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We’ll see a strong momentum build for an integrative medical model that blends what we have had in conventional medicine with alternative medicine. In 1999, a landmark study out of Stanford will be published that shows that people are willing to pay as much as $15.31 per member per month for alternative medicine coverage. In 1998, employer coverage [for alternative medicine] in large companies (with 500 employees or more) tripled, and 78 percent of the population used complementary therapies—energy medicine, herbal and manipulative therapies, and more. In 1999, 30 to 50 new integrative medical centers will be built across the country. What’s significant now is the serious attempts by health systems to truly integrate alternative medicine with traditional medicine.
The most important event I see for 1999 is a nonevent, a failure once again to come to grips with costs. For at least four decades, the cost of treating patients has risen at about twice the rate of other goods and services. Those who pay the bills—not just business and government but ordinary people—have seen their budgets hijacked by health care. Sooner or later these costs must be brought under control. Doing that properly—in a way that maximizes quality while staying within an acceptable budget—will require that we make explicit trade-offs between cost and quality. Unfortunately, we lack the courage and leadership needed to do that. We prefer to believe that we can demand all the care we want, while at the same time demanding that someone else should pay the bill. So 1999 will go down as one more year in which we push the problem off to the future.
1999 will be the year the managed care model is rethought and evolves into something more acceptable. It will mark the beginning of the development of new mechanisms and some significant evolution in the managed care model. But I just don’t think it’s viable to abandon managed care. I think premium increases are going to have substantial effects on how employment-based health insurance is handled.
What I foresee is the continuing implosion of the United States healthcare system. I think we’re seeing the increasing failure of market-driven health care. We’re going to see another giant increase in the uninsured … and much more shifting of the professional level of nursing care, to more of a burden on families and patients, and more death and injury as a result. We’re seeing the increasing dehospitalization of sick people and cuts in nursing care in the home on the part of HMOs and Medicare. From the point of view of nursing, we’re seeing a real disaster in communities as home healthcare agencies are folding at a great rate. But, maybe out of the negative there may come the positive of increased demand for more universal health care that this country has always lacked. Nurses should not just passively take what’s going on; if they actively become engaged, then they can transform the healthcare system just like they’ve done in the past. I think nurses need to really be fueled by their compassion, moral passion, and outrage.
We will begin a debate that will lead to the realization that those at risk because of inadequate healthcare coverage are not 42 million Americans, but virtually the entire nation. This is because of a little noticed event that occurred in 1995—for the first time more people died of chronic disease than acute disease. What physicians and nurses will be doing in the future is managing chronic illness—that is, long-term care—as fewer people enter hospitals for acute episodes and spend less time there. The major medical plans most American have are geared to acute care, which will have increasingly less relevance, and, of course, the great majority of Americans do not have coverage to assist with costs of long-term care.
The biggest change in health care is probably going to be managed care reform, both at the state and federal levels. There are going to be big changes in how we view and use managed care. The role of employers is going to be even stronger. Employers will be saying to heath plans: Tell me how well you provide health care. Hospitals will be under the same scrutiny in terms of outcomes and quality. Nurses are going to play an important role as managed care reform improves access to care. We’ll see nurses step up and take a leadership role in health care. How do we help patients access managed care? What do we do to ensure choice? I think nurses are now well-positioned to be talking about what’s essential.
I wish I could say with absolute certainty that in 1999 the most remarkable event to take place will be guaranteed universal access to quality health care for all Americans and the restaffing of hospitals with adequate numbers of RNs and LVNs. But I am assured by recent history that this is truly an unrealistic dream. Unfortunately, I think the more realistic change will be the escalation of replacing RNs and LVNs with unlicensed personnel. Why? Because corporate greed and exploitation of healthcare personnel will continue to triumph over patient safety and nurses’ efforts to save their profession. To my way of thinking, this is all the more reason to continue the good fight and to educate the public on the value of the nurse now, rather than having the public discover the nurse’s worth through her or his absence.
There will be a series of attempts, state by state, to regulate managed care. We’ve had enough pressure on legislators that many feel they have to do something to show they’re paying attention. It’s subject to a nationwide copycat wave. I don’t think the changes will be substantive, because legislators don’t want to spend more money. The problem is, regulation freezes the system where you are and limits innovation.
Hospitals and health systems will be stepping back and regrouping in 1999. They are discovering consumers do perceive a difference in health care. Facilities that provide greater staffing ratios have a higher cost, but are also perceived as being prestigious and having a higher quality of care. These hospitals have more RNs performing lower-order tasks and more RNs per bed. It’s a matter of perceived quality vs. low cost. When you buy chocolate at a store, you can buy Godiva, Hershey’s, or the store brand. If you want the chocolate that is perceived as having higher quality, you pay more money.
Our biggest priority is working with the Congress to pass legislation that would ensure basic patient protections. We are advocating a strong, enforceable Patients’ Bill of Rights. President Clinton has called on Congress for over a year to pass this legislation that offers certain guarantees, including access to needed healthcare specialists and to emergency room services and continuity of care protections to ensure patient care relationships will not change abruptly if a plan changes providers. Other guarantees include access to a timely internal and independent external appeals process for consumers to resolve their differences with their health plans, limits on financial incentives to providers, and assurances that providers and patients can openly discuss treatment options.
We may reach a crescendo in terms of comprehensive healthcare reform. There are now 42 million uninsured, and the number of uninsured children is up from a quarter to a little over a third of all children. Only 66 percent have health insurance now. The number of uninsured is going up a million people a year, even with record low unemployment. I don’t think it’s farfetched to say 50 percent of children will be uninsured in 2000. That’s the kind of scenario that set the stage for Medicare in the ’60s. If the economy deteriorates, making more kids uninsured, combined with major campaign finance reform that changes the way Washington works, the stage will be set for major health reform in Congress. |
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Leanne
Kaiser Carlson, MSHA
David
Eddy, PhD, MD
Paul
Ginsburg, PhD
Suzanne
Gordon
Val
J. Halamandaris
Susan
Harris, MPA, RN
Echo
Heron, RN
Wanda
Jones, MPH
J.D.
Kleinke
Donna
Shalala, PhD
Judith
Shindul-Rothschild, PhD, RN