HEALTH POLICY AND
POLITICS
Nursing leadership: influencing and shaping health policy and nursing
practice
The leadership discourse in the United Kingdom has to date
been concerned with professional issues and as a result has focused upon
developing nurses and nursing. This paper reports on the findings of a research
study which examined the broader socio-political factors impacting upon nursing
leadership. The study forms an integral part of the Royal College of Nursing's
leadership programme. The principal aim of the research was to examine
critically contemporary nursing leadership within the context of health policy.
An ethnographic approach was used. Informal semi-structured interviews were
undertaken with a purposive sample of 24 leaders who were recognized for their
effectiveness in leading nursing. Data were analysed for themes. The main
themes are presented and discussed here. The findings of the study question the
political success which the internally focused nature of leadership has had for
the profession. Nursing and therefore nursing leadership is shaped dramatically
by the impact of politics and policy. The research discovered that in
recognition of this, contemporary nursing leadership has both an internal and
an external focus. That is, effective nursing leadership currently is a vehicle
through which both nursing
practice and health policy can be influenced and shaped. The research also
identified the profile of the effective nurse leader, together with the
processes through which leaders interpret and translate between the macro
issues of policy and the micro issues of practice. In addition, an
understanding of what nursing leadership is, has been proposed. Appropriate
recommendations for the future of nursing and nursing leadership are outlined.
Purpose: To
describe ways nurses are and are not effective in the development of health
policy in the United States today, and to provide useful information for those
interested in making nursing a more vital part of the policy arena.
Design: Qualitative
examination of the career experiences and observations of a purposive sample of
27 American nurses currently active in health policy at the national, state,
local, or organizational level.
Method: Semi-structured
interviews regarding career path, contributing resources improvement of
resources available to nurses, and the strengths and weaknesses of currently
available information for policy work.
Findings: For
nurse participants, policy involvement meant speaking for patients in arenas
where those need of care have limited voice. Participation occured after
assessment, diagnosis, and planning revealed the need for change in the way
resources were allocated. Strong belief in the capacity and importance of people
caring for themselves distinguished nurses in their policy roles. Policy makers
responded to the experiences and determinants of health and illness as
presented by nurses.
Conclusion: Once
engaged, nurses seldom turned their backs on the world of policy-making.
However, they did not report significant use of nursing research or information
in policy making. Further investigation and testing of systems to connect nurse
policymakers with nurse scholars are recommended.
A new conceptual model of nursing and health policy was designed to
extend substantive knowledge of health policy within the discipline of nursing
through policy analysis, policy or program evaluation, and disciplinary
research that are conducted at five levels.
Level 1 focuses on the effectiveness of nursing practice processes on
the health outcomes of individuals, families, groups, and communities.
Level 2 focuses on the efficiency of nursing practice delivery systems.
Level 3 focuses on the effectiveness and efficiency of a specific
health care delivery system.
Level 4 focuses on equity of access to effective and efficient nursing
practice processes and nursing practice delivery systems.
Level 5 focuses on social justice. The five levels interact with health
policies and both constitute and are constituted by health policies. Of special
interest are the health care services, personnel, and expenditures components
of health policies formulated by geopolitical and governmental entities and
institutions and organizations.
Canada's national health insurance system
has also been subject to technological change and turmoil — strident debate
over cost controls, the availability of medical technology, hospital closures,
and the appropriate role of investor-owned providers. But its organizational
structure has changed little. We evaluated whether the adoption of a more
businesslike attitude, the proliferation of HMOs, and the automation of billing
and clerical tasks have trimmed administrative costs in the United States and
whether Canada's administrative parsimony has persisted in the years since our
earlier study.
To estimate administrative costs, we
sought data on insurance overhead, employers' costs to manage benefits, and the
administrative costs of hospitals, practitioners' offices, nursing homes, and
home care. Our estimates use 1999 figures, the most recent comprehensive data.
We used gross-domestic-product purchasing-power parities to
convert Canadian dollars to U.S. dollars, and we used SAS software for data
analyses.
