Managed Care and Nursing: Unmanageable

Managed Care and nursing: Unmanageable dilemmas?

Describe how managed care has affected patients, the healthcare system, and the role of the nurse

The current system of managed care was initially put into place mainly as a cost-cutting measure, to ease the financial stresses placed upon the healthcare system. However, many have argued that the impact of managed care upon patient health has been, according to most healthcare providers, largely detrimental. Before the advent of managed care, a healthcare provider's "obligations were owed almost exclusively to the patient" (Shapiro 2000). But in the era of managed care, physicians have had to become "more concerned with their obligations to the managed care organization -- so much so that their clinical behavior has been altered" (Shapiro 2000). The American health care system is the most expensive healthcare system in the yet America has a higher rate of infant mortality and lower life expectancy than other industrialized nations (Copeland, 2003, p.1)

Within managed care organizations, physicians report that they now are more likely to discharge patients prior to the patient's full recovery. Physicians have a greater reluctance to make treatment decisions regardless of cost or to refer patients to specialists or emergency departments. Nurses may find themselves in the uncomfortable position of having to choose between serving or advising a patient and keeping an eye upon cost containment. "While nursing care has always required "a sophisticated level of skills, knowledge and judgment," working within a managed care organization may requires the nurse to justify a particular course of treatment as necessary to an insurance company as well as to the patient and his or her family (McPeck 2002).

After all, "to deny insurance coverage is to essentially deny care because healthcare is so expensive [in America]... That's where nurses and other providers have ethical challenges as well as practical challenges" (McPeck 2002) Nurses may find themselves "smack dab" in the middle of a battle about what care is justified as part of a utilization review staff where they are asked to "help managed care providers determine appropriate interventions and judicious use of health plan resources"(McPeck 2002). Thus nurses, once seen as patient health facilitators and advocates, may find themselves in the uncomfortable position of financial managers. Along with physicians, nurses are increasingly overburdened as they have to deal with what may seem like increasingly insurmountable piles of paperwork, in addition to their primary duties, as they must grapple with complicated referral forms and justify the need for the treatments and specialists they believe are required to improve their patient's health (McPeck 2002).

How has managed care affected the knowledge and skills needed by the nurse

The added administrative burdens placed upon the nurse in a managed care system means that many managed care nurses must become more fully versed in the language of business, resource allocation, and the legal demands of the healthcare system than ever before -- as well as find a way of holding true to their ethical principles as a nurse. Managed care requires a "balancing act between needs and costs" and to "match the patient care needs to the resources and keep them at the appropriate level and facilitate any needed changes" is the new responsibility that must preoccupy nurses within managed care systems (Mc Peck 2002).

The reluctance to refer patients to specialists may also mean that nurses must practice more holistic, rather than specialized forms, of nursing. The desire for cost containment has resulted in many nurses assuming physician's duties, such as those duties confined in previous eras to the patient's primary care physician. In states with high HMO (Health Maintenance Organization) enrollment, more nurses were shifted to lower-paying nonhospital settings, such as in home health care settings, to defray costs (Buerhaus & Staiger 1996).

What affect has manage care had on nursing education?

Surprisingly, the majority of nursing schools still do not work with a managed care organization or with physician training programs to facilitate educating student nurses in managed care competencies. However, 57% of hospitals do offer continuing education to staff members though educational seminars, staff meetings, and other programs (Copeland 2003, p.2-3). Although the managed care system is likely to change in the not-so-distant future as calls for healthcare reform become increasingly loud, the fact that the managed care approach is unlikely to entirely to disappear, coupled with unique challenges posed by the financial demands of healthcare has caused many nursing schools to either revise their curriculums or to add certification for nurses seeking to specialize in managed care organizations or approaches.