For 25 years, Betty Rambur, professor of health policy and nursing, has worked on health care reform. In the early 1990s, she chaired reform efforts in her home state of North Dakota. One of the areas she has long wanted to address during her professional career as a practitioner, professor, dean, and member of the Green Mountain Care Board, is the lack of information connecting traditional nursing practice with health care finance, economics and policy.
Rambur addresses these increasingly critical issues, especially in light of the passage of the Affordable Care Act, and fills a major gap in the literature with her new book, “Health Care Finance, Economics, and Policy for Nurses: A Foundational Guide.” This undergraduate nursing text is a must-read for all nurses, according to Susan Reinhard, senior vice president and director of AARP Public Policy Institute, and is the only such text grounded in nurses’ understanding and experience written as an "easily understandable guide for nursing action from bedside to boardroom."
UVM Today: Why this book now?
Rambur: The bottom line for me is to help nurses serve society better through understanding the key influences that shape the entire terrain of care delivery. So in the end, it’s about the patient and serving society. I have taught a version of its contents for a long time, but I’ve never identified an appropriate text for an undergraduate with little background in finance and policy. The texts that assume substantial knowledge of economics are often so esoteric that a person without this background finds it tedious or confusing. There is a great book I use at the graduate level, but it is developed within the context of medicine, not nursing, and flows from the experience of the physician.
In this book I’m trying to create overlap between the reader's daily life and their professional life so that economic and policy issues make sense. And I wanted this rooted in nurses’ experience and everyday understanding. For example, several chapters illustrate how healthcare markets differ from other markets, so I give an example of people having to prioritize and make decisions between buying a desired but unnecessary item and paying the orthodontist or the rent. In classic markets you know what something costs, that you bear the cost of purchases, and can understand what you are getting for that purchase. In healthcare you are largely shielded from the immediate impact of seeking care and don’t know what it costs. Another difference is what is termed “asymmetry of information.” For example, when I go to the grocery store and I’m deciding between the fancy green beans and the cheaper green beans I can figure the difference in cost and quality, but when I don’t know if I need an aspirin or surgery I can’t sort that out; I’m dependent on the provider to tell me. So I tried to root economic concepts it in ordinary experiences to make it more understandable.
Why is it important for nurses to know about health care finance, economics and policy, and how does it relate to their actual care of patients?
Because everything nurses do matters, and if we can shape what we do within a larger context, we are better able to have more appropriate action for our patients, be more satisfied in our roles and help redesign care to better serve society. I see these issues as being interrelated. Our work has more meaning when it’s imbedded in a larger context. So macro issues like overtreatment have implications for that patient, but also for society in terms of cost and depletion of scarce resouces that could instead be used more productively. The Affordable Care Act and Medicare’s payment reform to financially reward the value of care rather than volume are huge contextual influences.
Often nurses enter the profession because they are interested in interpersonal relationships, science, helping and healing, but haven’t really wanted to think about the financial side of it. That’s why I wrote about concepts like “ethinomics,” because ethics and economics are not opposites, and we need to see that understanding finances is a professional obligation. In exit surveys, students have said they need to understand more about what healthcare costs. It’s a real question and not easy to answer: what does healthcare cost, and what’s the value?
Physician decision-making has largely driven health care, but with the advent of more team-based care, nurses’ roles have changed dramatically and will change even more in the future. In Accountable Care Organizations, for example, the providers are accountable for the quality and the costs. That’s a really radical change from a fee-for-service model, where providers really weren’t accountable for the costs or the overall outcomes. It’s a huge paradigm shift, and nurses’ holistic, person-centered, systems orientation is essential to making it all work.
Some of your book deals with the findings of a 2010 report by the Institute of Medicine on the future of nursing and its recommendation that more nurses should serve on governing boards (nurses currently fill six percent of board seats). Why is that so important?
It isn’t necessarily to represent nurses, but to bring what nurses know to the table. Nurses are at the working surface of healthcare in almost all settings and are educated across delivery settings. The book’s earlier chapters are about finance, economics, and health reform, and the last chapters are designed to illustrate how to use that foundation to serve on a governing board or be active in policy in some way. Nurses don’t tend to aspire to be on governing boards, but they are consistently voted as the most trusted professionals in the United States by Gallup polls. One tagline I saw said something like, "Let the most trusted be the trustee." If you are going to serve on a governing board and want to make change in an organization you have to understand how the money works, so two chapters provides basic information on boards. Another chapter deals with the policy process and ways to find political voice.
Do you think your book will become required reading at other universities?
We’ll see, but in many ways I felt like I had something to say, so I had to write it. It’s like the saying, "You don’t sing because you think someone is going to listen. You sing because you have a song." It seemed important to take the experience I started building in 1991 and try to make it simple and elegant. I think Einstein said that if you can’t explain it simply you don’t understand it well enough. My goal was to make the topics simple, but not simplistic. For my next book project I hope to do the same with a version for the general public.