Monday, November 9, 2009

What’s A Smile Worth These Days?

Medical personnel, like anyone else, like to get paid for what they do--usually as much as possible. Historically, the more “free-market” sentiment of the US has resulted in higher pay rates south of the 49th for the same work done north of the border. Canadians have long complained about the “brain-drain” of the US market on Canadian knowledge workers. Canadian industries lose technologists taking their education at UBC to Seattle and Cupertino; Phd geologists running to Texas after a winter in Edmonton, and; doctors porting their Quebecois licenses to join partnerships in New York. Stories are told in all fields--well, almost all fields. Nurses seem to stay where they are. But then, a nursing license does not mean the same thing across a border---or even across a state line. For a role so valued by society, this lack of portability is unusual. Do nurses do the same thing north of the border that they do in the States?

Nurses are famously underpaid, overworked and underappreciated. They are in the middle of pretty much anything going on in healthcare. Wherever you go they are there with you--from intake to invasive surgeries. Nurses have long held forth that “Nothing would happen without nurses;” yet, they are financed like an appliance--as just one more overhead cost of a doctor’s practice.

“If it cannot be measured, it cannot be managed,” say the MBAs. In this case, if it cannot be measured, it cannot be monetized. There is no way to accurately measure and to compare what nurses do in modern medicine. No standard CPT codes exist to document the work of nursing staff--nor of the services asked of them. No CPT codes means no reimbursements--not by insurance companies, not by governments. And so, while nurses are indispensable like lights and heating, they are paid the same way--as overhead to be managed by the accounting department.

If one asks, nurses will tell you that nursing is an artform--a creative, more intuitive, less rigid service bound to the fixed tasks of physical care. Like any artform, those who know it best often have trouble reducing it to descriptors and numbers. The choreographer Merce Cunningham left notes that are an unintelligible collection of stick figure drawings. They fail to capture the essentials of his work, and it is feared that his dances will be lost forever. Like modern dance, nursing is very much about the people involved; and like dancers, nurses are often compensated as fixed-price resources (“members of the Company”) without consideration of quality or breadth of performance.

Treating skilled human resources as commodities is not the best way to enable retention or quality. But if nursing staff are to be managed as anything other than a poorly defined “support service” to “real” providers, then their tasks and skills need to be measured. And coded. And billed. And reimbursed.

That means CPT coding of nursing services. With clear coding, nurses would be able to justify their salary expectations. The profession could better classify and qualify nursing skills. Facilities could better manage care by controlling nursing skills against better projected patient-care requirements. And patient care could be better standardized across facilities, across regions and across borders. Nursing could be portable.

But what would be coded? Can the delivery of just the right smile and touch of a hand to calm a hyperventilating child be measured? Would there be a triple-sub code for “touch:with gentle squeeze:lower extremity:upper?”

Human interaction studies, time-and-task research and human-factors studies are making the tools for these measurements more available and easier all the time. Codes can be developed and standardized. So why are they not ready now?

In the US (the largest market for coding and coding resources), insurance companies have little interest in documenting nursing services. In the fee-for-service model used by these businesses, coding nursing would just result in more services to be paid. While nursing goes undocumented, the costs are passed along to the providers and the facilities. Provider groups like the American Medical Association see no upside in coding nursing services, as an expected result would be a reduction in those fees paid the member doctors.

Still, there have been a number of efforts to code nursing in various ways. Mostly, these efforts have been by hospitals and provider groups working to manage nursing skills against patient-care requirements. Coding has also been developed to try to measure performance against outcomes. None of these coding schemes has been pervasive or standardized in any way.

And there may be another reason why not--nurses themselves. Some nurses are quick to declare “without nurses, the hospital would collapse.” Yet they will also refuse to describe what they do in detail. “Nursing is an art,” they will say, “and you can’t just break it down into widgets and codes.” Might it be--and this is a serious question--that nurses do not want their work measured and coded? Might some be afraid that if nursing were broken down into a documentable craft, instead of an inchoate art, it would reduce nurses to replaceable technicians? Are nurse afraid of becoming machinists?

What do you think?