• Bundled payments and nursing

    Interesting post by Gail Wilensky in the Robert Wood Johnson Foundation Human Capital blog. Her discussion of the impact of bundling on the role of nurses stood out:

    The move to more inclusive bundles, particularly those that differentiate according to the quality of care provided, should increase the role of nursing in providing care to patients. Since nurses have not traditionally been able to bill Medicare independently, except under limited circumstances, the value they bring is easier to capture the larger the payment unit. In capitated systems, such as HMOs, where a single payment covers all services provided over the course of the year, the incentive is greatest to use the mix of health care personnel that can provide the health services needed at the lowest cost.

    Not surprisingly, the role of nurses has tended to be greater at organizations such as Kaiser and Geisinger, as well as in the military relative to the care provided by more traditionally reimbursed physician groups. As the scope of services that is included in the bundled payment expand, some of the same incentives that have affected decision-making in the capitated systems will begin to dominate decision-making elsewhere. The repeated studies that have shown high quality associated with primary care services provided by nurse practitioners should only increase their attractiveness whenever payments are differentiated for quality.

    More on the potential impact of bundling on nurses from Ellen Kurtzman.

    • Let me correct one part of Gail’s post, while agreeing with the larger sentiment. During my 8 years in the military, 4 as a corpsman and 4 as a physician, most nurses worked mostly in supervisory roles. Techs performed most of the care that nurses perform in a civilian hospital. WHile deployed, I typically had one nurse on per shift, plus an OR nurse, and the techs did everything else. OTOH, PAs performed at a very high level. Specialty nurses were a different story. They functioned much more independently. (Caveat. It has been a while, Things may have changed.)

      To the larger issue, my practice is using specialty nurses much differently than we have in the past. We are expanding their scope of practice (with some grumbling). It is, we believe a more cost effective approach to care, while remaining safe.


      • @steve
        forgive my ignorance of the military system. When you were 4 years as a corpsman, does that mean you were in training to be a doc? And then you were a doc? Or were these not a continuous 8 years?

    • Not continuous. After I got out, I worked for a year, then started college. GI bill (mostly) paid for undergrad. Military paid for medical school. Had intended to make it a career, but wife insisted I get out after Desert Storm.


      • @steve
        OK, that makes sense. What type of training do you get to be a corpsman? Do you pick that or did they assign you to that? just curious…

    • I enlisted as a corpsman. After boot camp, I went to basic corps school. Nothing like the Great Lakes in the winter. Anyway, that was, if memory serves, about 12 weeks. It included basics like bed making, wound care, physiology and anatomy. You then had the option of advanced training. There is a fairly broad group of specialties into which you can train. Most people, in my day, ended up working on a ward or in the ER until their specialty school started. After specialty school, mine was neuropsychiatric training, you would work in your specialty area.

      You generally listed three, or so, specialties into which you wanted to train. They then matched that to their needs. I had enlisted as a corpsman, but you could not pick your specialty ahead of time. My cousins, Marines, insisted I go in as a corpsman. Something about not being able to shoot straight. (Towards the end of Nam. Kind of a family thing. If there is a war, you sign up.)

      Anyway, when I was a doc in the military, techs were still the driving force for getting most of the stuff done. As a group, they were very capable and worked well above their educational level in the military, doing things they would not be allowed to do in the civilian world. A lot of OJT that seemed to work pretty well. The downside was that when out of their comfort zone, they do not, usually, have the theoretical knowledge base to adjust very well. However, my enlisted background was invaluable while deployed in Saudi Arabia. I knew who to talk to in order to get around every obstacle and rule, or knew the guys who could do it, if I turned my head.