So once again, Nurses week rolls around. Only this Nurses’ Week, I gather things aren’t too great. I’d love people to write in and tell me if their hospitals have cut back on or completely eliminated Nurses’ Week celebrations because of the economic crisis. Please post and let me know. I’d also like to know if hospitals are cutting back on nursing positions, laying people off, or not filling vacancies. I’ve heard that the nursing shortage of just yesterday has miraculously been solved today. That hospitals don’t have vacancies or openings. That they can get plenty of nurses. So what I want to know is, how are things at your place of work? Is the shortage over and how do we measure that? By the amount of vacancies a hospital posts? Or by the amount of work a nurse is asked to shoulder? Is your workload suddenly more manageable on the floors and in the clinics and in home care? Do you have loads of help from other nurses because suddenly — no shortage — they have more time and can help you? Are patient falls, UIT’s CVC line infections decreasing because there’s more nursing care available because, after all , there ‘s no shortage? If you’re a manager, do you have three units to manage or one? If you’re a manager to you have time to actually learn what’s going on on your unit? This is how we should measure whether or not the shortage is over.
I think we need to make a distinction between a shortage of nurses and a shortage of nursing care. With the former, not enough people want to be nurses and not enough will stay in the workplace delivering direct care. That means if you want to hire more nurses and provide more nursing care, you can’t because there just aren’t enough bodies with educated brains to do the work. That’s a shortage of nurses. A shortage of nursing care, on the other hand, means that hospitals could deem that they have hired sufficient nurses but the reality is that those nurses cannot possibly deliver the high quality care each and every patient deserves. That’s because there are not enough bodies with enough educated brains to deliver the intensity of care patients with skyrocketing acuity need today. If you make this distinction, you can easily have a situation in which there is no “shortage of nurses,” but there is a “shortage of nursing care.”
I fear this is precisely the situation we are in today and that this shortage of nursing care will soon produce another shortage of nurses. Why? Because the babyboomers are poised to hit the hospital bed big time — with not just one disease but mulitple co-morbidities Then we have a whole cohort of nurses –babyboomers themselves –poised to retire. These nurses will stop giving care and start needing it themselves. If, however, nurses are being laid off or cannot get hired, well then, guess what, the word gets out and then people don’t enroll in nursing school. So then, when the patient demand increases, the older nurses have retired, and the economy has improved and suddenly hospitals and policy makers and politicians rediscover nurses and nursing, well, we won’t have enough students in the pipeline to produce the nurses we need.
The point here is the society has to begin to understand that there is no faucet whose spigot can be turned on to instantly provide a supply of nurses when we need it and turned off when employers and our society deems, sorry we can’t afford it, we don’t need it. To produce a compentent nurse — and I mean competent not expert, takes at least six to nine years. To produce an expert nurse takes more. Wouldn’t it be nice if just for one nurses’ week we celebrated nurses competence and expertise instead of how sweet and kind and compassionate they are? Wouldn’t it be nice if just for one Nurses’ Week we demonstrated that we understand that kindness and compassion depend not on the heart but actually on the brain and how educated and experienced it is?
I really want to support Barack Obama. I voted for him. I want his proposals to succeed. I also think one component of his health care plan — a public option to private insurance — may be the only way this country will ever join the rest of the industrialized world and create a tax supported national health plan that will provide quality health care — at much less cost — to all. But I am very, very worried about some of the polices and assumptions upon which he founds his health care proposal. His plan, for example, continues our reliance on the employment -linked, private, voluntary, for-profit, insurance industry. Obama tries to reassure people that if they like their current health insurance they can keep it. The assumption here seems to be that everyone who has health insurance coverage is just mad about it. Mad, i.e. happy. I think most people who have insurance in this poorly regulated, for-profit insurance market are mad all right. As in angry, and frustrated with their insurance company not thrilled and delighted with it. This is particularly true for anyone who gets sick or needs expensive services. Folks who aren’t sick and rely on their insurance for small routine things may feel just fine. But the moment you start needing expensive care, that’s when the industry reveals its true colors. The fact is, insurance companies rely on people staying health, that’s how they make their profits. Once you get sick, then all bets and promises are off.
