Check out this new book

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.

Don’t Let the Obama Administration Give Away the Store to the Insurance Industry

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.

Health Care Reform — a l’Americaine

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.