We obtained figures for insurance
overhead and the administration of government programs from the Centers for
Medicare and Medicaid Services8 and
the Canadian Institute for Health Information.
For the United States, we used a
published estimate of employers' spending for health care benefits consultants
and internal administration related to health care benefits in 1996. We
used this figure to estimate 1999 costs on the basis of the growth in health
care spending among employers in the private sector. No
comparable figures are available for Canada. We assumed that employers'
internal administrative costs plus the costs of consultants (as a share of
employers' health care spending) are the same in Canada as in the United
States.
For the United States, we calculated the
administrative share of hospital costs by analyzing data from fiscal year 1999
cost reports that 5220 hospitals had submitted to Medicare by September 30,
2001, using previously described methods. For
Canada, we and colleagues at the Canadian Institute for Health Information
analyzed cost data for fiscal year 1999 (April 1, 1999, through March 31, 2000)
for all Canadian hospitals except those in Quebec (which use a separate cost-reporting
system), using methods similar to the ones we used to calculate costs in the
United States. When questions arose about the comparability of expense
categories, we obtained detailed descriptions of the Canadian categories from
Canadian officials and consulted U.S. Medicare auditors to ascertain where such
costs would be entered on Medicare cost reports. For both countries, we
multiplied the percentage spent on administrative costs by total hospital
spending.
We calculated the administrative costs of
U.S. physicians by adding the value of the physicians' own time devoted to
administration to estimates of the share of several categories of office
expenses that are attributable to administrative work. We determined the
proportion of physicians' work hours devoted to billing and administration from
a national survey and
multiplied this proportion by physicians' net income before taxes. We
calculated the costs of administrative work by nurses and other clinical employees
in doctors' offices by assuming that they spent the same proportion of their
time on administration as did physicians. We calculated the value of this time
on the basis of total physicians' revenues and
survey data on doctors' payroll costs from the American Medical Association.
We attributed all of physicians' expenses for clerical
staff to administration. Although administrative and clerical workers accounted
for 43.8 percent of the work force in physicians' offices (unpublished data),
we attributed only one third of office rent and other expenses (excluding
medical machinery and supplies) to
administration and billing.
Accounting, legal fees (excluding the
cost of malpractice insurance), the costs of outside billing services, and
other such costs are subsumed in “other professional expenses,” half
of which we attributed to administration.
To estimate the administrative expenses
of dentists (and other nonphysician practitioners), we analyzed data on
administrative and clerical employment in practitioners' offices from the March
2000 Current Population Survey using previously described methods. Administrative
and clerical employees' share of office wages was 43 percent lower in the case
of dentists' offices and 14 percent lower in the case of other nonphysician
practitioners' offices than those of physicians' offices. We assumed that the
administrative share of the income of dentists and other nonphysician
practitioners mirrored these differences.
To calculate administrative costs in
Canada, we obtained figures from a Canadian Medical Association survey on the
proportion of physicians' time devoted to administration and practice
management and multiplied this proportion by
physicians' net income before taxes. To
calculate the cost of nonphysician staff time, we used figures from Canadian
Medical Association surveys of physicians' expenditures for office staff, which did not distinguish between
clinical and administrative staff. We analyzed special 1996 Canadian Census
tabulations to determine administrative and clinical workers' shares of total
wages in doctors' offices. We
attributed all of the administrative workers' share to administration and
assumed that nonphysician clinical personnel spend the same proportion of their
time on administration as did physicians.
To calculate the costs of office rent and
similar expenses, we attributed one third of physicians' office rent, lease,
mortgage, and equipment costs to
administration and billing. We attributed half of other professional expenses to
administration. To calculate the administrative expenses of nonphysician
office-based practitioners in Canada, we used the same procedure that we used
for the U.S. data and based the analysis on 1996 Canadian Census data.