Consider a typical case. My husband’s. He went to visit our daughter who was doing volunteer work in El Salvador. Before leaving he checked in at the travel clinic at the hospital that also houses our primary care practice — Mount Auburn Hospital in Cambridge, Mass. The doctor offered to give him one rabies shot as a precaution, a prophylactic, in case he encountered a rabid dog. The doctor said it probably wasn’t necessary because my husband was only staying in El Salvador for a week. So to save money, and be a responsible health care consumer my husband said no. Well, with the health insurance industry no good deed goes unpunished. He went on his journey and guess what, on day four, he got bitten by a dog. He didn’t worry too much about it because it wasn’t a serious bite. But just to make sure, when he returned home he called his primary care doctor and the doctor said, this is a no-brainer, you need to get a series of ten rabies shots and pronto. The shots weren’t given in the PCP’s office but back in the travel clinic. So my husband got his ten painful shots and the hospital submitted the bill for $1000 to Blue Cross Blue Shield. We also thought this was an insurance no brainer. Dumb us! My husband soon gets a call from the hospital saying the the insurance company has denied payment because the shots were coded as “not medically necessary,’ as if someone would get ten rabies shots just for fun. They’d confused the one shot, which wasn’t medically necessary, with the ten that were. So back and forth he goes with the hospital and the insurer. The diagnosis has to be changed. But who will change it, the PCP or the doc in the travel clinic? Finally, it’s correctly coded, and the insurance company finds another reason to deny payment. They will only pay for shots given in a doctor’s office or clinic but not in a hospital. More calls to explain that my husband was not checked into the Mount Auburn Hospital -but was in the hospital –as in inside its walls — because both the travel clinic and the PCP’s offices are in the hospital. No luck. Finally, my husband has to call his employer’s human relations department to get them to intervene. Meanwhile, the hospital has given the bill to not one but two bill collectors who are also dunning my husband. After months of phone calls, letters, emails, the insurance company finally pays the bill. But just yesterday, my husband received another bill from the bill collector.
So what’s the moral of this story. This is what happens when your health care system is run by prviate, for-profit insurers whose focus is only on the short-term, quarterly bottom line and for whom care of the sick or vulnerable is part of what the industry terms the “medical loss ratio”, i.e you get sick, we lose. This is one of millions of stories that could be told about our dysfunctional system, which, in the long-term, is completely irrational. Imagine, for example, how much the insurance company would have had to pay if my husband hadn’t had those rabies shots, and in a year or two developed rabies, which is invariably fatal. Of course, from their point of view, it’s better for enrollees to pay and then die. But his death would not have been instantaneous but prolonged and quite expensive. And imagine how much money was spent on all the letters, phone calls and time trying to deny the bill.
When I hear or relate stories like this, I’m reminded of a comedy routine that Boston comedian Jimmy Tingle often performs. It goes like this. We want health insurance to protect us when we’re sick but the industry only wants to deal with us when we’re healthy. It’s as if, he says, you called the police because someone was trying to break into your house and the officer on the other end of the line replied, “I’m sorry Madame but we only deal with the well-behaved.”
If you’re at all interested in what’s going on in the current economy and how to deal — or not deal with it — I suggest you check out Ariel Ducey’s new book Never Good Enough: Health Care Workers and the False Promise of Job Training. It was recently published in the series Sioban Nelson and I edit for Cornell University Press on The Culture and Politics of Health Care Work. Ducey, who is a sociologist, did a thorough study of 1199-SEIU’s job training activities in the state of New York. The union, in cooperation with the health care industry, got enormous amounts of money from the state of New York to implement and manage job training programs for health care workers. In fact, job training activities became a core focus of the union, which could not, or would not, get improvements in wages and working conditions for its members. Instead of trying to make jobs better at every level of the health care hierarchy, the union concentrated on moving workers from one rung of the ladder to the next. So a nurses’ aide was encouraged to become an LPN; an LPN was encouraged to become an RN; a janitor was encouraged to become a clerk and so forth. Universities and colleges in New York City reaped millions for job training programs. So did the union. The problem, as Ducey defines it, is that workers were promised not only better wages but better working conditions and better work. In order to pursue this promise, they were encouraged to fork out money and time to take course after course. Some courses did indeed,give them usseful, new skills, but many simply focused on changing their attitudes so that they would be more productive — not necessarily more satisfied — in the workplace. Many newly trained workers found that they were as poorly utilized in their new job as they were in their old one. Once in that new job, they were confronted with similar problems — understaffing, work intensification, under utilization of their skills, authoritarian management, little authority over their work, little voice in workplace organization and so forth. The solution? According to the relentless job training model — go back to school, take yet another training course and move on to the next rung on the ladder.
Ducey’s title suggests the problem. Workers are told that the problems they encounter in their workplace can only be solved through mobility. And that they are never good enough wherever they land. Above all, don’t stay where you are and fight to make it better, move West young man — or in this case, mostly women of color. This false solution fails to address the problem of how to improve work at the so-called lower rungs of the health care ladder. We need more, not fewer, nursing home aides. Desperately in fact. But rather than improve wages, working conditions and perhaps most of all nursing home management, under the job training model, nursing home aides, who have potential are encouraged to become something else — an LPN, whatever, anything but this. So all we do is reinforce the kind of turn-over, lack of on-site education, and low morale among staff that makes nursing homes so unsafe for residents. The same is true everywhere in health care.
