Balancing Act
As utilization review staff, nurses help managed care organizations balance care with costs

By Phil McPeck
April 30, 2002

In the coldest terms and in many ways, what the federal Patients' Bill of Rights is all about is patient care vs. dollars. And smack dab in the middle of that equation are RNs who, as utilization review staff, help managed care providers determine appropriate interventions and judicious use of health plan resources.

For consumers, enactment of a patients' bill of rights would represent guaranteed emergency room care, access to specialists including pediatricians, obstetricians and gynecologists, and the right to sue for damages-in some amount-resulting from the denial of care. The bill also contains assurances that health professionals would not be restricted from sharing information with patients and that groups of people would not be excluded from health plans based on genetics.

Managed care doesn't mean less care, but it might mean different care, said Diane Huber, Ph.D., RN, FAAN, an associate professor who teaches case management, nursing administration and health care policy at the University of Iowa. "The discussion about a patients' bill of rights helps consumers to be more aware of how to better manage their health care experiences," Huber said. "We're in an era of consumerism in health care."

Mary Foley, MS, RN, president of the American Nurses Association, said that many people in the mid-'90s made an assumption that cost-cutting was all about managed care and that managed care was bad. "It's less keeping the people away from necessary services. Managing care is actually a really good thing. It's nursing. It's holistic," Foley said.

Federal patients' bill of rights proposals require the utilization review process and say that it must be conducted by qualified health professionals.

Utilization review can be "an exciting coordination of care and services and equipment that can be individualized for each patient and family," Foley said. "Having the knowledge, particularly the expertise that a nurse brings to bear to the position, is extremely important."

Huber, who teaches at the undergraduate and graduate levels, said the balancing act between needs and costs is every case manager's dilemma. The concept of utilization review is clear, she said: "Match the patient care needs to the resources and keep them at the appropriate level and facilitate any needed changes. In fact, some cases are clear. Because many situations are sticky, it takes a well-prepared person with judgment skills. A lot of nursing care requires a sophisticated level of skills, knowledge and judgment.

"Probably the most difficult aspect for any care provider is when you come upon that point where an insurance policy or whatever form of reimbursement-whether it's Medicare or whether it's private or anything else-might not be covering certain aspects of care," Huber said. "To deny insurance coverage is to essentially deny care because health care is so expensive … That's where nurses and other providers have ethical challenges as well as practical challenges.

"I think centering upon the code of ethics for nursing, the nurse practice acts in every state and good nursing care usually guides people out of the worst of the land mines."