No published nationwide data on the
administrative costs of U.S. nursing homes are available for 1999, and only
Medicare-certified facilities (which are not representative of all nursing
homes) file Medicare cost reports. However, California collects cost data from
all licensed homes. Therefore, we analyzed 1999 data on 1241 California nursing
homes, grouping expenditures into three broad
categories: administrative, clinical, and mixed administrative and clinical.
We used methods similar to those employed
in our hospital analysis to
allocate expenses from the “mixed” category to the clinical and administrative
categories. To generate a national estimate, we multiplied the administrative
share of expenditures by total nursing home spending.
For Canada, we and colleagues at the
Canadian Institute for Health Information analyzed data for fiscal year 1998
(April 1, 1998, through March 31, 1999) on administrative costs for homes for
the aged (excluding Quebec) from Statistics Canada's Residential Care
Facilities Survey, using methods similar to those we used for the U.S. data. We
multiplied the share spent for administration by total nursing home
expenditures in Canada.
We analyzed data from fiscal year 1999
cost reports that 6633 home health care agencies submitted to Medicare. We
excluded agencies reporting implausible administrative costs that were below 0
percent or above 100 percent and then calculated the proportion of expenses
classified as “administrative and general.”
For Canada, we obtained data on
administrative costs in Ontario; the categories used appeared similar to those
used in the U.S. data.
We totaled the
administrative costs of Community Care Access Centres, which
contract with home care providers; home care providers (White G, Ontario
Association of Community Care Access Centres: personal communication); and
provincial government oversight of home care. We multiplied the proportion
spent for administration by total home care spending throughout Canada.
To calculate total spending on health
care administration, we totaled the administrative costs of all the categories
detailed above. In analyzing the administrative share of health care spending,
we excluded from both the numerator and the denominator expenditure categories
for which data on administrative costs were unavailable: retail pharmacy sales,
medical equipment and supplies, public health, construction, research, and
“other,” a heterogeneous category that includes ambulances and in-plant
services. These excluded categories accounted for $261.2 billion, 21.6 percent
of U.S. health care expenditures, and $21.0 billion, 27.6 percent of Canadian
health care expenditures.
How much administration is optimal? Does
the high administrative spending in the United States relative to that in
Canada (or to that in the United States 30 years ago) improve care? No studies
have directly addressed these questions. Although indirect evidence is sparse,
analyses of investor-owned HMOs and hospitals — subgroups of providers with
relatively high administrative costs — have found that for-profit facilities
have neither higher-quality care nor lower costs than not-for-profit facilities. Internationally,
administrative expenditures show little relation to overall growth in costs or
to life expectancy or other health indicators.
Several factors augment U.S.
administrative costs. Private insurers, which have high overhead in most
nations — 15.8 percent in Australia, 13.2 percent in Canada, 20.4 percent in
Germany, and 10.4 percent in the Netherlands —
have a larger role in the United States than in Canada. Functions essential to
private insurance but absent in public programs, such as underwriting and
marketing, account for about two thirds of private insurers' overhead.
A system with multiple insurers is also
intrinsically costlier than a single-payer system. For insurers it means
multiple duplicative claims-processing facilities and smaller insured groups,
both of which increase overhead. Fragmentation
also raises costs for providers who must deal with multiple insurance products
— at least
The existence of global budgets in Canada
has eliminated most billing and minimized internal cost accounting, since
charges do not need to be attributed to individual patients and insurers. Yet
fragmentation itself cannot explain the upswing in administrative costs in the
United States since 1969, when costs resembled those in Canada.
This growth coincided with the expansion
of managed care and market-based competition, which fostered the adoption of
complex accounting and auditing practices long standard in the business world.
Several caveats apply to our estimates.
U.S. and Canadian hospitals, nursing homes, and home care agencies use
different accounting categories, though we took pains to ensure that they were
comparable. The U.S. hospital figure is consistent with findings from detailed
studies of individual hospitals. The
California data we used to estimate the administrative costs of U.S. nursing
homes resulted in a lower figure (19.2 percent of revenues) than a published
national estimate for 1998 (25.2 percent).
