Over the past decade, health care has been changing and with it comes along the ever-increasing medical costs that are affecting nearly all patients. Both the insured and uninsured individuals are facing prohibitive medical costs, with some being unable to finance their care. Even those covered with exceptional insurance premiums are faced with accelerating premiums and increased out-of-pocket expenses. At the middle of this, patients are demanding for answers about their medical bills and physicians and nurses are caught up in the uncomfortable position of playing the role of caregivers and financial advisors.
John is a past patient who calls the office of the nurse manager in the Emergency department with questions about his medical bills. He does not understand why even after the insurance coverage paid for his bill, he still has to pay out-of-his-pocket and besides before leaving the hospital, he was required to make a payment.
Advising Patients with Medical Billing Questions
An emergency nurse manager has several responsibilities, among them handling questions from patients regarding the quality of service and medical bills. It rests with the nurse to ensure that all the patients’ questions are well answered, without coming as too domineering or evasive. In the case of helping patients interpret their medical bills, the nurse manager must be able to explain to the patient how much the insurance cover pays, how much the patient is required to pay-out-of-pocket and why. In essence, transparency towards the patient is critically significant at this point. When faced with such a situation, it is always important to let the patient know that anticipating bills is not easy especially with the nature of emergencies at the department. However, let them know that there are various consumer rights, and in future, they should demand to be informed about certain procedures, their costs and the alternatives involved. Another thing, tell patients that during emergency services, it is highly likely for patients to get high bills because of all the procedures involved and especially because of consultations with an out-of-network doctor. According to Buff and Terrell (2014), when an out-of-network doctor attends to patients, the bill is higher as compared to when the consultation is limited within their hospital network because the insurance cover only pays the provider for the services offered. Similarly, it is possible for patients to be requested to make a payment in case the accrued hospital bill exceeds the amount payable by their insurance cover.
Recommended Resources concerning Health Care Costs and Insurance Coverage
Essentially, there are considerable differences in individual insurance premiums and financial situations. It is also hard to ascertain the actual expenditures of consultations, medical procedures, drugs, and referrals among others. According to Gesme & Wiseman (2011), there are national, state, and local programs that may provide financial assistance to some patients. Some government and private programs also offer financial support to low-income patients as long as they qualify. Similarly, some pharmaceutical companies also extend medication assistance programs to needy patients. Along with that, patients can avoid spiraling medical expenses by ensuring accurate billing of services extended at the health facility. Human is to err, and sometimes hospital administrations make mistakes when recording charges, which end up increasing the bill. In this case, patients should ask the billing officer to interpret their medical costs and avoid jargon to be able to have a clear understanding of what exactly is included in the medical bill. In addition to the above, patients are entitled to their health rights to ensure that they are aware of the medical procedures. This way, patients are informed about the medical plans and their alternatives alongside costs.
Significant Changes in Hospitals
Over the past five or ten years, hospital experience involved lengthy stays, lack of patient respect, severe blind spots in prevention among others. The medical staff always superior and patients had no rights. However, all that has changed alongside technological advances that have transformed the health care sector with a strong focus on patient-oriented care delivery. According to Obama (2016), hospitals continue to evolve, integrating big data as they move from an objective of a services-oriented model to a patient-centered model. Patients have also been empowered about their rights and have a right to comprehensive information about their medical plan and alternatives as well as costs. Another thing that has significantly changed in the state of health care is technology (Sharma, Chandrasekaran & Boyer, 2016). Compared to the way health care delivery was in 2000, there have been dramatic changes. For instance, there has been an emergence of massive CT scan machines, which take x-rays from various angles and give results instantly. Apart from equipment, technology has also improved communication and hospital management. Records are now stored online where they are safer and easy to retrieve. Through technology, hospitals have effective communication channels that make it easy to exchange medical record for improved care delivery.
Personal Reflection on Acquired Values from interacting with Patients
Initially, at the back of my mind, I only conceived professional nursing as a field where I have to attend to patient needs, assist physicians in their treatment plans and not a place where I would be involved in handling patient questions with their billing questions or advising them. Interacting with patients has offered me a chance to have a solid understanding of the wider context of health care including care delivery, billing, and reimbursement structure. The interaction was also a learning experience for me in that; it gave me a chance to understand some of the challenges patients face, especially when they have to handle exaggerated bills.
