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Risk Induced Professional Caregiver Despair

Voices of Nurses

Society of Rogerian ScholarsSavannah, GA

October 22, 2005

Thomas Cox PhD, RNAssociate ProfessorCollege of Nursing

Seton Hall University



How Risk Induced Professional Caregiver Despair Developed

Mathematics and statistics…

Social work

Nursing

Insurance

Planning and research

Hobbyist creator of vapid research on PCIR

Reflecting on roles, duties, and responsibilities





Risk Induced Professional Caregiver Despair?

Changing face of healthcare finance

Caregivers manage insurance and clinical risks

Is this consistent with quality health care

Disrupted bonds between RNs and clients

Character, quality, & rapport of relationships

Issues neglected - need new to understand the new

HC environment

Some RNs experience despair in this ‘new’ environment

RNs stories about fiscal constraints & caring



Professional Caregiver Insurance RiskUnexamined/undisclosed insurance risk transfers occur between and within organizations

Inadequate funding unavoidable with insurance risk transfers

Risk transfers cause financial, professional, spiritual, and affective disharmonies to emerge

‘Listening’ to the spiritual, affective, physical, and cognitive wounds of nurses may be critical to the well-being of nurses, nursing, nursing clients, and the health care system as a whole


Professional Caregiver Insurance RiskThe Statistics Version 1

Insurance, financial, and clinical risks borne by health care providers (PCs) when they accept insurance risks from 'insurers' under capitation, PPS, Managed Care, and fixed operating budgets

Aggregate risk reduction by insurance is eliminated when public/private insurers cede insurance risks to PCs

PCs have higher risk - adversely affecting PCs, marginalized consumers, and marginalized geographic or social regions, due to limited financial & social capital

Fosters HCP consolidations and lower service capacity Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

Direction of Risk TransmissionThe Statistics Version 1InsurerClientAgent

AgencyDistrict

StateInsurer

Reinsurer

PCIRInsurer

CorporationHospital

DepartmentPhysician

NurseClient

In 'insurance' risk transmission is toward more capable entitiesIn PCIR risk transmission is toward less capable entities

We should NOT assume that insurance risk transfers to PCs have no effect on quality until proven otherwise – we should assume that

they have an untoward effect until proven otherwise

Which Type I and Type II Errors?The Statistics Version 1

Which set of null & alternative hypotheses are most appropriate for evaluating risk transfers?

H0: Risk transfers to PCs do not affect healthcare quality

Ha: Risk transfers to PCs do affect healthcare quality

ORH

0: Risk transfers to PCs do affect healthcare quality

Ha: Risk transfers to PCs do not affect healthcare quality

Causality: I am happy to report that the architects of prospective payment systems have embraced acausality…

When you are travelling on a curve – there is only forward and backward

Steady State Assumptions for PCIRThe Statistics Version 1Large population of potential policyholders

IID loss characteristics N(0.85, se = 0.05 for N = 1,000,000)

Random sampling by insurers

Random sampling by PCs from insurer portfolios (R/T industry, social class, dependency status, and geography)

Free, competitive, and efficient insurance markets

Free, competitive, and efficient healthcare markets

Ratemaking is prospective - not re-coupment of past costs

Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

Problems Caused by Insurance Risk AssumptionThe Statistics Version 1

Non-random sampling from Insurer's policyholders

Contracts of adhesion between insurers and PCs

Inadequate actuarial analysis, underwriting & claims handling

Documentation systems inadequate for retrospective audits

Lack of liquid capital

Service capacity more complex than underwriting capacity

Insurers motivated to select cost-minimizing PCs

Exposure to conflagration hazards due to non-random selections

Exposure to self-selection risks by ill clients

Different benefit plans ===> increased inefficienciesCopyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

Risk PremiumThe Statistics Version 1

Insurance rates must cover:Losses + Loss Adjustment ExpensesExpensesProfitsRisk Premium

Risk premium = F(Population variance, Portfolio size, Financial status, Risk aversiveness)

Large Insurers - Small se – Low risk premium v smaller insurersLarge insurers - better data, better estimates of loss distributionSmall Insurers (PCs) should charge higher risk premiums to manage smaller portfoliosPCs are very, very small and extremely inefficient insurersCopyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU

Insurance Ratemaking & ReservingParallels for Professional Caregivers

The Statistics Version 1

Class plans – Clients with different benefits, status, geography, age, gender...

Credibility weighted rates

Expectations for fair rates and equal services

PCs cannot provide uniform services – Inefficient operations

High benefit clients leave if treated like low benefit clients

Impacts all provider-client interactions

Ethical and management issues in clinical decisions


Aristotle's Geocentric UniverseThe Statistics Version 1

Why not just fix our deficient healthcare finance system with a hodgepodge of financial 'epicycles' – SMSA adjustments, Carve-

outs, Wage adjustments, Volume adjustments, Equipment exceptions, Facility size adjustments...

