Yesterday I woke up to my morning Boston Globe. The headline of the right side of the front page — its major story — was “AG finds clout of hospitals drives cost.” “State’s insurers pay twice as much to some providers. http://www.boston.com/news/local/massachusetts/articles/2010/01/29/attorney_general_says_clout_drives_up_health_costs/. The gist of the story is that the big giants in Mass health care, Partners,i.e Massachusetts General Hospital, the Brigham and Women’s are paid “15 to 60 percent more for essentially the same work as other hospitals, even though the equality is not superior.” In other words, it’s not the users of health care, i.e. patients who are driving up health care costs, but doctors, hospitals, medical equipment companies, insurers, Big Pharma. Big Surprise!!!
So why are economists, health policy experts, political representatives, and our President promoting — nay broadcasting — this myth, that people who have decent health care plans — those pesky Cadiallacs — plans the ones at fault. These Cadillacs are really Chevies, i.e. plans that everyone should have, not just the diminishing few who can bargain for them or who have enough individual bargaining power with an employer to get them. Yet instead of holding these plans up as a minimum standard, our p0litical representatives are bad mouthing them and, by extension, those of us who use our health care judiciously.
It may seem that health care reform is dead in Washington. Maybe it should be. What we need is a movement to bring it back to life in a form that we all can use. Which is some form of tax supported national health care. We should all be broken records on this.
I just got so irritated hearing people call the kind of decent health care plans I and my family have as Cadillacs. So I wrote the following which appeared in the Salt Lake Tribune. So here it is.
I’ve had enough of the derisive talk about “Cadillac” health insurance plans. They’re not all that they are cracked up to be, and they are not what is driving health-care costs skyward.
My husband has been a union member and staffer for many years, and his employer provided my family (as a hard-won benefit of union negotiating) with what is now considered an unnecessarily “luxurious,” “wasteful” insurance vehicle.
So let me tell you how we’ve used our insurance plan over the past few years and how, in turn, it has misused us.
Three and a half years ago, I had an emergency appendectomy. During the surgery, I suffered several preventable complications, one that has proved to be quite serious. As a result, I needed extra visits to multiple doctors and physical therapists, as well as MRIs, ultrasounds and a variety of painkillers and other medications.
My husband was bitten by a feral dog in El Salvador and had to get 10 rabies shots when he got home.
Our daughter needed a variety of pills and shots before going to Rwanda to work for a group that helps women who were raped and infected with HIV/AIDS.
How have we fared when we’ve taken the Cadillac for a ride? Not well.
For more than 25 years, I was on the rolls as Suzanne Gordon, but then the insurer suddenly renamed me Suzanne Early (giving me my husband’s last name) when I submitted bills for my emergency appendectomy. Since there is no Suzanne Early (at least
not one who’s actually me), it was no surprise that they couldn’t identify me as an enrollee. Claim denied. That took months to sort out.When my husband got his rabies shots, the insurer denied the $1,000 claim because somehow the services weren’t coded as “medically necessary.” In his lengthy conversations with the insurer, he reminded them that since rabies is invariably fatal, dying of the disease would cost the company a heck of a lot more than $1,000.
No matter. To get the bill paid, it took a year of haggling, including receipt of many threatening letters from not just one but three bill collectors. And for months after the problem was resolved and the bill paid, we still were receiving dunning notices from one bill collector.
When my daughter needed more than the formulary-allotted supply of malaria pills (you can’t easily get them in Rwanda), it took dozens of calls to pharmacists, doctors’ offices and the union’s human relations department to get them and renew them.
Driving a Cadillac, it turns out, is almost a full-time job.
Like so much else in our health care debate — “death panels,” “socialized medicine” — the depiction of the so-called Cadillac option is a scare tactic meant to deceive and derail.
The tragedy is that in this instance, the scaremongers and derailers include President Obama, some of his party and too many of the progressive policy commentators.
Instead of blaming unions for bargaining for better (but still insufficient) health benefits for their members, we should be clear on who is really to blame for the real cost escalators in health care: a for-profit private insurance and a pharmaceutical industry that puts us all at risk.
On Tuesday January 19, a mini-earthquake occurred in my home state of Massachusetts that will have a significant impact on the chances for health care reform in the United States.
