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Nurses also would demand and get more respect from physicians and administrators, Sanford said. They would sit on hospital boards and would be consulted about hospital policy changes. "If nurses ran the system, there would be a better relationship between doctors and nurses," she said.

"We would say, 'We're your equal and we're going to work together.' "

Senior support

A nurse-run system also would deal differently with issues around aging and dying. "They'll probably pay attention to it, which is a lot different from what we have now," said Bernice Buresh, a health journalist and co-author, with Suzanne Gordon, of From Silence to Voice: What Nurses Know and Must Communicate to the Public, a book about the need for nurses to speak out.

Now, older people go to the doctor, get more medications and go home, Buresh said. "It's not really a care system at all." Nurses would look at ways to manage chronic illnesses through other methods than strictly medication. They would look for environmental and social factors that might affect an elderly person's health.

Porter-O'Grady, a nurse gerontologist, said nurses would be more in tune with the idea of "aging in place," keeping people at home rather than sending them to institutions. The largest part of the U.S. population is between 45 and 70 years old, he noted. Money will be insufficient to care for everyone in institutions.

Nurses would work to provide more home care, elderly support services and aging communities where people could support each other. "We need to keep people independent for as long as life permits," he said.

Nurses also would focus on palliative care and quality of life rather than new interventions for people who did not have much longer to live. They probably would allow more people to die than the present system does, Sanford said.

Waste not

Many nurses said they would not ask for more money to spend on a nurse-run health care system. "I think the distribution is inadequate," Porter-O'Grady said. "I think we have as much waste in health spending as anywhere else."

The United States spends about $6,000 per person on health care annually, far more than any other country, Buresh said. But the country is ranked 37th by the World Health Organization in health care quality, she said. "We fritter away 35 percent to 50 percent of our health care dollars on administration, marketing, lack of coordination in health care facilities, middlemen, profit-making and fraud."

Lundeen estimates that costs saved from reduced emergency room visits alone could provide enough money to set up community clinics in most urban areas. Blakeney quoted a report estimating that 39 cents of every health care dollar was spent on administration, something that could easily be reduced with better methods of documentation. Something as simple as legislation requiring that all insurance companies use the same billing codes would save an enormous amount of money and nursing time, she said.

Nurses would make great cost-cutters because they are the ones at the bedside, seeing where the waste occurs, Johnson said. "Most nurses are cost-effective up the wazoo. Nurses could tell you right now about waste because they're usually standing around crabbing about it."

If nurses were working directly with the pharmacists, she said, they wouldn't have to spend time dissolving pills because patients are too ill to swallow them. If they worked with architects, they could help design patient rooms that saved nurses time lifting, turning and walking.

Because nurses know how much care actually costs-and because they have nothing to gain by overcharging the system-they could design a Medicaid and Medicare reimbursement system that accurately reflected how much should be spent on each patient, Johnson said. Nurses' notes would count as much as physicians' notes in determining reimbursement, Sanford said.

"Nurses could tell which patients are the most difficult, consume the most care and should be paid more for," Sanford said.

Nurses also see duplication in tests and procedures that could be avoided with good patient management, Sweeney said.

One specialist might order an ECG, not realizing that the patient had just had an ECG a week ago, ordered by another physician. "Was there a true need for that duplication?" she asked.