Saturday, September 28, 2002

This presentation is part of : Research Topics in Nursing Practice and Perceptions

Professional Caregiver Insurance Risk and Average Cost Based Reimbursement Plans: Implications for Nursing

Thomas Cox, RN, MS, MSW, MS, doctoral student, School of Nursing, School of Nursing, Virginia Commonwealth University, Richmond, VA, USA


To describe the nature of Professional Caregiver Insurance Risk and how it impacts providers and consumers of health care services


Examine the underlying risk theoretic structure of average cost based reimbursement finance mechanisms. Perform statistical and financial analyses to determine the impact of portfolio transfers from large policy aggregators and insurers, to smaller provider groups.

Population, Sample, Setting, Years:

Affected populations include professional caregivers and consumers. Providers and consumers in resource scarce areas, such as inner cities and rural areas, are particularly vulnerable as are disease specific populations such as HIV+/AIDS clients and severely and chronically mentally ill clients.

Concept or Variables Studied Together:

Professional Caregiver Insurance Risk is the financial risk assumed by caregivers when they enter certain financial agreements, such as capitation contracts and Diagnosis Related Group financing. The financial risks introduced to professional caregivers by these agreements impose constraints on operations that necessarily entail reduced service delivery target levels. Reduced levels of service entail risks for consumers and these contracts adversely affect caregiver operations, placing caregivers in the insurance business and decreasing the efficiency of operations. These risks also vary with the levels of both ACBRP and non-ACBRP financing available to caregivers.


An analysis of the mathematical and risk theoretic structure of insurance contracts, ACBRPs and actuarial science as it relates to professional caregivers assumptions of insurance risks. Small sampling theory and simulation exercises demonstrate the relative risk of financial ruin for small providers compared with larger, financially stronger insurers.


ACBRPs place professional caregivers in the role of insurers, with insurance risks and financial risks that do not exist, absent these contracts. The roles of insurer and trusted caregiver are incommensurable and place both clients and providers at risk.


ACBRPs are incompatible with the long term health and well being of the health care system, its providers and consumers. Alternative health care financing plans must remove insurance risks from providers, guarantee access to basic preventive and diagnostic services for consumers and insure the integrity of the insurance market, through regulation and monitoring of portfolio transfers. A single payer insurance system is the most effective, efficient, and ethical system for managing aggregated insurance risk.


When Nightingale went to the Crimea, one of the most important tasks she accomplished was the statistical analysis of the military hospitals and the caregiving environment. Nursing practices and health care organizations that fail to perform the same type of analysis of the financial risks in different financing mechanisms will re-experience adverse financial consequences that have affected medical, nursing, and health care practices during the last three decades. Organizations that correctly appraise financial risk will avoid negative consequences and be in a stronger position to affect health policy decision-making at the local and national level.

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