For the first time in decades, the voters of Massachusetts elected a Republican as their Senator. For nearly five decades, Senator Edward Kennedy –Democrat (Teddy, President John F. Kennedy’s brother), represented the state in the Senate. After his death in August months before he could cast his vote for health care reform, the state was forced to hold a special election to find someone to fill out the last few years of his term. If that seat is not filled by a Democrat, the majority Democratic party lacks the 60 votes needed to stop a Senate filibuster that could derail health care reform.
In the case of health care, because some moderate and conservative Democrats have joined the Republicans in their opposition to the Obama plan, the Democrats cannot muster the 60 votes necessary to end Republican obstruction of the bill.
Massachusetts is supposed to be a blue state – i.e. a safe Democratic state. In fact, the state has a history of electing affable, semi-conservative Republicans as Governor. On Tuesday, Scott Brown, a handsome (he used to be a male model), affable state senator, who was unknown on the national stage ran against the Democratic state attorney general Martha Coakley. He won by 100,000 votes. Because Brown vowed to oppose health care reform as conceived by Obama, (and to support waterboarding) conservative pundits have conveniently interpreted his election as a state referendum on genuine health care reform. In fact, the voters of Massachusetts were not registering their disaffection with genuine health care reform but rather with the Obama health care plan. They were also registering their disaffection with political arrogance and the failure of the Obama administration, and the state and national Democratic party to deal with a floundering economy and its human consequences.
Let’s take arrogance first. Instead of aggressively campaigning for office, Attorney General Martha Coakley, insisted she didn’t need to campaign assertively or even debate Brown in public because the seat she was running for was “Kennedy’s seat” and thus somehow belonged to the Democrats. Massachusetts voters were really turned off by this ploy and rallied behind Scott Brown when he announced that the Senate seat doesn’t belong to the Democrats but rather to the people of Massachusetts. Although I am no fan of Brown, I heartily agree.
When it comes to health care, a lot of people in Massachusetts are unhappy with a national bill that mimics the plan we have in Massachusetts. The Obama/ moderate Democratic plan offers only tinkering with noxious health care insurance practices, forces people to buy for-profit insurance thus strengthening the insurance industry’s grip on America, does little to curb pharmaceutical costs and profits, and does not even fully cover the 47 million (and climbing) uninsured. As political commentator Robert Kuttner expressed it in the Huffington Post, “Cutting a deal with the insurers and drug companies,who are not exactly candidates to win popularity contests, associated Obama with profoundly resented interest groups. This was exactly the wrong framing.Thiås battle should have been the president and the people versus the interests. Instead more and more
voters concluded that it was the president and theinterests versus the people.
As policy, the interest-group strategy made it impossible to put on the table more fundamental and popular reforms, such as using Federal bargaining power to negotiate cheaper drug prices, or having a true public option like Medicare-for-all. Instead, a bill that served the drug and insurance industries was almost guaranteed to have unpopular core elements.” (http://www.huffingtonpost.com/robert-kuttner/a-wake-up-call_b_426467.html).
More importantly, Obama has failed to address the twin problems of loss of jobs and loss of housing that resulted from what is now referred to as the Great Recession but which is for some people seems more like a Great Depression. Unemployment remains in the doublt digits with six people chasing every one job. People have lost their homes and can’t get work.(see my daughter Alexandra Early’s blog on what it’s like to be a young and unemployed http://www.helpwantedrecovery.blogspot.com/)
Voters also watch as government bails out big business but does little to help them. The health care bill seems to mirror this dynamic with Big Pharma and big insurance making out like bandits while the public as well as patients and their families get band aids.
As I write this, I have to admit that it’s tempting to give way to despair about the political situation in the United States. The Supreme Court has just ruled against limits on the influence of money in politics. The Democrats have been justifiably punished in my home state and conservative commentators draw all the wrong lessons about the future prospects of any health care reform. The real meaning of this election is that health care reform will only be possible when it really reforms the health care system not when it rewards the very players that have created the health care crisis in the first place. So while we may despair this week, we need to start fighting next week and in the weeks and years to come.
I recently opened my email to find this letter from a nurse from the United Kingdom. She asked for my help. I replied that I wished I could wave a magic wand but that the best I could do — at least at the moment — was post her letter and subsequent ones on my website. So here is her first letter. As well as the second giving me permission to print her letters. Please respond if you have had similar experiences, if you can think of something for her today.