Our figures for physicians'
administrative costs relied on self-reports of time and money spent. We had to
estimate the time spent by other clinical personnel on administrative work and
the share of office rent and expenses attributable to administration (together,
these estimated categories account for 5 percent of total administrative costs
in the United States). Physicians' reports and our estimates appear congruent
with information from a time–motion study
and Census data on clerical and administrative personnel
employed in practitioners' offices. Our estimates of employers' costs to
administer health care benefits rely on a consultant's survey of a limited
number of U.S. firms. Though subject to error, this category accounts for only
5 percent of administrative costs in the United States.
Cross-national comparisons are
complicated by differences in the range of services offered in hospitals and
outpatient settings. For instance, many U.S. hospitals operate skilled-nursing
facilities, whose costs are lumped with hospital costs in the national health
accounts. Similarly, the costs of free-standing surgical centers, more common
in the United States than in Canada, are lumped with practitioner costs.
Although these differences shift administrative costs among categories (e.g.,
from nursing homes to hospitals), their effects on national totals should be
small.
Price differences also affect
international comparisons, a problem only partially addressed by our use of
purchasing-power parities to convert Canadian dollars to U.S. dollars. (Using
exchange rates instead would increase the difference between the United States
and Canada by 27 percent.) Canadian wages are slightly lower than those in the
United States, distorting some comparisons (e.g., per capita spending), but not
others (e.g., the administrative share of health care spending or personnel).
Our dollar estimates understate overhead
costs in both nations. They exclude the marketing costs of pharmaceutical
firms, the value of patients' time spent on paperwork, and most of the costs of
advertising by providers, health care industry profits, and lobbying and
political contributions. Our analysis also omits the costs of collecting taxes
to fund health care and the administrative overhead of such businesses as
retail pharmacies and ambulance companies. Finally, we priced practitioners'
administrative time using their net, rather than gross, hourly income,
conservatively assuming that when physicians substitute clinical for
administrative time, their overhead costs rise proportionally; using gross
hourly income would boost our estimate of total administrative costs in the
United States to $320.1 billion.
The employment figures used for our
time-trend analysis exclude administrative employees in consulting firms, drug
companies, and retail pharmacies, as well as insurance workers, who are far
more numerous in the United States than in Canada. Number of Enrollees and Employees of Selected Major U.S.
Private Health Insurers and Canadian Provincial Health Plans, 2001.).
Despite these imprecisions, the
difference in the costs of health care administration between the United States
and Canada is clearly large and growing. Is $294.3 billion annually for U.S.
health care administration money well spent?
Supported by a grant (036617) from the
Robert Wood Johnson Foundation.
Policy encompasses the
choices that a society, segments of society, or organizations make regarding
its goals and priorities and the ways it will allocate its resources. It reflects
the values of those setting the policy. (5)
Nurses maintain values that promote
individualized patient care and collaboration among health care professionals.
(6) It is important that nurses are represented in the formation of health care
policy and that these values, as well as nursing knowledge and expertise, are
shared with politicians and reflected in quality health care legislation that
is cost-effective. Nursing's active involvement in the molding of public policy
through political commitment is a necessity; it is not enough to wait and see
where legislation takes the profession and how changes in public policy will
affect patients. If nurses do not become involved and employ a values-laden
approach to politics, they have no power over their own future, and health care
will suffer from their lack of participation.
Politics is viewed by most in a
traditional manner, when in reality, politics involves many facets of everyday
life, in addition to the legislative arena. The traditional approach to politics
is reactive. Typically, people consider political action to be composed of
lobbying, letter writing, voting, and other conventional means of influencing
politicians and public policy initiatives. The nontraditional approach to
politics is proactive. (7) One component of proactive politics is public
education regarding such issues as
* preventive health care,
* staffing levels in hospitals,
* Medicare reimbursement issues, and
* the political structure of the health
care system.
