Physician supervision and insurance reimbursement: policy implications for nurse practitioner practice in North Carolina

The presence of regulatory requirements that physicians supervise nurse practitioner (NP) practice and of policies that affect insurance reimbursement policies create barriers that limit North Carolina NPs from practicing to the full extent of their licensure, education, and certification. This article reviews these barriers and offers policy recommendations to ensure that NPs are equal partners in health reform innovations.

Mandatory malpractice insurance Increases CS rate & profitability of litigation, decreases planned homebirths

Making malpractice insurance mandatory by law for homebirth midwives serves two purposes: to make lawsuits more profitable and to decrease the number of homebirth midwives. Malpractice insurance has encouraged and increased number of lawsuits, which increases maternal morbidity and mortality rates by promoting the practice of "defensive medicine" on healthy women experiencing normal pregnancies. No evidence shows that mandatory malpractice insurance has any effect on improvement birth outcomes or public health.

[Effects of nursing insurance on caregiving daughters--the role of professional nursing care]

In view of the demographic development the topic of "Nursing of elderly relatives" is gaining more and more importance within nursing research. The object of the investigation described in this paper was to assess the measures of the Pflegeversicherung [Long Term Care Insurance] with regard to its effects on care-giving daughters. This publication assesses one of the questions of the study--what part professional services play in the support of care-giving daughters. The data was collected by individual biographic-narrative interviews in the private household of care-giving daughters. The data was then evaluated according to the method of biographical case reconstruction developed by Gabriele Rosenthal. This way we were able to gain a deeper insight into the situation of care-giving daughters and analyse the consequences of the Pflegeversicherungsgesetz [Long Term Care Insurance Law] from an "inner perspective". The results of the study point to both the positive effects of the Pflegeversicherungsgesetz and its limits. We were able to show that the expansion of out patient services leads to an enhanced nursing infrastructure. In view of the part that professional nursing services play, however, the biographical access also made it clear that the Pflegeversicherung will not lead to far-reaching changes in nursing arrangements. In spite of Pflegeversicherung caregiving relatives still suffer from personal and emotional strain. Also the legal requirements are too narrow and allow hardly enough space for the consideration of the family environment and the history of life of relationship between daughter and mother.

Der Beitrag von Pflegefachpersonen ambulanter Pflegedienste in häuslichen Pflegesituationen

Die ambulante Betreuung von pflegebedürftigen Menschen gewinnt national wie international zunehmend an Bedeutung. Die Implementierung des Pflegeversicherungsgesetzes in der Bundesrepublik Deutschland ist dafür ein Beispiel. Im Kontext dieser Entwicklungen entstehen für das Berufsfeld Pflege Herausforderungen, die auch das pflegerische Selbstverständnis beeinflussen. Aus dieser Problematik ist die forschungsleitende Fragestellung dieser Untersuchung entwickelt worden. Sie lautet: Wie beschreiben Pflegefachkräfte ambulanter Pflegedienste ihren Beitrag in häuslichen Pflegesituationen? Das Erkenntnisinteresse dieser Arbeit liegt darin, sich der Innenansicht der Pflegefachkräfte zu nähern und dadurch ihre Handlungsweisen und Interaktionen zu verstehen. Für die Untersuchung wurde ein qualitatives Forschungsdesign ausgewählt, welches sich an den Prinzipien der Grounded Theory nach Glaser und Strauss orientiert. Die Stichprobengröße umfasst insgesamt neun Pflegefachkräfte. Die Ergebnisse dieser Untersuchung zeigen, dass die Pflegefachkräfte bestrebt sind, die Pflegebedürftigen möglichst lange zu Hause zu versorgen. Um dieses Ziel zu erreichen, beschränkt sich der pflegerische Beitrag nicht ausschließlich auf refinanzierbare Leistungen. Zusätzlich werden freiwillige Interventionen geleistet wie die Gestaltung des Wohnumfeldes und die emotionale Unterstützung des Pflegebedürftigen. Dies ist von unterschiedlichen Einflussfaktoren abhängig wie beispielsweise der Beziehungsgestaltung, der Situation des Pflegebedürftigen oder dem Berufsverständnis der Pflegefachkraft. An dieser Stelle entwickeln die Pflegefachkräfte Handlungsstrategien, um eine Balance zwischen freiwilligen und refinanzierbaren Leistungen herzustellen. Die Diskussion greift sowohl die gesetzlichen Bestimmungen wie die Einflussfaktoren dieser Untersuchung auf und thematisiert dies vor dem Hintergrund professionellen pflegerischen Handelns.