Dear Ms. Gordon:
I have just today finished reading your book entitled “Nursing against the Odds”. I wanted to congratulate you on writing such an outstanding book.
I have recommended it to almost everyone I know. It was so well written I am in awe. It has really helped me to articulate my feelings about nursing.
I am an RN who is currently working on a large general medical ward in the NHS. I spent over 20 years in North America and completed my nurse education at a respected school of nursing in the States before coming back to the UK.
For two years I have been blogging about my experiences as a bedside nurse and have been fighting an ongoing battle here. I believe that the situation
with nursing in the UK has deteriorated significantly since you wrote “Nursing against the Odds”. It’s still very good on some wards but the staffing continues to be criminal on too many wards. This situation is not being addressed because stereotypes about nursing are getting in the way.
Burned out from caring for anywhere from 12-30 acute and dependent medical patients as the only RN and despairing at the fact that the NHS
was denying jobs to new graduate RN’s while hiring 16 year old cadets with absolutely no training to place in nurse’s uniforms and staff the wards I
took some time off of research attitudes towards nursing and vent my frustration via blogging.
I just never could understand how the public could be silent and watch their
highly skilled ward nurses get replaced with untrained kids, and than complain that the few nurses who are left “are too posh to wash patients” and “to clever to care” as a result of nurse education moving into the universities. Many of these ward RN’s are the sole RN for anywhere from 10,20, even 35+
patients on acute care wards with no back up, no staffing by acuity and no support from their managers. Some of our new grad degree nurses cannot even
find employment on the wards. Most of our current bedside nurses (from my viewpoint) did train back in the “good old days” and they are also on their knees and unable to cope. The government is mandating insane targets for the hospitals to achieve while cutting them off from funding. But they always seem to hire more and more highly paid management consultants.
We certainly do not have dietary staff to pass trays or assist with meals. On my ward we don’t even have a ward clerk to answer the phone much of the time. Beds are filled the minute they become empty. We take critically ill patients as well as frail,dependent, and elderly patients with dementia.
How could we possibly attend to basic care or feed 20 elderly and confused patients singlehandedly whilst monitoring and implementing life saving care for critically ill patients?
The major media outlets are running story after story about “Fallen Angels who starve patients” and “Callous nurses who do not clean up soiled patients immediately” but they never seem to write about the appalling nurse patient ratios or ward conditions.
They seem to be completely unaware of the fact that patients are sicker, more complex and the number of trained nurses at the bedside are being slashed. On my ward which is about 25 beds on a good day we will have 2 RN’s and 2 young untrained cadets who cannot even take a set of vital signs. On some occasions it is better but often it is worse.
What I am finding is that these kinds of numbers are becoming the norm up and down the country on general medical wards. My hospital sometimes leaves one RN to 35 med/surg patients on the floor below mine. They do this And then they get great joy over accusing RN’s of not wanting to bedbath patients and dumping all basic care onto care assistants/cadets out of “laziness”. Even our medium sized ED department was left with only one RN and one care assistant for the entire department on some shifts.
The media is going crazy with stories about poor nursing care in our hospitals. Many stories seem to focus on the fact that around 1990 this country started educating nurses in university.
This is supposedly the entire reason that nursing care is so terrible now.
Apparently people seem to think that educated nurses have no “compassion” and see patient care beneath them. While this may be true for a rare individual I firmly believe that the real problems are staffing,lack of respect for bedside nurses and ward conditions.
Even now, two years into blogging and months after I wrote a piece for the Guardian about staffing I am still getting hit with comments about how “nurse education” is to blame for poor nursing care.
And the worst thing about it is that many of these public statements, stories, and comments are coming from retired nurses who haven’t been anywhere near a patient since the 1970′s. They claim that newer nurses are not given enough clinical placements and are not taught to care.
Based on what I am seeing from my students and new graduate colleagues I think that these accusations are for the most part groundless.
I believe that university education is vital for RN’s. Our university students must take nearly 3000 hours of clinical time to graduate. However the quality of their time on the wards is poor even if the quantity is good.
They are only mentored on the wards by a harried nurse with 11+ patients. This hurts new nurses but it does not excuse the poor staffing and abusive working conditions. It would not be any better if their training was vocational only. The ward conditions just do not allow the student to have a good learning experience.
