Analyze This
Utilization review nurses must painstakingly weigh cost issues against their primary obligation to patient care

By Glen Fest
February 19, 2004

The family of a hospice patient decides after admittance that they want their loved one back on life-extending medications—while remaining at the hospice. The parent of a child treated for lacerations at an emergency room demands an alternative (but medically unnecessary) second dressing, and wants the insurance company to pay for it.

For nurses working in utilization review, choosing to approve or deny care proves a daily test to their ethical resolve. They weigh their responsibility to patient need against medical necessity provisions under managed care organizational guidelines, and provide the “yea” or “nay” on medical procedures.

“It’s often difficult for nurses to follow protocols because they hear the emotion behind the need or behind the request, and they want to take care of that,” said Sue Ellen Bell, Ph.D., RN, an associate professor and researcher at Detroit’s Wayne State University College of Nursing.

Some decisions are black-and-white, and others are as gray as the hairs that utilization review nurses grow fretting over tougher choices. Dealing with these dilemmas is becoming more crucial for these nurses, say experts, as the ranks of the uninsured in America grow and pressure mounts to contain costs through siphoned care parameters.

Increasingly, many are facing these choices on their own without ethical guidance or support from their managed care organizations, according to a recent study by Bell published in Nursing Administration Quarterly.

A large majority of utilization review nurses interviewed in the study said their organizations lacked formal ethics committees. Less than 10 percent of those surveyed said their employers had a process in place for dealing with ethical issues in the utilization review environment.

This represents a critical shortcoming, Bell said, because utilization review RNs are frequently the final arbiter in the approval chain.

“In utilization review, I think the nurses are much more autonomous than they are in a hospital setting,” Bell said. “The [utilization] cases usually only go to a physician if there’s some sort of appeal or there’s some question the nurse has in making the decision.”

Many with a background in the utilization review field, including Bell, said recognition of the primacy of patient need in the nurse’s code of ethics has grown substantially within the managed care field during the past decade.

“Utilization review has evolved significantly,” said Shelly Martin, MHSA, RN, president-elect of the American Association of Managed Care Nurses in Glen Allen, Va. “We want to make sure the patient gets everything they need in the benefit plan. I think, for the most part, utilization review nurses are looking for reasons to approve the care.”

“The role of the nurse has to be that of patient advocate, and that doesn’t change because the nurse changes to a managed care position,” said Rhonda Sortullu, RN, a member of the board of directors for the association.

Ethical catch-22

The prevalence of ethical catch-22s is a long-standing concern for all nurses, and has prompted the periodic update of nurse ethics guidelines through the American Nurses Association. The most recent changes occurred in 2001, when nursing’s ethical responsibility to patient efficacy in research and management was codified.

“The earlier versions of the code were more geared toward staff nurses,” said Laurie Badzek, JD, RN, director of ethics and human rights at the ANA and a professor in the school of nursing at West Virginia University. “But when we redid the code, we made sure it covered a broader base of nurses. And when you look at that document, it doesn’t necessarily speak to any specific situations.”

Bell culled numerous examples of utilization review nurses caught between their ethical leanings for patient care and organizational goals. The uninsured wife of a covered cardiac patient refuses to let the home health care team treat him unless they give her care, too. Sometimes, it’s the pressure to do something illegal, such as when an employer asks for the denial of a workers’ compensation claim not because a worker is faking an injury, but because the worker is a “malingerer” on the job.

In ethics, “we tend to think about the big questions like abortion, genetic engineering,” Bell said. “Perhaps what is more important to nurses are the ethics of things that happen day to day.”

But without an organizational code of ethics, according to Bell’s report, utilization review nurses are left to rely on professional ethics codes and personal beliefs. Frequently, those two issues might collide in case management, Bell said. When utilization review nurses are “asked to make a decision based not on this individual patient, but based on the average patient or the patient in general, that’s very difficult for nurses to do,” she said.

“It’s a direct conflict between those two because you have to take a population point of view if you’re going to use protocols,” Bell said, “and that’s different from taking an individual point of view.

Different outlooks

Many utilization review nurses adopt the view that the nurse and patients have different outlooks. One respondent to Bell’s study noted that patients want individual attention to medical needs, but the utilization review nurse “has a different paradigm. The benefit is for all, not just for one. The nurse thinks about the patient, the provider, the employer, the insurance company, etc.”

The need to make such judgments stirs debate on how ethical guidelines for case management can be improved. Nurse administrators within managed care organizations are encouraged to develop structured ethical decision-making support for nurse utilization reviewers, according to experts.

But there are apparent signs in recent years that the ethics concerns of utilization review nurses are being considered by their employers.

Another study by Bell showed a majority of surveyed utilization review nurses are not being used as “technical resources” to justify claim denials in managed care organizations, and that most utilization review nurses still base a majority of their decisions on care-based criteria.

“We have had no [national] discussion of the real need to have rationing or maybe cutting down on excess medical care when we have so many people who don’t have any sort of good medical insurance coverage,” Bell said. “So, in lieu of having some sort of public debate, it’s nice to have a nurse making those decisions, because at the base of nursing is this idea that we will be benefiting the patient.”

Contact Linda Childers at eastbaypr@aol.com.