By Anne Federwisch
Illustration by Malcolm Garris
March 11, 1999

How do we keep the steadily increasing cost of health care in check without sacrificing quality of care? By using professional staff to their full potential, say some healthcare experts.

Why the high costs?

The rate of healthcare spending increases has actually leveled off in recent years. In the ’70s and ’80s, expenditures were increasing by double-digit percentages, but the increase shrank to less than 4.5 percent between 1995 and 1996 (the most recent data available). But Health Care Financing Administration officials expect those rates to once again accelerate in the coming decade because pharmaceutical expenses are escalating and we seem to have reached the maximum savings from managed care. HCFA estimates that healthcare expenditures will reach an astronomical $2.1 trillion by 2007. That’s double the amount spent in 1996.

Other factors probably also play a role in those increasing costs. "I think technology is the primary driver," said Kammie Monarch, MS, JD, RN, senior policy fellow in the department of health and economic policy at the American Nurses Association (ANA). "How many CT scanners do hospitals in one geographic area really need?"

Fraud cannot be overlooked as a factor either, according to Janet Davis, PhD, MBA, RN, director of the Center for Learning Excellence at the University of Illinois College of Nursing. She advocates stricter controls on billing and reimbursement.

Longer life spans and aging baby boomers will continue to drive up healthcare costs, said Nancy Garland, director of government affairs for the American Physical Therapy Association. "The bottom line is that we have more people who live longer and need more care," she said.

Three alternatives

No matter what the origin of the increases, the industry has limited options to curb costs overall, according to Michael L. Millenson, principal with William M. Mercer Inc. in Chicago and author of Demanding Medical Excellence: Doctors and Accountability in the Information Age (University of Chicago Press, 1997, $24.95). "There are only three ways to control total costs of any service," he said. "One is to pay less." Millenson said that many managed care companies have used this tactic by demanding discounts from physicians and hospitals. "Pay less has limits," he said. "Eventually you can’t knock people’s prices down any more."

The second way is to use less. Utilization review is an example of this strategy. "Do less has limits because eventually people push back and say, ‘Wait a second, you’re not just cutting fat, you’re cutting bone,’ " Millenson said.

The only other option is to do things better, he explained. "If you’re going to do things better, that means you have to get the same level of quality for less money." Computers are a good example; as technology has improved, the cost of computers has decreased dramatically without sacrificing quality.

For health care, Millenson said, doing things better requires evaluating the outcomes of different interventions to determine the best treatment, developing a consistent standard of care based on that research, and then reliably measuring the quality of that care across the continuum.

Professionals do it better

Many healthcare professionals believe that the key to doing things better is using adequately trained staff. Outcomes studies are already showing that nurses are a key to better, more cost-effective health care, Monarch said. "The studies are showing that the presence and use of registered nurses really does help patients achieve the best outcomes possible," she said. Better outcomes translate to lower costs overall because of fewer expenses treating complications.

Those studies include one funded by the Agency for Health Care Policy and Research and published in the fourth quarter 1998 nursing journal Image. The study found fewer complications in surgical patients at facilities with more nurses per patient. A 1997 ANA-sponsored study by Network Inc. reached similar conclusions.

Yet many facilities continue to replace professional staff with unlicensed assistive personnel in an effort to save on labor costs, to the chagrin of many practitioners. "[Administrators] are looking at a short-term solution that’s ultimately going to cause a long-term problem," said Garland.

Davis agreed. With the increasing complexity of health care, evidence-based practice, and technology, "you need a better educated nurse, not a paraprofessional," she said.

Aides trained on the job may have some of the procedural skills to provide health care, but they don’t have the knowledge to evaluate whether a different intervention is needed, according to Sam Giordano, RRT, MBA, executive director of the American Association for Respiratory Care. "So you get somebody who may be able to provide the motor skills of the procedure, but lacks the ability to decide when the procedure is not warranted anymore," he said. Unnecessary and ineffective treatments drive up costs, Giordano said. Emerging data shows that misallocation of treatments can be diminished with a properly trained professional and the use of protocols, he said.

Patient education

Professional staff are also better able than assistive personnel to educate patients about their condition, Giordano said. "Consumer empowerment [through education] is a key strategy if we’re to balance costs with care," he said. With education, patients use healthcare resources more efficiently and prevent costly complications or emergencies.

Patient education was an integral part of the costly 10- to 12-day hospital stays of the past, said Cathy Michaels, PhD, RN, a post-doctoral fellow in community-based interventions at the University of Arizona College of Nursing in Tucson. Shorter hospital stays have essentially re-engineered that crucial element out of patient care, even though good patient teaching can help keep costs down.

Michaels advocates increasing emphasis on community care to fill the gap in teaching patients about their conditions. Patients can interact with care providers at clinics in their own neighborhood and learn how to make lifestyle adjustments to improve their health—even if they have a chronic disease.

A community-based practice would also improve the patient-provider relationship, she said, which would ultimately decrease costs. "If somebody did not know this very complex person, they would overtreat them," she said. For example, patients who trust their healthcare providers are likely to call them and follow their advice. A fearful patient, though, is likely to call 911 and access the system in the most costly—but not necessarily most effective—way. If patients understand their conditions better, they’re likely to be able to prevent expensive hospitalization, Michaels said.

More evidence needed

More research is needed to prove that suggestions like these do indeed cut costs. The responsibility of providing empirical evidence of their value and cost-effectiveness lies with the professions themselves, Davis said. "No one else is going to make the case for them," she said.

Proving lower costs is not enough, Millenson emphasized. "We need to know that real efficiency is resulting," he said, "not just cost cutting. Only then can there be true savings overall."

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