Hopefully another major newspaper will be doing an article about nurse staffing on our general wards this weekend (so they said when they contacted me). I am bedside nurse but not a journalist, writer, or PR specialist by any means. My blog is more emotive than anything, used as a stress reliever for me. I never really expected that many people to read it. I feel a bit over my head here and was hoping I could get some advice or tips from you?
Here are examples of the only kinds of story we are seeing in the media here about nurses:
How are we supposed to demonstrate compassion and NOT delegate to healthcare assistants when we are one nurse to 12+ med/surg patients?
This lady is always in the newspapers here and deams herself a spokesperson for nurses. She worked as a nurse for a few years in the 60′s and 70′s.
No mention of the fact that that large wards are being staffed with 2 nurses who are on their knees merely with the medications and 3 care assistants who have had no training. No mention of the fact that they have cut domestics and are expecting the nurses to clean. Or that nurses are working 12+ hours without a break in an abusive environment. No mention of the fact that we are forced by the hospital to wear falling apart, torn, and stained hospital provided uniforms only. They have cut down on allowing the nurses to request replacement uniforms and we are forbidden to purchase our own. No wonder we look awful. It’s just sad about the cleaning. We have 4 commodes to be shared by all the patients on the ward and the hospital is demanding that the nurse spends a full 11 minutes between each patient use cleaning the commode. My ward is full of immobile elderly patients who are all crying for the commode at once!
I have personally seen plenty of visitors call the nurse lazy when she doesn’t respond immediately to a callbell. Never mind the fact that at that very moment in time her other patient is about to die and she is trying to get an airway in or she is administering long overdue pain medicine to another patient who is in agony. It takes a long time to handover all pertinent info for 25 patients to the oncoming shift. Then throughout the shift we are constantly bombarded with phone calls (only phone is at the station) and handovers on incoming patients (also via phone). The hospital demands that all staff coming on duty listen to handover for all patients on the ward. This often leads to accusations of staff “gossiping” around the nurses station by visitors and patients.
I know that not all nurses are perfect and blameless but from my vantage point all I am seeing is excellent hardworking nurses set up to fail day after day. Repeated communication with our unions and professional bodies have failed. Completing incident forms and taking our cases to our hospital chiefs have failed. I am not sure where to go from here. I have this blog that was started to vent some negative energy (it’s ahem, less than professional at times) but even though there has been some bad language etc I have always promoted excellent bedside nursing care and maintained confidentiality.
I recently wrote a piece for the comment section of the guardian about nurse staffing numbers but I don’t think I really made my point. It had to be kept short and I had about 5 minutes to write it. Most newspapers only seem to speak to older retired nurses who talk about how wonderfully they washed the floors. I am trying to get them to see the light a bit.
I hate to bombard you with all this but have you any advice?
When I wrote to Anna, she sent the following, which arrived this morning.
Dear Mrs. Gordon,
Thank you for replying. I recently came off of a shift where there were only two staff for 20+ patients. We had no ward clerk. No housekeeping. Nothing. We got slammed for not answering the phone right away in order to receive report on 2 new admissions. Our ED units are fined for not getting patients moved on in less than 4 hours in a government intiative to reduce hospital waiting times. There is one working ward phone and it is located quite far away from the patients. The two of us could not answer the phone because we discovered one of our patients about to crash and we were swinging into action. Ten other patients were crying for help and were being ignored during this situation. We were told that if those new patients breached the ED waiting times as a result of us not answering the phone to take report and get them onto the ward we would be held accountable. The problem here is the general attitude towards nurses.
I don’t know what else to do but keep shouting out about it. Nurses up and down the country are telling me that they are experiencing the same things. If you want to put my letters on your site that’s fine with me.
Boston surgeon Atul Gawande has become one of the most acclaimed mainstream media critics of American health care. An elegant writer with first-hand hospital experience, he has pointed out, in many articles for The New Yorker and several books, a number of ways that patient care could be improved. My major concern about his reporting has been its consistent failure to acknowledge the critical role that nurses and other non-physicians play in our health care system. For more details of this critique, see ” The Cure: Can Doctors Change How They Think?” (http://bostonreview.net/BR33.2/gordon.php). I now have another. In his December 14, 2009 New Yorker commentary, entitled “Testing, Testing,” (http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=2) Gawande discusses the fact that Administration backed health care plan about to be enacted by Congress will fail to address medical cost inflation. ”Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality?,” he askss. ”It does not,” is the obvious reply.
