Healthcare Reform: The “Ideal” Plan

Politicians, lobbyists, reform advocates, the insurance industry, and healthcare practitioners are all talking about healthcare reform. Something will likely change regarding health care in the near future. But what will it be? How will it happen? Many of us are guessing; more of us are hoping. By the time this column is published, legislation may have been passed. But what comes out of all of this will likely not be the "ideal" plan. Why? Because, at least in part, people do not agree on what the ideal plan is. More likely, what we will see is a change in the direction of health care rather than a dramatic overhaul of the healthcare system.

Even before we know exactly where we're headed in terms of an ideal health plan, people are talking about who will pay for it: private insurers, mixed private and public payers, or a single payer. I have my own opinions about who should pay, but I believe that reform should focus less on who will pay and more on three elements that I believe are essential to this ideal plan: (1) health coverage for everyone, (2) improved quality of care, and (3) reduced cost of care.

As nurse practitioners, we have a lot of experience and expertise in these three areas; we have proven ourselves in all three realms. As such, we need to be major participants in the process of healthcare reform. It may be easier to sit back and see what will happen, but the effort we expend now will pay off in the long run. We need to talk to our legislators, not necessarily in support or opposition to specific legislation, but about key concepts of what is needed in healthcare reform. I offer the following "talking points" regarding how NPs will fit into healthcare reform.

Key to achieving the three goals of the ideal plan is the recognition of the importance of the primary care practitioner (PCP) and the healthcare home that he or she provides (something that we NPs have been doing for years!). In the past, I used the term specialist to refer to a clinician to whom I referred patients for focused care that I could not provide myself. This clinician was usually a physician such as a cardiologist or dermatologist, although now many NPs practice these same disciplines. We all know the term specialist. But because the term has the word special in it, some people think that these clinicians are smarter or better than PCPs. Yes, they have more knowledge in specific areas than I do, most of them get paid more money than I do, and I need them as part of the healthcare team. Yet I prefer to call these clinicians consultants. I consult them and send patients to see them for specific areas of care, but they are not better or more special than PCPs.

In fact, I like to think of PCPs as specialists. We specialize in what we do, which is to coordinate care for our patients while providing comprehensive care. How many times has one of your patients come in asking for a referral because he or she doesn't realize that you can handle the problem yourself? How often have you referred a patient to a neurologist, who refers him or her to a gastroenterologist, who refers him or her to another consultant-the latter two of whom may not have even been needed? But the central coordinator of care-you, the NP-was left out after the first referral was made. As we look to healthcare reform, we should note that the specialist is really the PCP, with more and more PCPs now being NPs. The PCP is the specialist we need to anchor healthcare reform; to coordinate care, referrals, and diagnostic tests; and to facilitate communication between consultants and hospitals, thereby reducing redundant testing or referrals, and providing more information for patients about the big picture of their health.

And now, back to the three essential elements of the ideal health plan:

1. Health coverage for everyone. NPs have been at the forefront of providing health care to persons who otherwise might not receive it. In fact, this is how our profession was founded. Many of us work in underserved areas, in community health centers, or urban or rural clinics. We take care of people who are either uninsured or underinsured. We help them find ways to lower their healthcare costs, help them find resources, and support them emotionally as they try to maintain and improve their health.

2. Improved quality of care.Healthcare reform must focus on the delivery of high-quality care, which is not only good for patients but also saves money in the long run. High quality doesn't necessarily involve the most complex surgical procedure or the latest technology. Quality has to do with care that makes a difference, that keeps people healthier and in less need of the expensive procedures and technology. Many of us are paid based on the numbers we produce, be it RVUs, visit volume, or income generated. But under ideal circumstances, we'll be paid for delivering better care and producing better outcomes. The heart of nursing is just that-prevention and health maintenance. We cannot control everything our patients do, but when we listen to our patients, when we try to understand them and what makes them tick, we are better able to motivate them to make health-promoting changes. NPs have proved that we don't just treat illness, we promote health. We have a record of delivering high-quality care.

3. Reduced cost of care. Do you know that, in this country, we spend more money per capita on health care yet have worse outcomes than many countries that spend half as much per capita on health care? As NPs, we play a large role in reducing healthcare costs by focusing on prevention and health maintenance. Many of us order fewer expensive tests and diagnostic procedures, and many of us make fewer referrals. Those of us in the primary care "specialty" know our patients, their family, and their history. Consider the patient coming in with a rash, vaginal discharge, and palpitations. We could spend very little time with this patient and refer her to a dermatologist, a gynecologist, and a cardiologist, each of whom would bill 2-3 times what we would bill for diagnosing and treating all three of these conditions.

Primary care is the specialty that can really cut healthcare costs. Just this week, a patient of mine was seen in the ER for an acute condition. Rather than perform a CT scan, the ER practitioner called me, the PCP, and requested that, instead of doing the scan, I see the patient the next day in the clinic. Because this patient had a PCP (yours truly) who knew her and could follow up on the care she received in the ER, an expensive diagnostic test was avoided. By faxing records and laboratory results from our clinic to the ER or to a consultant, we can eliminate duplicate diagnostic testing. The coordination and communication of the PCP, enhanced by an electronic health record can be another huge factor in reducing healthcare costs.

We NPs need to be part of the dialogue on healthcare reform. As we speak out, we may receive a more equitable reimbursement for what we do-thereby promoting health while saving money. We must not sell ourselves short. We must not sit back and wait. Healthcare reform is here. It is needed. The time is ripe for change. Let's speak out, not only through the care we give but by keeping in touch with legislators, writing letters, and keeping ourselves informed. It's our opportunity to be part of the solution.

Tom Bartol can be reached at Bartol @gwi.net