As the editor of this book, I was particularly interested in its subject and analysis because of what I had long observed in nursing. As the problems of the nursing workload and work hours increase, as nurses become more and more frustrated with their inability to give quality care in hospitals and other facilities where they deliver direct care to the sick and vulnerable, many decide not to stay and fight but to leave the bedside to become nurse practitioners or other “advanced practice nurses.” Just the other day, I was talking to a nurse in the South who had had it with dangerously high patient- to -nurse loads and said she’d decided to go back to school and get a masters degree so she could get the Hell out of the hospital. ”Would you have stayed at the bedside longer if your workload was more manageable?” I asked her. ”Yes, absolutely,” she said. ” I love bedside nursing but I work on a telemetry unit and we take care of 7 to 10 patients in the daytime and 10 or more at night. I’ve tried to change that, but no one listens.” I’ve had it. I’m getting out was her bottom line (she was also fighting for better staffing ratios nationally.) Many nurses are encouraged to get out and move “up” not only by academic institutions but by hospitals or other facilities that provide, as a perk of employment, educational stipends. The problem is, in nursing at least, few of these subsidies go to nurses who want to remain at the bedside because masters degrees in nursing simply aren’t geared to encouraging bedside RNs so stay at the bedside.
Job training as a solution to the crisis in both education and health care has been one unions and health policy experts have frequently championed. Today, SEIU is pursuing that solution to both health care workers’ complaints and the employment crisis. The union and other job training advocates seem to ignore the fact that as one moves up the ladder people are losing their jobs and hospitals and other facilities aren’t interested in spending money on a new crew of newly trained workers to replace them. In fact, even though we still have a nursing shortage, hospitals that feel strapped for cash are laying off RNs or they aren’t filling jobs when someone retires. So training LPNs or aides to become RNs is hardly a solution to either health care workers’ dissatisfaction with their jobs, or the unemployment crisis we are now facing thanks to out of control global cowboy capitalism.
Ariel Ducey’s book is the perfect way to jump start a long over due conversation about how to deal with poor working conditions in health care or for that matter in any other industry. Of course, I am a bit prejudiced, since I edited the book. But I think it’s well worth your attention. To check it out click on the Cornell University Press heading under my picture.
On Wednesday March 25, the New York Times ran a front page business section story announcing that the American insurance industry is proposing to make major concessions on health care in return for major concessions in the Obama health plan. The insurance industry promises that it will get rid of its “preexisting conditions’ limitations on private insurance if only the administration will not — that is not — propose a national public health plan that people could enroll in as an option to private insurance. As anyone who’s an American citizen or resident knows, private insurance plans have founded their business model on either excluding people with so-called “prior conditions” or charging much higher premiums if people are sick. This is called expereience rating in contrast to what other countries with national health plans do — which is called community rating. When people lose their health insurance because they change jobs, and get new insurance with a new job, their pre-existing condition (if they have one) is excluded and they are not insured for that illness. Which, of course, nullifies the very meaning of health insurance. It also makes Americans terrified to change their job even if its a terrible one.
Apparently the insurance industry is willing to give up this critical component of their business practice because they are more terrified of the financial consequences of the lynchpin of the Obama plan, which is the creation of a public health care plan that would be a federal, Medicare like plan available to anyone of any age (for those unfamiliar with the US system, Medicare is the tax supported health plan that is only available to people over 65). Why is the insurance industry so worried about this option? Because, the industry correctly understands that private insurance is beyond the means of most uninsured Americans and that a government plan would attract many more subscribers than private insurance. It also knows that the government has the power to negotiate lower fees with doctors and hospitals and that their plan would therefore eventually be more efficient than private insurance plans. This could attract people with private insurance who would disenroll from private plans and enroll in the public one.
Right now Medicare has much lower administrative costs than private insurance companies that spend almost 23 percent or more of their revenues on administration, huge executive salaries, and marketing. Medicare does not pay its administrators something like over $18,000 an hour — yes that’s an hour — like Aetna paid its former CEO John Rowe. Needless to say salaries like that have a way of driving up health care costs, which is why most citizens in other countries with national tax supported health care plans spend about $10 a day per capita and we spend $21, Imagine what kind of great system we could have if we could capture the money spent on those full page ads in the New York Times and other daily papers, the millions spent on advertising in baseball stadiums (a couple of years ago the Beth Israel-Deaconess Medical Center spent $1 million advertising in Fenway Park), and high salaries and channel them to nurses, primary care docs, public and community health workers and other people on the front-lines of care delivery?