Forces promoting health insurance coverage of homebirth: a case study in Washington State

The movement of childbirth to the hospital in the early 1900s and the eventual establishments of health insurance reimbursement for hospital birth--but not for homebirth--solidified and reflected physician dominance in the area of obstetrics. Until recently, it was rare that a health insurer or a health maintenance organization (HMO) would cover a homebirth. However, in Washington State the majority of health insurance groups cover homebirths, which are generally attended by licensed midwives. In this context, our research is a case study focused on answering the question: What are the forces promoting the extensive coverage of homebirth by health insurers in Washington State? Data were gathered primarily through fourteen (14) in-depth, audiotaped interviews with key informants in relevant agencies and organizations in the state (i.e., state offices; midwife and other professional associations; and health insurance groups). Results suggest that consumer demand was an important precipitating factor without which changes to health insurance coverage would likely not have been made. Additionally, changes in state policies and professional mobilization on the part of licensed midwives were critical factors facilitating the widespread reimbursement for homebirth. Health care organizations' concerns for cost containment had little impact on this health insurance trend. Our study concludes that jurisdictional openings in the system of professions can be facilitated by a small number of strategically positioned individuals.

[Validity of care assessment in disabled and mentally retarded children]

16 children with spastic cerebral palsy and 25 mentally retarded children were assessed via the scales "Self-Care" and "Mobility" of the Pediatric Evaluation of Disability Inventory (PEDI). Age-adjusted PEDI scores were compared with the classification according to the three levels of the German statutory nursing insurance. Good correlations and highly significant dependence were found in children with spastic cerebral palsy but no dependence was seen in mentally retarded children. Apparently, assessment guidelines of the German statutory nursing insurance do not guarantee a valid assessment in all disabled children. In conclusion, future assessments of nursing needs in children should employ standardised assessment methods.

Changing social policy: Grassroots to legislation

Health care in the United States has evolved into a multimillion dollar business. As the health care industry has grown, so too has government regulation and involvement. As both insurers and patients vie to get the most for their health care dollars, federal and state governments attempt to mediate, prevent fraud and abuse, and protect all parties involved. Consumers feel the effects of this "tug of war" in the form of higher copayments, premiums, and out-of-pocket costs, as well as denial of coverage. This denial of coverage sparked a very successful grassroots effort to stop commercial insurers in the state of Connecticut from defining ostomy supplies as cosmetic and thus denying reimbursement. A tremendous amount of collaboration between Connecticut WOC nurses, state legislators, local American Cancer Society advocates, United Ostomy Association chapter members, and health care providers resulted in a powerful mobilization and support for House Bill No. 5120. This bill went beyond defining ostomy supplies as medically necessary but also set a minimum rate for reimbursement. Social policy changed, improving the lives of Connecticut citizens with an ostomy. Although many people fear they do not have the power to make necessary changes in government, this experience proved otherwise. The collaboration that occurred was patient advocacy at its best. This article describes the process that allowed this successful collaboration to take place with the hope that others will be inspired to get involved with patient advocacy through political involvement. It is the intention of this work to capture the essence of dedication of a grassroots campaign involving a small group of well-organized, highly focused participants who were responsible for changing public health care policy in the state of Connecticut.

[The "Barthel Index": alternative to expertising in compulsory care insurance?]

Measuring the level of care needed is difficult and since the introduction of nursing care insurance in Germany in 1995 the assessment method applied by the MDK (Medizinischer Dienst der Krankenversicherung) has repeatedly been criticised. The method is very costly and not broadly tested for its validity and reliability. The question arises whether similar results can be obtained by applying another instrument, like the Barthel Index (BI), which is easier to use and more reliable. In this article the authors show - based on a preliminary study in 1999 - that by using the Barthel Index a discriminance analysis will show identical results in 80 % of all cases. The authors regard this identical measurement of care needs, which is reached by scoring only ten items (BI) versus thirty (MDK's assessment method) and with a presumingly higher reliability, as a major progress and reason enough for further discussion and studies of the use of the Barthel Index for care needs assessment.