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WASHINGTON — After years of shipping data-processing, accounting and other back-office work abroad, some healthcare companies are starting to shift clinical services and decision-making on medical care overseas, primarily to India and the Philippines.
Some of the jobs being sent abroad include so-called pre-service nursing, in which nurses at insurance firms, for example, help assess patient needs and determine treatment methods.
Outsourcing such tasks goes beyond earlier steps by healthcare firms to farm out reading of X-rays and other diagnostic tests to health professionals overseas. Those previous efforts were often done out of necessity, to meet overnight demands, for instance.
But the latest outsourcing, which have contributed to the loss of hundreds of domestic health jobs, is done for financial reasons. And the outsourcing of nursing functions, in particular, may be the most novel -- and possibly the most risky -- of the jobs being shifted.
At the forefront of the trend is WellPoint Inc., one of the nation's largest health insurers and owner of Anthem Blue Cross, California's biggest for-profit medical insurer.
In 2010, WellPoint formed a separate business unit, Radiant Services, aimed at advancing outsourcing and other cost-saving strategies. WellPoint has eliminated hundreds of jobs in the U.S. over the last 18 months as it has moved jobs overseas, a company spokeswoman acknowledged.
The spokeswoman, Kristin Binns, said WellPoint's shifting of clinical jobs overseas was a small part of the outsourcing and being done through Radiant because it has the technical expertise and can ensure compliance with laws.
Nursing organizations, however, were cautious.
"It's obviously a very disturbing trend," said Chuck Idelson, a spokesman for the California Nurses Assn. "There are serious questions if you're talking about utilization reviews ... and making recommendations on procedures."
Nursing experts said there also may be licensing issues as states generally require certification for those practicing and dispensing health information.
Current and former Radiant executives declined to comment or weren't available.
It's not clear how many other U.S. healthcare firms have contracted with Radiant or other outsourcing specialists, but industry experts said companies were increasingly looking at more healthcare tasks that could be outsourced globally as they face greater cost pressures and sweeping changes in how they do business.
Aetna Inc. has an arrangement with EXL Service, a U.S.-based company with operations in Manila, to provide "targeted care-management support," spokeswoman Cynthia Michener said.
Health Net Inc., which is laying off dozens of information technology and accounting workers whose jobs are being sent to India, said its outsourcing has generally been confined to administrative and IT functions.
UnitedHealth Group, the nation's largest health insurer, didn't respond to inquiries.
Outsourcing jobs out of the country has become a hot issue in the presidential campaign: President Obama is pounding Republican challenger Mitt Romney for his private equity firm's involvement with companies that sent jobs abroad.
Although such outsourcing has been going on for years, American manufacturers in recent years have brought some jobs back to the U.S. as labor costs have risen in China and elsewhere.
Some experts argued that sending jobs abroad could help U.S. companies by enabling them to tap global talent and efficiencies, making them more profitable. When U.S. companies are stronger, the thinking goes, it creates more opportunities for American workers. Also, shifting operations to lower-wage countries can help consumers by holding down prices.
Outsourcing jobs to places such as the Philippines can save U.S. healthcare firms 30% in labor costs, according to experts. But the practice remains controversial, especially with the U.S. unemployment rate hovering above 8%.
Patient advocates worry about crucial decisions involving a patient's care being in the hands of foreign insurance adjusters. Analysts said there was another concern as well: patient privacy.
Even something as straightforward as medical transcription can raise questions, said Uwe Reinhardt, a healthcare economist at Princeton University. Over the last year, Iowa Health System and hospitals in Utah and Washington state have joined other medical centers that have outsourced the transcribing of doctors' notes and other records.
"Suppose I'm an AIDS patient," Reinhardt said. "That person in India would know -- and [the information] could be valuable to someone.... For the U.S., there's nothing more personal than healthcare."
Dr. Kaveh Safavi, head of the North American health practice for Accenture, a major consulting and outsourcing firm that has partnered with WellPoint's Radiant, said nearly all countries have laws for protecting patient privacy.
And to safeguard patients' records, he said, healthcare companies store and maintain their records locally.

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A nurse who works on an oil platform needs some special skills, among them the ability to function on little sleep if she is on call for long periods. She must be comfortable traveling to the platform by helicopter or boat and making decisions with no support, as she may be the only medical professional on the rig. She must also be able to work in an environment that -- unlike the nursing profession -- is heavily male-dominated.
The first decision on the road to becoming an oil platform nurse is basic nursing education. Nurses can take the NCLEX-RN licensing exam by completing an associate degree, a nursing diploma or a bachelor's degree, according to the U.S. Bureau of Labor Statistics. The first requires two years, the second two or three years and the third takes four years. Although any of the three degrees may help a registered nurse obtain an entry-level position, oil rig nursing is likely to require an experienced nurse with training in communication, leadership and critical-thinking skills, which the BLS notes is more likely to be found in a baccalaureate program.
Licensing and Experience
After graduation the nurse must complete the NCLEX-RN exam with a passing grade. She will then be able to apply for a license in her home state. A new graduate nurse is unlikely to have the skills needed to work on an oil rig immediately. For example, she will benefit from critical care or emergency room experience, according to a career profile on the Petroleum Industry Human Resources Committee website. She may also need to perform routine screening exams, such as blood pressure and cholesterol checks, or treat chronic medical conditions, so training in outpatient care is also useful.
Providing Nursing Care
A nurse who works on an oil platform must be prepared to treat a wide variety of medical conditions, but she may also be required to deal with emergencies such as heart attacks or injuries. Oil rigs can be dangerous places. Weather conditions can be severe, especially in winter or during a storm, leading to slippery conditions. Workers can slip and fall from catwalks to the platform below, and there may be the possibility of falling off the platform into the sea. The nurse is the first responder in all of those conditions and may be required to complete a survival training course in some organizations.
Demand and Job Outlook
Demand for registered nurses is expected to be higher than average, according to the BLS, with a job growth rate of 26 percent between 2010 and 2020. Although the bulk of drilling rigs are land-based, the “Oil and Gas Journal” reports in an August 2013 article that the United States has 62 rigs drilling offshore. Almost all of those rigs were in the Gulf of Mexico. The job of an oil platform nurse is not a high-demand occupation with so few rigs working. Although the average annual salary for an RN in 2012 was $67,930, according to the BLS, the Petroleum Industry Human Resources Committee reports an average annual salary of $70,000 to $100,000 for oil platform nurses.

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