In my view — as a supporter of some form of tax supported national health system — one of the only good things about the Obama plan is the fact that it is guaranteed to help us finally get some from of rational health system. What we need Medicare For All. But in exchange for eliminating the prior illness exclusion, the insurance industry wants the administration to force people to buy private insurance. The New York Times reported that “many in Congress were receptive to this idea.” That’s why we all need to hit the phones and call our Congressional representatives and tell them no, no way are we going to use tax dollars to fund an insurance industry that has — in the name of profit — already compromised the health and well-being of Americans for too long. People need to support some form of public national health program, even if it is only baby steps toward what every other industrialized country on earth provides its citizens — high quality health care at far less cost than we do. Which is why the World Health Organization ranks the US health system 37th in efficiency and effectivness.
When you’re thinking about health care reform, think AIG — do you want the same folks who have wrecked the global economy to have even more of a say in your health. I don’t.
As I begin my first blog, it seems appropriate to talk about one of the most pressing issues in American society — health care reform and how it’s being defined in our society and by the new Administration. Don’t get me wrong. I’m all for letting the new president go at it. But how is the problem being defined? What’s being discussed? What’s being left out? Like the kind of national tax supported health care system every other developed country has — except our’s. But more on that in another blog. What I want to talk about now are some of the hidden cost escalators in the system and why they are rarely included in the discussion about generating the kinds of cost-savings that would allow us all the get the kind of high quality care we need.
What’s rarely put on the table is the scandalous over-use of health care resources in futile care that simply drives people into the ground. Here’s an example. She’s a 91 year old woman had a triple A — an abdominal aortic aneuryism. She’s operated on — of course — recovers slightly and then begins to decline. One thing after another happens — falls, infections, paralysis that no one can figure out. Things go from bad to worse to worst. There is no significant involvement of a primary care provider. No one in the family is willing to discuss DNR (Do Not Resussitate) not to mention Do Not Hospitalize. No one is reading the excellent Handbook for Mortals by Joanne Lynn and Joan Harrold. (Instead of getting an offer for AARP membership when you’re in your fifties, we should all receive a free copy of this book, courteous of a government that really wants to save money). The woman goes from hospital to home, from home to nursing home, from nursing home to hospital. Etc. Finally, a few weeks before she dies, physicians find what might be (might being the operative word here) a tumor on her spine. So it’s into the OR for her. Guess what? No tumor. She does, however, end up on the ICU, develops pneumonia. She’s transferred yet again to a different hospital where the brilliant new ( the family has by this time lost count on how many doctors have been “in charge”) physician takes over and discontinues the anti-biotic and her infection really takes off. Finally, by the last day of her life, more heroic measures are proposed and finally — finally after months — the family is ready to get the message that someone with some time and empathy could have conveyed months earlier — the 91 woman is going to die. They actually beg for mercy and she dies that same day. Hearing the story I was reminded of poor George Washington’s horrendous last days when physicians bled him almost to death and he just begged STOP!!! THE TORTURE!!! and died.
Only more than 200 years later the torture is a lot worse and a whole lot more expensive. I can’t imagine what the cost of this exercise in futility came to. $500,000? A little more? A little less? This family suffered needlessly because no one had the time or expertise to have a serious talk about the facts of life — one of which is that none of us make it out of here alive. More to the point — and this is the horrible thing — the system and all its players benefit from this drawn out kind of death. Every time the doctor visited, there was a charge. Every time she was put on a IV drip, someone benefited. All those anti-biotics sold, all those dollars gained by some institution or other.
How many people — young and old — go through that experience every single day because doctors aren’t trained (and I use that word advisedly) to deal with death. Because we don’t have enough primary care providers and at least some of them (like the one who was supposed to take care of this woman) are missing in action. Because nurses aren’t empowered to say, “stop the action.” There are so many cases like this. The New York Times did an incredible front page story on the unnecessary and exorbitantly expensive ($100 million a year) use of cardiac CT scans — scans that actually deliver more than 200 worth of X-Rays at one time — usually for no clinical benefit. Yet Medicare — after announcing it would not pay for the scans — copped to pressure from cardiologists and said, okay, you can do them in spite of the fact that there is no evidence of benefit and only evidence of harm. So now we, the taxpayers, are giving cardiologists federal money so, like the leaders of the nation’s collapsing banks, they can use it for the equivalent of hefty bonuses. Does this make sense? When are we going to stop using our now very scarce resources like this and start a national conversation about using them more wisely. If discussions about health care reform don’t include topics like this then we will never be able “afford” the care we really need.