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Micromanaging healthcare

IT'S ALMOST 2006, but for the patients at Tufts Health Plan it might as well be 1996. In an effort to stem escalating health insurance premiums, the plan has reinstated the kind of 1990s micromanagement that requires doctors and bedside nurses to get 1-800-mother-may-I review for medical treatment and hospital stays.

In fact it is placing company nurses in Massachusetts hospitals so they can better patrol the course of patient stays.While the company may insist that this will reduce healthcare premiums and ease the nation's healthcare crisis, this couldn't be worse news for nurses or the patients they serve. Plus, returning to micromanaged care -- or mangled care as some think of it -- leads us further away from a long-term solution to this country's healthcare woes.

If you don't believe it, just consider the sad history of mangled care. During the 1990s, insurance companies promised that by micromanaging physician practice and patient hospitalizations, they'd reduce healthcare costs. So doctors had to hassle with insurers whenever they wanted to perform a procedure or get an OK for patients' hospital stays. A lot of the micromanagement was done by nurses, paid to sit in front of video screens flashing insurance company algorithms that dictated length of hospital stay and permissible treatments.

Although some of the effort to rein in physician practice and to shorten stays was necessary, insurers went way too far, cutting hospitalization to the bone and stopping patients from getting some necessary treatments -- which is why patients and physicians quickly rebelled against these practices.

As if this wasn't bad enough, mangled care also exacerbated the already parlous state of nurse-physician relationships and hurt nurses' image with patients and the public. Nurses have long sought better collaborative relationships with doctors. When nurses are hired to tell doctors ''No!" this is hardly the kind of collaboration that builds trust and teamwork. If nurses once again are viewed as HMO handmaidens, doctors will not be encouraged to consider them to be partners who have important information and insights about patient care.

Mangled care also hurts nurses' relationships with their patients. It is not, after all, the insurance company executive or hospital administrator who prowls the halls of hospitals looking for ''outliers" (people staying past their insurance company determined length of stay). It's the nurse reviewer and the bedside nurse who enforce hospital ''throughput" by sending sick patients home where ill-prepared family members are usually asked to provide professional-level nursing services.

In the '90s, these practices led to dramatic hospital cost cutting, nurse layoffs, and widespread disaffection among those nurses who remained in the hospital setting. This in turn has helped to create one of the worst nursing shortages this country has experienced. If more insurers return to this model of cost management, it will not augur well for the nursing crisis.

What's perhaps most important is that micromanagement of medical treatment and nursing care will do no more to help stem rising healthcare costs now -- as the population ages and suffers more chronic illness --than it did in the 1990s, when it failed miserably. The only thing that will stop out of control healthcare cost escalation is the kind of tax supported, universal healthcare system that exists, in some form, in every other industrialized country in the world.

This is the only way to squeeze out the billions of dollars we now waste on insurance company administration, marketing, and profiteering, the most expensive prescription drug costs in the world, unnecessary clinical care, and fraud and abuse. It's also the way to create some stability in hospital budgets so that administrators don't lurch from crisis to crisis with their eye firmly fixed on short-term profit or institutional survival. That's why many nurses in Massachusetts are fighting for universal healthcare and why their patients should join them.

Suzanne Gordon is the author, most recently, of ''Nursing Against the Odds: How Hospital Cost-Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care."

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