Managing Health Costs
Budgeting in health care organizations involves the process of planning and controlling future expenditure by comparing actual results with expectations. According to Sullivan (2013), a budget represents the way resources are acquired and used over a specific duration and allows management to project activities in the future so that the organization’s objectives are met successfully. Ostensibly, there are several types of budgets such as incremental budget, zero-based budgets, fixed or variable budgets. Similarly, managing resources in health care organizations to cut down on expenditure costs and maintain quality care is hard, but not impossible to accomplish. Firstly, before embarking on a cost-cutting mission, there are things to consider such as fixed costs that are likely to remain the same regardless of the level of activities within the organizations. Other expenses include variable costs that are typically determined by the level of activities within the health facility, direct costs that affect patient care, and indirect costs that do not necessarily affect patient care. At the center of this information, the stakeholders also play a major role. In this case, stakeholders involve patients who will be affected in case cost cutting compromises their quality care, medical staff who will be expected to work with a stringent budget, and hospital management who will oversee the implementation of the budget. After this, the second step involves identifying items that are over budgeted and ways to cut down on such expenses. Sometimes, it is possible for hospitals to use overtime personnel even when it is not necessary, which adds on to the payroll and affects hospitals revenue. In this regard, it is important to validate the necessity of overtime or to have additional personnel as another way of cutting down on costs. As Sullivan goes on to note, a nurse manager is responsible for reviewing the activity level of their assigned unit. In most cases, the variance in the budget is dependent of another and sometimes outside the scope of the manager’s department. In light of this information, it is hard to make decisions individually; rather a group decision-making process is necessary if the cost cutting exercise is expected to be successful without compromising on the quality of care delivery.
Envisioning the Future in a 10-Year Career Plan
The future is filled with a lot of uncertainty and sometimes misleads people to believe they cannot plan it. However, as Sullivan asserts, the future is shaped by individual decisions and actions especially the actions of today. As a student nurse, I understand that a successful career will not occur by default or as an accident, rather it is a deliberate and informed process determined by education, professional growth, family, and the life of the people I love. Ten years from now, I envision taking an administrative post as a nurse manager in a vast and busy health facility. My priority right now is finishing school by passing the overall GPA exams to secure my first position as a professional nurse. The purpose of this job is to allow me to learn as much as I can, put my learned theory into practice and perfect my clinical skills. It is in this position where I will also make contacts with colleagues and supervisors. Among the many important tasks in my career is to identify and cultivate a relationship with a mentor who will be willing to help me progress in my career. The mentor will be a senior nurse or someone closely aligned to the nursing profession who has contacts that can be useful for me in future. The first position will also prepare me for next job, and I hope to be more experienced than I am right now. I will also be in a position to negotiate the terms, working conditions, salary, and the possibility of pursuing further learning as I work. During my job, I will be attending various nursing camps and volunteer programs if any to develop skills necessary for my professional career such as communication, conflict resolution, and decision-making skills among others. Before applying for my second position, I will consider several things such as salary, job satisfaction, and be cautious about taking the wrong job. After practicing for about five years, I will consider going back to school to continue my education as higher education levels will help to get me a senior managerial position. Afterward and with the experience I will have gained, I will consider applying for a managerial position with the help of my mentor and begin my career in an administrative post as a nurse manager. Most importantly, at the center of my nursing career, my family and children come first, and I understand it will be tough balancing between work and family. My parents will also be a bit older, and due to the nature of my job, I will consider hiring a caregiver to take care of them.
Decision-making for nurse managers are often synonymous with management and forms a strong criterion on which management is evaluated. Much of a nurse manager’s time is spent critically evaluating issues, solving problems, and come up with informed decisions. The quality of the decisions that managers make is the factor that evaluates their success or failure. For instance, handling hospital bills is a sensitive issue in that nurses must ensure that the patient is satisfied without compromising the reputation of the hospital. Similarly, it is also the responsibility of nurse managers to manage variances in budgets when they occur especially in their particular unit without compromising on the quality of patient care. The exercise is a necessity in that it helps in managing escalating health costs and increases revenue. Alongside that, nurse managers do not just get the position by accident. Rather it is a process that is shaped by decisions and actions, which means that it is important for nurses to plan their career and envision how they want their professional career to be in years to come.
Buff, M. & Terrell, T. D. (2014). The Role of Third-Party Payers in Medical Cost Increases. Journal of American Physicians and Surgeons, 19(2), pp. 75-79.
Gesme, D. H., & Wiseman, M. (2011). A Financial Counselor on the Practice Staff: A Win-Win. Journal of Oncology Practice, 7(4), pp. 273-275.
Obama, B. (2016). United States Health Care Reform: Progress to Date and Next Steps. JAMA, 316(5), pp. 525-532.
Sharma, L., Chandrasekaran, A., Boyer, K. K., & McDermott, C. M. (2016). The impact of Health Information Technology bundles on Hospital performance: An econometric study. Journal of Operations Management, 41(4), pp. 25-41.
Sullivan, E. J. (2013). Effective Leadership and Management in Nursing. Boston, Pearson.
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