people are the first priority of the nurse. This principle is, in today’s health care industry, directly and inherently in conflict with the principle of business, which is to make money by minimizing costs. The problem and source of conflict is that in providing maximum quality care, the cost of this care cannot be quantified, at least not by the nurse who is truly dedicated to practicing the profession in accordance with the first three provisions of the ANA Code of Ethics. Unless the patient comes first in the practice of quality care, the nurse has no reason to be there.
Viewpoint of Stakeholders/Viewpoint of the ANA
Stakeholders in health care all have different viewpoints. Stakeholders in administrative positions come from the standpoint that health care services must be of a high quality but that they must also be cost-efficient in their delivery (cost-efficient for the provider that is). Administrators recognize that service must be high in order to be of use to patients but they also recognize that there is a business aspect to the service that is a top priority as well and that if the services rendered are not profitable then they cannot be provided for long. Representatives of the administrative viewpoint in health care include organizations like the American College of Healthcare Executives (ACHE), the Medical Group Management Association (MGMA), the American Association of Healthcare Administrative Management (AAHAM), the Health Care Administrators Association (HCAA), the Professional Association of Health Care Management (PAHCOM), the American College of Healthcare Administrators (ACHCA), and the Association for Healthcare Administrative Professionals (AHCAP).
Stakeholders also include patients, and their viewpoint on the issue is similar: they also want quality care—but they want it at a price that is not too costly for them. If their insurance covers it or if a government program like Medicare or Medicaid covers it, they typically have no complaints. However, they also require access to care, and sometimes this access does not come with many options under their current insurance plan or medical coverage. Organizations that represent patients include the American Hospital Association (AHA) which also represents hospitals, Consumers Advancing Patient Safety (CAPS), Just Culture Community (JCC), The Commonwealth Fund, and the Department of Health and Human Services (HHS).
The viewpoint of nurse stakeholders is represented by the ANA, which has as its mission the aim of advancing nursing to improve health care for all. This mission is consistent with the ANA’s Code of Ethics and especially the articulation of these ethics in the first three provisions of that Code. The main view of nurses is that they should be able to provide quality care to all persons, regardless of their socioeconomic background. Cost is not a primary concern of nurses, but rather care is.
Recommendations of Stakeholders
The general recommendation of administrative stakeholders is that health care leaders must work to use the tools they have to balance quality and efficiency. One of the ways they recommend doing this is through the use of Big Data: as … point out, many “opportunities exist to reduce costs through the use of big data: high-cost patients, readmissions, triage, decompensation (when a patient’s condition worsens), adverse events, and treatment optimization for diseases affecting multiple organ systems” (p. 1123). By using Big Data to better manage both the quality and the efficiency of health care, administrators believe the right balance can be achieved.
The general recommendation of patient stakeholders, as represented by the various groups and organizations that exist, is that health care costs are eroding the very basic value of the industry and either coverage for care needs to be given to all patients regardless of their socioeconomic background or that care should be available through low-cost options. For many of them the Affordable Care Act was a first step in addressing these issues in that it helped to provide more coverage to more people—but problems remain (for example, premiums and deductibles have risen). One recommendation provided by HHS is that alternative payment models be utilized in the industry to better tie quality care to cost efficiency: “alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements under which health care providers are accountable for the quality and cost of the care they deliver to patients” (Burwell, 2015, p. 897). Alternative payment models would help to ensure that care and cost are balanced in a way that promotes the needs of patients.
The general recommendation of nurses is that quality care and cost efficiency can be achieved by practicing more preventive medicine and health literacy along with better chronic disease management and practice operations, all of which not only help patients to reduce the risk of health problems but also give them a way to empower themselves and take ownership of their own health (Smolowitz, Speakman, Wojnar et al., 2017). By focusing on the fundamental needs of patients and ensuring that these needs are adequately addressed in the most effective manner possible, nurses believe the right balance of quality and efficiency can be achieved. This balance is in accordance with the provisions of the ANA Code of Ethics and the need for nurses to practice “with compassion and respect for the inherent dignity, worth, and uniqueness of every individual”; it also aligns with the provision that the nurse’s “primary commitment is to the patient” and that the nurse must “protect the health, safety and rights of the patient” (ANA, 2010).
Impact on Health Care, the Public and Nursing
The impact of the issue of balancing quality care with efficiency can be seen in the health care industry itself, on the public and in nursing. The impact of the issue in health care is that the industry is under increased pressure to address the relationship between quality and cost (Burwell, 2015). The pressure is building to the point that providers, from nurses to physicians, are experiencing a very low job satisfaction as they are torn between providing and practicing quality care and having to address issues of efficiency and cost that relate to administrative demands (Sikka et al., 2015). In the public, the impact is seen in the increasing demand for government to “fix” health care by making it more affordable, addressing the issue of quality, and providing some sort of guarantee that cost and quality can be balanced so that the needs of all stakeholders can be met. Now that the Trump Administration has canceled the penalty for people who do not buy insurance, there is likely to be an even higher spike in premiums and deductibles as insurance providers take steps to cover their own costs. This spike acts as a drain on the public, on nurses, and on the industry as a whole as the continued rise in the cost of care weighs on everyone’s ability to provide or receive quality care.
My Recommendations
My recommendations are for the government to stop subsidizing health care treatment as subsidizing treatment only leads away from practicing preventive care: the more that the government is willing to backstop payments for treating patients, the less likely the industry is to be concerned with practicing quality preventive medicine to ensure that treatments are not needed in the first place (Sommers, Gawande & Baicker, 2017). Treatments are costly both for patients and for providers. Treatments can be avoided if effective preventive medicine is practiced, which is what the ACA was originally intended to promote—as Obama (2016) points out, “most private insurance plans must now cover recommended preventive services without cost-sharing, an important step in light of evidence demonstrating that many preventive services were underused. This includes women’s preventive services, which has guaranteed an estimated 55.6 million women coverage of services” (p. 526). Emphasizing preventive care practices and ridding subsidies for treatment will help to orient the industry back to the patient and away from the all-consuming focus on profits. This would help to affirm the provisions of the ANA Code of Ethics in a more meaningful way for nurses whose goal is first and foremost to provide quality care for all patients.
The second recommendation is for the industry to focus on improving the patient-provider relationship by allowing nurses to focus on abiding by the ethical principles that support their mission: working towards protecting the rights and health of patient and demonstrating respect for every patient regardless of socioeconomic background. By supporting this perspective of the nurse, the experience of providing care can be improved across the board, and the satisfaction of patients will be likely to rise (Sikka et al., 2015). This would support the practice of preventive care and health literacy as well, as preventive care and health literacy correlate with the ethical aims of nurses.
The third recommendation is for administrators to recognize that in health care people must come before profits. The people in this case are both patients and providers. Patients need quality care and nurses need to be able to provide that care. Stringing patients along so that more tests and treatments can be conducted for the sake of making profits for the organization is not an efficient or effective way of providing quality care. Methods for promoting more preventive care, more effective management, and greater health literacy must be established by administrators.

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