PC RisksThe Statistics Version 1

Insurance risk assuming PCs face concatenated losses:

Costs of clinical services

Bonus plans often reward low costs – not high costs

High costs jeopardize future contracts

High referral rates/costs trigger more reviews & retrospective audits

Prior year losses non-random selection losses uncompensated if other contracting PCs didn't have them

High prior losses & high current risks jeopardize PC financial stability


Clinical ConstraintsThe Statistics Version 1

Insurance risk transfers move, through organizations, ever closer to clients:

Variability in costs/service demands r/t small samples increases

Financial risks increase – not necessarily organizational – “personal”

Risk aversive behavior increases

Risk premium adequacy decreases

Scrutiny of clinician’s decisions increases as costs increase

Breakdown in provider-consumer relationships

Lack of clinician consciousness about their claims management role

Parallels to insurance – Sales agents not held liable for ‘bad’ risks – clinicians are held responsible for ‘high cost’ clients

Ex post facto auditing – reduced reimbursements

Clinical efficacy decisions are instantaneous – reviews are ‘referent to infinity’

High costs


Reinterpeting the Standard ErrorThe Statistics Version 1

Normally the standard error relates to the accuracy of the insurer’s estimate of the true loss ratio for the population of all potential policyholders based on past insurer sampling/underwriting

In PCIR, there are critically important additional meanings:

Measure of PC’s ability to analyze/price/select renewal contracts

Measures reduced service capacity/delivery levels needed to

maintain PC bankruptcy risk at pre-set level

Measures lost insurance risk aggregation benefit due to insurance risk cessions to PCs

Indirectly measures loss in health system capacity

Measure of disparity between 'pure premium' and service capacity


Insurer v PC Standard ErrorsThe Statistics Version 1

Ideally, both the insurer and the provider portfolios are random selections from the population of all possible policyholders:

Population SD = sigma

Insurer standard error

LR Target

0.0010.001P(Insolvency)

se*2*sqrt(5)seVariability

5100285,000Number

Provider

1,000s

Insurer

1,000s

Population

1,000s



Risk Induced Professional Caregiver Despair

RNs experiences, perceptions and expressions of despair about their careers and working environments

Reasons for despair - not biological/chemical/Rx deficiency

Unmet expectations, unfulfilled hopes & dreams, opportunities lost, challenges too hard to meet, harsh and uninviting futures, and a past impossible to replicate or resurrect

Many RNs created new meanings of their experiences by blending art, science, perception, feeling, and intuition into organic and meaningful wholes, representing and revealing their unique constructions of the world



Correlates and Corollaries of Professional Caregiver Despair

Burnout Depression

Unhappiness Anomie

Angst Dissatisfaction

Alienation Suffering

Stress Poor Attitude

Ethical Conflict Moral Distress




Burnout Depression

Unhappiness Anomie








Burnout Depression

Unhappiness Anomie








Burnout Depression

Unhappiness Anomie








Burnout Depression

Unhappiness Anomie








Burnout Depression

Unhappiness Anomie








Burnout Depression

Unhappiness Anomie









Unitary Appreciative Inquiry ITheory generating, practice and research method

Appreciation of humans and human phenomena as wholes

Co-researchers shared experiences, perceptions & expressions, from their unique vantage point and without the need to justify themselves, their thoughts, beliefs, actions, or decisions

Goal – Appreciation of co-researchers' experiences of RIPCD

Researcher sought a ‘healing appreciation of co-researchers’ not just data capture



Practicing Unitary Appreciative InquiryAcceptance and validationEmpathic and appreciativeSee through the eyes of participantGain deeper understanding of/with participants as wholesHealing intention - assisting participants toward freer expression, greater insight, and greater integration

Dwell in preconceptions and assumptions favorable to participantsFoster rapport and promote harmony and mutuality

Participants may not yet feel themselves to be wholes

Researcher:Assists participants in healing appreciation of their own wholenessFacilitating insight, growth, and transformation

Not just data collection – IRB issues



RIPCD – A Unitary Appreciative InquiryExperiences, intuitions, reflections of RNs RIPCD experiences

Collaborative, theorogenic, research, and ‘healing’ journey

Opportunity to reveal, explore, and represent effects of HC financing experiments, adding substance, humanity, faces, and feeling to the soulless explications dominating the landscape

8 Participants shared experiences of the impact of risk transfers on nursing care and nurses:

OPERATING ROOM ONCOLOGY

MATERNITY AND PEDIATRICS

PSYCHIATRY and MEDICAL-SURGICAL

RNs



Why UAI Was ImportantWholeness & healing occur with free unstructured expression

Most participants thankful for opportunity to discuss their experiences until THEY were satisfied, citing prior inabilities to achieve closure

Some feel others prematurely react, designing interventions to ‘fix’ them or see them as ‘problem employees’

Appreciative profiles may be helpful to nursing and other disciplines and settings - fundamental features of modern life and mismatches between expectations and capacities in the face of unanticipated and unplanned variability and unpredictability



