If one word taps into Americans’ fears about the changes going on in their healthcare system, it’s the R-word: rationing. It’s spoken often by critics of the Affordable Care Act, who used the issue to push out Donald Berwick as administrator of the Centers for Medicare and Medicaid Services in 2011. They worry the law will pressure health providers to ration patient care, because it imposes new constraints on the costs of certain medical tests and procedures.
To Terry Jones, however, rationing is already here. It happens on a regular basis in hospitals and other healthcare facilities — not as a result of government policy, but rather due to practical limitations on staff and other resources. It’s also invisible, because it happens mostly inside the minds of nurses.
“It’s sort of hidden from the general public,” says Jones, assistant professor of nursing in the University of Texas at Austin School of Nursing. “It goes on all the time, but it’s rarely ever talked about. We sometimes think it doesn’t exist, because it doesn’t exist in an explicit form.”
She’s talking about a phenomenon known as “implicit rationing.” It happens when nurses have too few coworkers and too many demands on their time — or, as Jones describes it, “fixed budgetary allowances and variable care demands.”
As a former critical care nurse, Jones recalls facing split-second decisions about postponing lower-priority tasks when caring for patients. Later, as an administrator, she often worried: “‘Do I have enough staff? If not, is something bad going to happen?’”
She dreamed of a way to measure implicit rationing, so she could adjust staffing to prevent it.
In 2011, she found a survey tool that did just that, developed by Maria Schubert at the University of Basel, Switzerland. With Schubert’s permission, she adapted the form and mailed it to a random sample of 3,500 Texas nurses. She received 242 responses.
The survey asked nurses to rate how often they had rationed 31 types of patient care responsibilities over the previous week, from changing dressings to evaluating care plans. Jones defined rationing as “the withholding of or failure to carry out necessary nursing measures for patients due to the lack of nursing resources (staffing, skill mix, time).”
The results confirmed her personal experience: Of the 31 activities, all but three had been rationed by more than half the nurses. The duties rationed most often included paperwork tasks (such as reviewing and updating documentation) and conversational ones, including patient teaching, emotional support and talking with other team members. The least-rationed tasks were clinical: tube feeding, infection control and administering medications.
Most disturbing was the frequency of rationing. The average nurse claimed to ration patient care only “rarely” on a scale that ran from “never” to “often.” But 97 percent of the survey takers reported rationing more than one activity within the past week.
Once a week might not sound like a lot, says Jones, until you start adding it up. “A single nurse may not miss an intervention very often, but if I happen to get five nurses that miss it, then it’s frequent for me.”
In Schubert’s research, Jones points out even infrequent rationing is linked to worsened patient outcomes, in areas from infections and pressure ulcers to medication errors.
Jones adds that her sample is too small to be conclusive. She’s already working with researchers in Australia and New Zealand to run additional versions of the survey, to see whether similar patterns of implicit rationing emerge.
Rationing is not limited to nursing, notes Reuben McDaniel, the Charles and Elizabeth Prothro Regents Chair in Health Care Management at McCombs. “Doctors with busy schedules may not ask patients to come in for a return visit, where if their schedules were not so busy, they might want to see the patient again.”
It’s based on money, as well as time, says Kristie Loescher, a former hospital administrator who is now a senior management lecturer at McCombs.
“Our system rations healthcare throughout the levels of the system,” Loescher says. “If you have insurance or money, you can get whatever services you want. Without resources, you get a very different level of care. This difference is particularly striking outside the hospital setting, in ambulatory, skilled nursing and home care.”
Still, Jones hopes that in the future, her survey might be used to decrease implicit rationing. If administrators can measure where and how often care is being rationed, they can plug staffing holes before problems cascade.
“It’s not a question of if it happens,” says Jones. “The evidence clearly says it’s happening. Hospital administrators should ask, ‘How often does it happen in my hospital?’ You can fix it earlier, long before the infection rate or the number of falls on the unit goes up.”