- Email: [email protected]
Building bridges between the clinical provider and payer systems: A timely challenge for the nursing profession
Insights and Inquiry Building Bridges Between the Clinical Provider and Payer Systems: A Timely Challenge for the Nursing Profession NE OF THE REASONS I have stayed in nursing more than 30 years is the fact that there is always O some new area to conquer and interesting things to learn. With that principle guiding my choices, last year I commenced a new chapter in my career by accepting a newly created position at CIGNA HealthCare in Hartford, CT, the insurance capital of the world. The position is one of nurse leader in the area of medical strategy and health policy, which means that in my role I have the opportunity to influence the quality of the member services involved in health benefits management, from the perspective of a nurse. My assignment in coming to this role was to build a cohesive nursing community among the more than 3,200 nurses employed by CIGNA HealthCare. Transitioning from an 8-year nursing leadership and health policy role at the Department of Veterans Affairs in Washington, DC, and then moving into the milieu of a Fortune 500 company—CIGNA HealthCare serves 14.2 million members—was an exciting challenge. In this setting I have become a student again because I have been required to be an astute learner of a wide variety of topics, not the least of which is how health insurance benefits actually work. But what I did not know about the insurance benefits industry, but am learning, was made up for by the fact that I understand nurses and their value to any organization. As I began my journey in this new world, I wore the lens of both a nurse executive and the lens of the average consumer. Because I could not present myself as an insurance expert, I was unfettered with the details of how the business is conducted. Early on I could be free to learn the business and the culture through a combination of reading, observing nurses and others at work, and talking with as many different people as I could
NANCY M. VALENTINE, RN, PHD, MSN, MPH, FAAN National Nursing Executive, CIGNA HealthCare, Medical Strategy and Health Policy, Hartford, CT E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 8755-7223/02/1805-0005$35.00/0 doi:10.1053/jpnu.2002.129578
find in a day’s time. From the very start, I adopted the approach that before being able to build a nursing clinical community identity, I needed to first learn about the existing nursing community, within the business context in which nurses are employed. When I came to the company, I was not sure if some of the stereotypes of what nurses in the insurance industry generally are understood to do, which often is interpreted to be to “just say no,” was indeed what I would find. Also, because managed care is often demonized in the press, I was not sure if I would find that these nurses were somehow different from those in clinical arenas. From these many interactions over the past year, there were two areas that I found to be particularly noteworthy. The first was how many different roles nurses have in the company and the second was the characteristics of the nurses themselves. With my average consumer lens I was surprised to find how many more roles nurses have than the gatekeeper role most often associated with the nurses in health plans. Nurses are involved in a wide spectrum of programs that are focused on disease management for disorders such as heart disease, diabetes, and asthma. Participation in advocacy programs such as the Pink Ribbon campaign in which CIGNA HealthCare nurses set up phone banks and call members reminding them to have their annual mammography screening was an eye-opener. Nurse case managers function in roles similar to their counterparts in the delivery system in which they assist members and their families to access care, follow-up with appointments, and provide support in moving on to independence. And in cases in which the case management relationship was long term, such as in an organ transplant case, nurses developed close interpersonal relationships with members and supported them through the good times and the not-so-good times. Often they continued in short-term supportive grief work with surviving family members, assisting them to get needed services that contributed to their health and wellness. The day-to-day services that these nurses provide to
Journal of Professional Nursing, Vol 18, No 5 (September–October), 2002: pp 253-254
253
254
the members often can be viewed as the behind the scenes work of the company, when in fact it is in many ways at the heart of what is going on in health plans. If the public and the broader nursing profession knew more about this range of services and how helpful nurses are in assisting members in navigating the health care system, I think there would be a more positive view of managed care overall. As for the nurses themselves, they are the same as nurses on the care delivery side of the health care equation. Some have come to CIGNA HealthCare seeking a change from the frantic pace of a hospital. Others have come because they found that their roles as case managers, for example, have given them more time to focus on a particular client than they had in the transactional clinical environments. And still others, such as myself, have come because we were attracted to a new area and to gain new and different experiences. I found that CIGNA HealthCare nurses seek to make a difference just as every other professional nurse I have ever met has strived to do. They are nurses. Although there are adaptations that need to be made in a business setting such as conducting much of their work by phone, their basic natures and desire to help members have not changed. What I recognized is that there are barriers that need to be broken down in the provider community. Nurses in health plans told me stories of colleagues who accused them of being traitors for leaving the clinical units, where colleagues were left with more overtime
VALENTINE
shifts to fill. Or on-site review nurses spoke of how they were not allotted space to plug in their computers to do their chart review work in the hospitals, or instances in which they were verbally attacked by doctors in front of others for dictating care. It did not take me long to realize that this world needs to be opened up, explored, and acknowledged within the nursing profession. Perpetuating a view that health plans are the dark side or believing that nurses are no longer helping people when working for a health plan is not only inaccurate, but does nothing to benefit the larger nursing community. Knowledge of evidence-based care and best practices, in which quality and cost outcomes intersect, is the basis of health benefits administration that can be shared with clinical nurse colleagues to the benefit of all. If bridges of greater understanding are built between the clinical provider and payer communities, I think we will find that each has much to learn from the other, and, most importantly, that the people we all care about may be even better served as a result. “CIGNA HealthCare” refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company; CIGNA Vision Care, Inc.; Tel-Drug, Inc. and its affiliates; CIGNA Behavioral Health, Inc.; Intracorp; and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.