How The Research UnfoldedRNs who wanted to share stories

RNs provided new insights about how difficult bedside nursing had become for them

Research question:

“What does risk induced professional caregiver despair mean to you”

Stories about effect on nurses and clients of risk assumption and declining nursing capacity - the organized, synergistic, capacity to provide high quality nursing care



The Participant - Carol

OR Nurse

Self-identified as experiencing RIPCD

Volunteer

20+ years as a nurse

Revealing stories about corporate response to finance changes:

Desire to practice more independently

Loss of control over work environment

Recycled equipment and supplies – failures in service

Supplies come from over 100 miles away

Therapeutic to discuss RIPCD



Some Thoughts on the Research Process IIRB – Difficult to explain ‘praxis’ to panels focused on risk reduction in ‘designed experiments’

How does one distinguish between ‘healing intent’ and ‘intervention’ aimed at specific outcomes?

Not interventive in the same sense as a RCT

No objective goals beyond revelation, insight, growth, healing, transformation – the ‘small effects’



Work Products?

Dissertation

Many presentations on research findings, method, PCIR, financial and risk management…

Development of tools for monitoring and forecasting nursing capacity needs in risk assumption

Collaborations with other nurses, researchers, practitioners, educators, & administrators

Greater insight into the impact of managed care and capitation on organizational and professional behavior

Better refined theory of PCIR



Practical and Theoretical Insights

Allowed to freely consider, explore, and express the essence of their experiences, most of the RNs developed new ideas and attitudes about themselves and their experiences

Researcher gained important insights into how RNs respond to environmental impediments to caring practice

New theories and strategies for preparing RNs in their roles have emerged – greater need to understand how to deal with insurers, how to read and understand budgets and management reports, ethical reasoning regarding quality of care issues

New ideas about healing for individuals, groups, and systems



Some Guiding Principles of Healing Synoptic Narrative Construction

Allegorical – Metaphors encompass past, present, and future

Collaborations, incorporating multiple methods of cognitive, affective, aesthetic interpretation, and representation

A reaching forward, grounded in the past, present, and alternative possible futures

Researcher as guide, reference point, healer, and co-inquirer, journeying with co-researchers

Embrace contradiction, dissimilarity, and incoherence as birthing the future





Some Guiding Principles of Risk Induced Professional Caregiver DespairRIPCD is rhythm, flowing in & out of despair, hope, joy, and pessimism

RIPCD not ‘observable’ - must engage co-researcher

Naturalistic setting - where people are comfortable

RIPCD isn’t binary, emerging, shifting, changing, reforming coherence from time to time as different patterns form with an ever-changing environment – Most loved jobs, peers, and nursing

For some, flooding their experiences out, seemed to dramatically alter their lives, impelling them to action



An Experiment in Data SummarizationData collection and management

Interviews digitally recordedDigital files encrypted mp3 filesmp3 files sent via secure internet connection for transcriptionText for Carol – including two face-to-face interviews, several emails, review of two appreciative profiles – 160+ pagesTarget length of appreciative profile ~ 7 pgsWanted participant ‘voice’ – own words



An Experiment in Data Summarization

The Solution

Data saturation

Initial appreciative profile construction

Breaking raw data into significant vignettes

Ranking of vignettes in terms of representativeness of the whole appreciated during data saturation

Data summarization and formatting

Appreciative profile construction



Carol - 1a

operating room is really costly… supplies…

we exist on supplies we use to do the surgery

operating room… negotiate their own contracts… different

companies…

different types of supplies

what has changed is, it’s not {our surgery}, it’s {parent

corporation}

big contract … one company… lower rates.



Carol - 1b

don’t know whether it’s… going back to school…

getting older, being so long…

But I’m starting to feel that I want to go

beyond what I’m doing now



Carol - 2

Frustration… anxiety… out and out fear about the quality of nursing...

Not being able to provide things for my

patients

not being able to… protect my patients...

not being adequately protected myself



Carol - 3

We even have the times… had to send a courier to another hospital to get one...

one or two instances… in the middle of

things… not good for the patient



Carol - 4a

another thing that has changed… last six months…

used to get our case cart; the rolling carts… filled with

all the sterile supplies

the packs, the towels, the basin, everything

used to come from {Medical Supply}… right here in

Richmond

they would deliver the case carts to the OR



Carol - 4b

either evenings or nights {shift}… have a list of instruments… to be picked

attendants are supposed to have a list of

equipment… microscopes, headlights…

they should be brought to every room…

in a perfect world, everything would be there

when you walked in



Carol - 4c

because of {Parent Corp}… contract dropped… gone to {Other state}

So, they drive down the truck every day

make do as best you can… pull from what you

have there in the hospital

run and borrow things… make do with

something else



Carol - 5It’s been very therapeutic

It does help to talk and to vent about

your frustrations with someone

sometimes it just really does help

you…

to get these things off your chest

verbalize them




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