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 January 1, 1998

Hospitals hold line on nurses; aides help fill the gap

Managed-health maintenance organizations are increasing reliance on poorly trained health-care workers to save money and putting the health care of patients at risk.

That’s the opinion of Alison Biggs, executive director of the Colorado Nurses Association. It’s a trend, she claims, that has her worried.

“The substitution of skilled personnel with minimally trained individuals has a tremendous potential for lowering the standards of care,” Biggs said recently. Hospitals especially are using health-care professionals who lack the training of licensed nurses, Biggs said.

The goal? To save money, she said.

At Boulder Community Hospital, however, there have been no cuts to the direct patient-care provider areas, said Gail Osterbur, vice president. There has been pressure from insurance companies and HMOs challenging the hospital to streamline, but the change is reflected more in shortened hospital stays, she said.

“We’re committed to using the most quality care we can,” Osterbur said. “We will never have a non-professional provider at the bedside until they meet the competencies that are required. I don’t think the quality of care has suffered at all.”

At the same time, the number of nurses in the hospital, compared to nurse assistants, has changed in the last 10 years. But those positions fluctuate, depending on the health-care industry, Osterbur said.

In an area like intensive care, for example, probably 90 percent of workers are nurses, she said. In other areas, there’s a 50/50 mix, with a nurse/nurse assistant team responsible for four or five patients.

“They (insurance companies) don’t tell us how to get the budge down, they’ll just come in and negotiate pay systems,” Osterbur said. “Our challenge is to reduce the cost of what it takes to provide care.”

The amout of time a patient stays at the hospital has dropped to just more than four days, Osterbur said, cutting some costs.

“By the time people are getting to the hospital these days, they are sick cookies,” Osterbur said “They’re running them through the system so fast, we can’t afford not to have trained personnel with them.”

At Avista Adventist Hospital in Louisville, which is owned by Centura Health, based in Denver, the number of nurses compared to other health-care professionals is still at 100 percent in areas like intensive care, pediatrics and obstetrics, said Carol Schmidt, vice president of operations. In medical/surgical areas, the ratio is about 75 percent nurses to 25 percent certified nursing assistants.

“At Avista we do things differently. We have nursing assistants in a different uniform, and professionals in a certain uniform, so that’s helped patients understand the difference,” Schmidt said. “We do ask our employees to introduce themselves and say what their role is.”

Boulder internist Dr. William Blanchet, who closely monitors HMOs and health-care trends as president of the not-for-profit Boulder Valley Individual Practice Association, said individual physicians are relying more heavily on nurses and physician assistants because HMOs have reduced payments to physicians.

Other problems he sees with HMOs? They create hassles when patients need to see specialists, he claims, and they have the potential for denying patient access to treatment they need.

“The potential abuse by an HMO to deny a patient access to appropriate treatment is the scariest parts of HMOs,´ said Blanchet. “I’m not seeing that happen with the HMOs I participate with, but it’s happening.”

The physician group represents 250 physicians who work with managed-care organizations, negotiating contracts and trying to smooth problems between HMOs and physicians and HMOs and patients.

It is one of four physician groups in Boulder County that have formed to deal with managed-care organizations. The others represent doctors at the Boulder Medical Center, in Longmont and at Avista Adventist Hospital in Louisville.

Biggs said that in recent years, HMOs’ reliance on less-skilled health-care practitioners — some of whom have only six weeks of training — has slowed the number of entrances into nursing school. Nurses have at least a two-year degree and continuing education.

But the trend now is turning around, she said.

“We’re beginning to see places bring RN positions back, and we’re beginning to see the start of a shortage creeping up,” she said. “Some of them have learned that some of the cuts that were made have had a negative impact on levels of care.”

While the demand for nurses has decreased in hospital settings, their role as community health-care providers has grown, she noted. “There are increased opportunities outside hospitals for nurses,” she said. “And there’s more interest in the public health field has increased. “

Despite all the complaints you hear or read about HMOs, nearly all doctors are affiliated with at least one HMO, and up to 50 percent of all employees enroll in HMO plans instead of traditional fee-for-service plans, said Jim Hertel, director of Colorado Managed Care and publisher of a monthly newsletter on HMOs.