NANCY M. VALENTINE, RN, PHD, MSN, MPH, FAAN National Nursing Executive, CIGNA HealthCare, Medical Strategy and Health Policy, Hartford, CT E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 8755-7223/02/1805-0005$35.00/0 doi:10.1053/jpnu.2002.129578
find in a day’s time. From the very start, I adopted the approach that before being able to build a nursing clinical community identity, I needed to first learn about the existing nursing community, within the business context in which nurses are employed. When I came to the company, I was not sure if some of the stereotypes of what nurses in the insurance industry generally are understood to do, which often is interpreted to be to “just say no,” was indeed what I would find. Also, because managed care is often demonized in the press, I was not sure if I would find that these nurses were somehow different from those in clinical arenas. From these many interactions over the past year, there were two areas that I found to be particularly noteworthy. The first was how many different roles nurses have in the company and the second was the characteristics of the nurses themselves. With my average consumer lens I was surprised to find how many more roles nurses have than the gatekeeper role most often associated with the nurses in health plans. Nurses are involved in a wide spectrum of programs that are focused on disease management for disorders such as heart disease, diabetes, and asthma. Participation in advocacy programs such as the Pink Ribbon campaign in which CIGNA HealthCare nurses set up phone banks and call members reminding them to have their annual mammography screening was an eye-opener. Nurse case managers function in roles similar to their counterparts in the delivery system in which they assist members and their families to access care, follow-up with appointments, and provide support in moving on to independence. And in cases in which the case management relationship was long term, such as in an organ transplant case, nurses developed close interpersonal relationships with members and supported them through the good times and the not-so-good times. Often they continued in short-term supportive grief work with surviving family members, assisting them to get needed services that contributed to their health and wellness. The day-to-day services that these nurses provide to
Journal of Professional Nursing, Vol 18, No 5 (September–October), 2002: pp 253-254
253
254
the members often can be viewed as the behind the scenes work of the company, when in fact it is in many ways at the heart of what is going on in health plans. If the public and the broader nursing profession knew more about this range of services and how helpful nurses are in assisting members in navigating the health care system, I think there would be a more positive view of managed care overall. As for the nurses themselves, they are the same as nurses on the care delivery side of the health care equation. Some have come to CIGNA HealthCare seeking a change from the frantic pace of a hospital. Others have come because they found that their roles as case managers, for example, have given them more time to focus on a particular client than they had in the transactional clinical environments. And still others, such as myself, have come because we were attracted to a new area and to gain new and different experiences. I found that CIGNA HealthCare nurses seek to make a difference just as every other professional nurse I have ever met has strived to do. They are nurses. Although there are adaptations that need to be made in a business setting such as conducting much of their work by phone, their basic natures and desire to help members have not changed. What I recognized is that there are barriers that need to be broken down in the provider community. Nurses in health plans told me stories of colleagues who accused them of being traitors for leaving the clinical units, where colleagues were left with more overtime
VALENTINE
shifts to fill. Or on-site review nurses spoke of how they were not allotted space to plug in their computers to do their chart review work in the hospitals, or instances in which they were verbally attacked by doctors in front of others for dictating care. It did not take me long to realize that this world needs to be opened up, explored, and acknowledged within the nursing profession. Perpetuating a view that health plans are the dark side or believing that nurses are no longer helping people when working for a health plan is not only inaccurate, but does nothing to benefit the larger nursing community. Knowledge of evidence-based care and best practices, in which quality and cost outcomes intersect, is the basis of health benefits administration that can be shared with clinical nurse colleagues to the benefit of all. If bridges of greater understanding are built between the clinical provider and payer communities, I think we will find that each has much to learn from the other, and, most importantly, that the people we all care about may be even better served as a result. “CIGNA HealthCare” refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company; CIGNA Vision Care, Inc.; Tel-Drug, Inc. and its affiliates; CIGNA Behavioral Health, Inc.; Intracorp; and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.