Nurses and the general public need to
move past the assumption that traditional political approaches are the only way
to influence public policy. Non-traditional approaches, such as professional
practitioner visibility, membership on local school boards, and involvement in charitable
organizations, are extremely effective methods of influencing public opinion
regarding nursing's role at the community and national levels. (8)
When nurses rise to a level of political
awareness, most tend to have a narrow political focus that centers on specific
issues directly concerning the nursing profession (ie, staffing levels for
nurses). (9) One author, however, states, "Politics affect virtually all
levels of individual and community life." (10) Nurses need to incorporate
this mentality into their political repertoire and address not only specific
nursing issues but also major social issues that affect the general public and
the nursing profession in an indirect manner. Most nurses are aware, to some
extent, of legislation that involves health care reform and nursing practice.
Nursing organizations are involved heavily in protecting or promoting these
agendas and make an effort to inform their members and solicit their support.
Nurses and nursing organizations often
ignore issues that affect public health on a national and international level
because these issues do not directly involve their specialty. These issues
include environmental protection and social problems (eg, unemployment,
poverty), which are not always seen as direct contributors or detractors to
public health. These issues most certainly involve the welfare and health of
the public, and nurses have significant insight into how these issues will
affect the world population. Nurses hold a level of stature that is highly
respected and trusted. They are viewed as professionals who truly are
interested in the welfare of others. The role of nurses in health promotion is
recognized by international, national, and state organizations. (11) Organized
support of these issues can greatly affect world health, so nurses have a duty
to investigate their role and increase their level of participation. This type
of empowerment broadens nursing's political focus and increases respect for the
profession on all political levels.
POLITICAL KNOWLEDGE AND INFLUENCE
Nurses, as individuals, frequently do not
address political issues that affect the profession. A lack of knowledge of the
legislative process causes them to be overwhelmed by the complexity of public
policy. Nurses focus on clinical care and sometimes ignore larger issues,
partially due to a heavy workload, but also due to a lack of understanding of
how to influence public policy. Governmental bodies influence or control many
issues that affect nurses' clinical environment, such as
* nurse practice acts,
* reimbursement issues,
* resource allocation,
* Medicare reimbursement, and
* health care structure reform.
Yet nurses often do not see the
relationship between their lack of political action and their inability to
influence health care policy decisions, which in mm, affects their clinical
environment. (12)
Public policy formation. There are four
main steps in the process of public policy formation: setting an agenda,
government response, policy design, and program implementation. (13) The first
step is setting an agenda, which entails identifying and defining the problem
to ascertain how much of the population might be affected by the problem. This
affects the second step, which is determining the amount of government response
that will be directed toward the issue. Setting an agenda and researching
related issues provides a strong basis for government response if the agenda is
well stated and supported properly. The third step occurs when a legislator
produces and introduces a law, regulation, or program to address the problem.
(14) Communication with legislators and committee members who are drafting the
legislation is extremely important at this stage of the process. Nurses have
the potential to largely affect health care legislation through their sheer
numbers and expertise. (15) Communication at the policy design and
implementation level is important because nursing expertise is necessary for
the development of a practical program that meets the needs of the people it is
designed to serve. (16) The final step in public policy formation is
implementation of the program.
In addition to a basic comprehension of
how legislation is enacted, nurses need to understand that many factors affect
public policy development. The size of an issue can determine the timing of
implementation (ie, how quickly change can be implemented). When a single issue
that has minimal effect on other disciplines is introduced, marginal resistance
can be expected; however, when something as large as health care reform is
introduced, can be implemented only on an incremental basis. Legislation can
become a partisan issue as well when one political party refuses to allow the
legislation to be considered seriously; thus, change can be almost impossible.
Another factor affecting public policy development is the effect of "pork
barrel" politics, which is attaching numerous items of a piece of
legislation, causing many legislators to object to an aspect of the
legislation, thus, preventing it from becoming law.