As health-maintenance organizations continue to capture a larger piece of the health insurance pie, they are coming under increasing scrutiny by patients, nurses, doctors and government regulators.

And there are signs that managed-care companies are trying to straighten up their acts and do a better job of meeting health-care needs at lower costs than traditional insurance companies can do, Hertel said.

Hertel, who tracks the industry and reports his findings in a monthly newsletter, said if it weren’t for HMOs, health-care premiums would have skyrocketed in the past five years.

“It’s my observation that the last five years has seen relatively stable level of health-care premiums for employers after a 15-year period of health-care costs being out of control,” Hertel said. “It’s only through increased employer usage of managed-care plans that we have been able to stabilize health-care premium costs in the United States.”

Much of the “HMO bashing one hears” comes from employees who have switched from a traditional health insurance that covers everything to an HMO to save money. Many then complain when they find out coverage is limited.

Blanchet agrees HMOs have helped control health-care costs. “That’s their biggest plus,” he said.

But by steadily reducing the reimbursement they pay providers, they reduce the amount of time doctors can spend with patients during the day to meet their overhead and income requirements.

Another potential advantage of HMOs, Blanchet said, is that “in a utopian HMO, they can put a system in place to insure patients are aware of and following health-care screenings.

“But these are more theoretical advantages, and to imply HMOs are making a difference in these areas a this time is stretching things a bit, ” Blanchet said.

Although Blanchet is not aware of HMOs denying life-saving care to anyone in Boulder County, he said patients often complain about being forced to see certain specialists. “A patient might not be thrilled because they can’t see the specialist they want to see, but they can see a specialist,” he said.

And most HMOs require patients to get referrals through their primary-care physicians before they can see specialists, Blanchett said. That’s creating headaches for physicians and patients alike.

“If you don’t do it in the right sequence, the HMO won’t pay the specialist, and that doesn’t have anything to do with health or medicine,” he said. “It’s bureaucracy.”

Experts say the key to finding a satisfactory HMO is to assess your biggest medical risks (a family history of breast cancer, for example) and then evaluate plans to find one that matches your needs.

Many employers offer a menu of health-care choices to meet your needs. Several organizations monitor HMOs and will provide their conclusions to the public. Information is also available from the state insurance commissioner, 894-7499.

The Colorado Business Group on Health recently issued a “report card” of Colorado health plans that can help consumers select a health plan that fits their needs. It evaluates things such as immunizations for children, pap smears and customer satisfaction.

A copy of the report is available by calling 708-8135 in the metro area or 888-281-4300 in other areas.

Biggs said it’s important for consumers to ask questions of providers, such as if they cover professional nursing care. “The more questions people ask, the better off we’re all going to be,” she said. “Health care is a partnership.”

BVIPA also tries to help consumers through its negotiations with HMOs.

Mary Mock, BVIPA’s chief operating officer, said BVIPA helps physicians and patients by offering “safety in numbers” without forcing doctors to form group practices.

As a liaison between doctors ad insurance companies, the BVIPA handles administrative tasks, including contract negotiations, leaving doctors more time to focus on health care.

Boulder Medical Center was the first to see that need and formed a partnership with Nashville, Tenn.-based PhyCor to handle administrative issues with HMOs, according to Executive Director Brad McKane. PhyCor handles management and owns the equipment while the doctors practice medicine. Medical-care decisions are made by physicians, he said.

Managing Editor Beth Potter contributed to this report.

Managed-health maintenance organizations are increasing reliance on poorly trained health-care workers to save money and putting the health care of patients at risk.

That’s the opinion of Alison Biggs, executive director of the Colorado Nurses Association. It’s a trend, she claims, that has her worried.

“The substitution of skilled personnel with minimally trained individuals has a tremendous potential for lowering the standards of care,” Biggs said recently. Hospitals especially are using health-care professionals who lack the training of licensed nurses, Biggs said.…

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