Managing Financial and Clinical Risk: Risk Theory and Operations Research for Nurse Administrators

Sharon L. Bradley, MSN, RN, Spokane VA Medical Center, Spokane, WA, USA and Thomas Cox, PhD, RN, Department of Supportive Sciences and Health Systems, Seton Hall University, College of Nursing, Gainesville, FL, USA.

Purpose: This paper defines, discusses and provides mathematical tools needed to manage professional caregiver insurance risk, the assumption of insurance risks by health care providers occurring in capitation agreements, prospective payment plans, managed care, and budgeted operations.

Background: Insurance risk transferring health care finance mechanisms often appear benign: encouraging efficiency and having minimal impact on service quantity or quality. However, proper actuarial analyses show that the smaller the cohort of patients involved in insurance risk transfers, the more likely that the reimbursement rate will prove unsound, requiring providers to limit the impact of such insurance risks. Actuarially unsound reimbursements will constrain nursing services available to consumers if not properly anticipated and planned for executives, managers, bedside, and home caregivers.

Approach: The opportunity for and need to apply more functional economic, insurance, mathematical, and actuarial tools, commonly used by insurers to manage risk were reviewed and applied to nursing service management imperatives in context of an acute hospital setting.

Major Points & Rationale: Nursing executives and managers play critical roles in mediating institutional insurance risk assumption at the bedside. Using risk theoretic principles and tools, managers and executives will improve their planning processes and optimize service quantity and quality. Effectively identifying and inadequate reimbursement and high demand variability for nursing resources and services is critical to success. Nurses using actuarial risk theory, statistical sampling theory, and game theory to analyze past and project future costs will improve decision making, contracting and budgeting activities, resource management, and improve staff and program evaluation processes.

Conclusions: Nurse managers and executives who most accurately analyze the financial, staffing, equipment, and supply needs associated with insurance risk assumption, will create more efficient and effective nursing environments, promote stable operating environments, and better match available resources to meet highly variable service demands.

Learning Objective #1: Describe financial and clinical risks that occur in nursing environments due to insurance risk assumption occurring with managed care, capitation, DRGs and budgeted nursing services.
Learning Objective #2: Use tools derived from risk theory and operations research to improve their management of clinical and financial risks in nursing environments.