The essence of public health, in the eyes of most
researchers and practitioners, is a struggle to understand the causes and
consequences of death, disease, and disability. Often an even greater struggle
emerges when policy makers attempt to put that understanding to work, to
translate knowledge into action for our collective well-being. Science can
identify solutions to pressing public health problems, but only politics can
turn most of those solutions into reality. Lindblom sets forth an important
distinction: “When we say that policies are decided by analysis, we mean that
an investigation of the merits of various possible actions has disclosed
reasons for choosing one policy over others. When we say that politics rather
than analysis determines policy, we mean that policy
is set by the various ways in which people exert control, influence, or
power over each other”.
Politics, for better or worse, plays a critical role
in health affairs. Politics is central in determining how citizens and policy
makers recognize and define problems with existing social conditions and
policies, in facilitating certain kinds of public health interventions but not
others, and in generating a variety of challenges in policy implementation. It
is essential that public health professionals understand the political
dimensions of problems and proposed solutions, whether they hold positions in
government, advocacy groups, research organizations, or the health care
industry. This understanding can help leaders to better anticipate both
short-term constraints and long-term opportunities for change.
WHY HEALTH IS A
POLITICAL ISSUE
Public health
commonly involves governmental action to produce outcomes— injury and disease
prevention or health promotion—that individuals are unlikely or unable to
produce by themselves. Gostin argues, “A political community stresses a shared
bond among members: organized society safeguards the common goods of health,
welfare, and security, while members subordinate themselves to the welfare of
the community as a whole. Public health can be achieved only through collective
action, not through individual endeavor”.
Although this
perspective is deeply ingrained in most public health students, researchers,
and practitioners, it runs counter to a fundamental emphasis on property
rights, economic individualism, and competition in American political culture.
The exceptionalism of the United States lies in its antistatist beliefs:
Americans are less concerned with what government will do to benefit
individuals than what government might do to control them. To the extent that
Americans support collective action in the pursuit of public health or any
other social good, they exhibit a strong preference for voluntary organization
and participation.
Nonetheless,
there are many reasons why the health of individuals and the general public is
a political issue, not merely a private matter. First, individual and
institutional actions often produce significant spillover effects—what
economists call externalities—some of which are beneficial and some of
which are harmful. To compensate for externalities associated with private
actions such as smoking, vaccination, driving while intoxicated, sexual
practices, and the manufacture and sale of products requires political
decisions about when and how to impose restraints on individual liberties or
commercial interests. In the eyes of John Stuart Mill, this would be the sole
principle justifying public health policy: “The only purpose for which power
can be rightfully exercised over any member of a civilized community, against
his will, is to prevent harm to others. His own good, either physical or moral,
is not sufficient warrant”. A prominent expression came a century ago in
the landmark Supreme Court case of Jacobson v. Massachusetts, validating the
city of Cambridge’s program of compulsory vaccination against smallpox.
Second,
citizens look to government to identify and satisfy a variety of physical,
economic, and psychological needs that extend well beyond the means for
survival. The public may support certain “merit goods” that should be
distributed to intended beneficiaries whether or not they have an ability
to pay for those goods. Such merit goods include elementary and secondary
education, medical care for the poor and elderly, and food assistance and
require political decisions to define their scope and substance,
eligibility to receive them, and the source of revenues to purchase them or
provide them directly.
Third,
protecting public health involves moral judgments that acquire legitimacy
through political debate and resolution. Kersh & Morone argue, “Despite
myths about individualism and self-reliance, the U.S. government has a long
tradition of regulating ostensibly private behavior”. The appropriateness of
offering clean needles to injection drug users, funding stem cell research,
supporting medical uses for marijuana, ensuring access to contraception and
abortion, and legalizing physician-assisted suicide are among the moral issues
that are hotly contested in the political arena.
Fourth, a
healthy population and workforce is vital to economic growth and social order.
Threats from AIDS or bioterrorism are not only public health problems but also,
when they reach a certain scale, may become national security issues and thus a
potential source of political instability.
These justifications
for public action have produced a body of law and a politics of health that
must balance “. . . the legal powers and duties of the state to assure the
conditions for people to be healthy, and the limitations on the power of the
state to constrain the autonomy, privacy, liberty, proprietary, or other
legally protected interests of individuals for the protection or promotion of
community health”.