Ending the 'Sick Care' System

As a nurse who worked for a manged care insurance company for five years, and hospitals for over 20, let me make a few suggestions.

1) Right now the emphasis on reimbursement is stacked in favor of surgeons and diagnostic tests, and stacked against primary care providers, pediatricians, and ob/gyn's - and mental health providers frequently aren't reimbursed at all. Take all the diagnostic codes in the CPT book (the diagnostic bible) and cut the surgical and diagnotic test code reimbursement rates by 10%. Increase the Evaluation and Management codes for primary and preventative care by 10%.

Let's put our money were our mouth is: if preventative care is preferrable to end-result care, let's pay for it that way.

2) Start reimbursing for nurse visits in the doctor's offices that include things like pre-natal teaching, asthma management classes, diabetes management, cardiac management, etc. Include nutrition and diabetic teaching by registered nurses. We badly under-utilize the valuable insights and training that nurses have to offer - they are the ONLY group of health care professionals that are trained to look at the whole patient from the first day of nursing school , and the ONLY group of health care professionals that have patient teaching as a significant part of their training. MD training is not set up to provide holistic care, although primary/family care schools are doing a better job of training in this area than they used to, and medical schools seldom if ever include patient/family teaching in their curriculums.

Again - if you want true preventative care, start reimbursing for it.

3) Eliminate the Homebound Rule as the criteria for who gets a nursing visit at home after discharge from the hospital. Base the criteria on whether or not a home nurse visit will prevent a hospitalization, not whether the patient can't get to the doctor's office. This is an outdated rule, based strictly on keeping the reimbursement in the doctor's office, and has absolutely nothing to do with what is best for the patient. We need to change the emphasis on WHERE we provide care - into the cost effective settings of homes, schools and places of work, and out of the expensive settings such as doctor's offices, clinics and especially, the hospital emergency rooms.

4) Every frail elderly patient needs a baseline evaluation by a podiatrist. Patient falls are one of the most expensive and preventable problems in health care for this population, and untreated feet/ill-fitted shoes are frequent culprits, yet so inexpensive to fix. Don't over-estimate the impact a good podiatrist can have for this group, ditto the chronic back pain folks, another population that uses millions of health care dollars in inefficient ways.