The author points out that these fundamental flaws have drawn heavy flak from a right-wing determined to block “ObamaCare” in any form. Progressive economists and single-payer advocates have also sharply criticized both the House and Senate health care reform bills—that are currently awaiting joint-committee “reconciliation”–for their deeply flawed incrementalism.
Nevertheless, Gawande remains quite bullish about this emerging Capitol Hill mishmash because, despite its many troubled compromises, “what it offers is . . . pilot programs.” Gawande reassures New Yorker readers that a watered-down, piece-meal approach to governmental reorganization of private markets (in this case, for health insurance) may not be so bad, after all. To make his case, he takes us down legislative memory lane and recounts the fitful 20th century evolution of public intervention in agriculture.
In the early 1900’s, the U. S. Department of Agriculture began to sort out—for better or worse, depending on your point of view—the problem of food in America. Like health care today, the crisis then involved a big disconnect between widespread social need and affordable private provision.Gawande recounts how a patchwork quilt of federal regulation and costly tax-payer subsidies ended up producing safer, cheaper, more plentiful food stuffs for the nation. Meanwhile, farmers were forced or helped to “innovate,” just like doctors and hospitals must do now, as part of the “reform” process.
Gawande does acknowledge, in passing, that U.S. farm policy has had a few glitches of its own over the years. But that is a political understatement of massive proportions. Our special interest-driven reshaping of agriculture has placed the bulk of it firmly under the control of “agri-business.” Its first cousins include all the big drug and insurance companies now expecting to reap a very profitable harvest from federally-mandated private medical coverage. Just as the medical industry has largely driven the solo physician practitioner out of business, federally supported agri-business driven the family farmer into near extinction. The overall result of what Gawande applauds, down on the farm, has already proved to be pretty disastrous, in different ways, for small family farmers, consumers, and the environment, it has also had disaterous medical side effects. And there is a direct link between this public policy back-fire and one major contributor to rising health care costs—namely, obesity and its myriad medical side-effects. Has the obviously well-read Dr. Gawande never bothered to peruse Michael Pollan’s The Omnivore’s Dilemma , with its a well-documented indictment of the public health consequences of tax-supported industrial agriculture?
For decades, the heavily-subsidized production of corn, corn and more corn has unleashed a sugary flood of Katrina proportions that’s now nationwide in scope. As Pollan points out, our millions of overweight corn syrup, and corn fed meat and chicken (and now farm- fed fish) “survivors” face an epidemic of heart attacks, high-blood pressure, and diabetes—each condition a costly hospital stay waiting to happen. (see Annual Medical Spending Attributed to Obesity. Health Affairs http://content.healthaffairs.org/cgi/content/short/hlthaff.28.5.w822) And, speaking of “testing, testing,” that list doesn’t even include the current and future casualties of USDA-approved meat eating!
Among the threats facing carnivores these days (and I’m one of them) is a stream of contaminated food items, from here and abroad. On December 31, 2009, The New York Times ran a front-page story exposing the failure of federal inspectors to stop Beef Products Inc. from sending large quantities of tainted hamburger to the market. Officials at the United States Department of Agriculture endorsed the firm’s ammonia treatment process as a way of keeping deadly E. coli bacteria “to an undetectable level.” In 2007, they decided it was so effective that the firm should be exempted from routine USDA testing. Unfortunately, some Beef Product burgers turned out to be very unsafe to eat. http://www.nytimes.com/2009/12/31/us/31meat.html. This article followed an even more horrific NYTimes front page story about E.coli tainted hamburgers produced by Cargill that crippled a 22 -year- old dance instructor. http://www.nytimes.com/2009/10/04/health/04meat.html.
Anyone concerned about the overall health and well-being of Americans is faced with a tremendous dilemma when it comes to the current health care bills wending their way through Congress. These bills promise to address the problem of the uninsured. The problem is they do little to protect the American public and American patients from the rapaciousness of the private, for-profit insurance and pharmaceutical industries. That’s why people genuinely concerned about the fate of reform should be wary of hyping the kind of regulatory “reform” and industry restructuring process that helped many of us get heavier and sicker in the first place. But that’s exactly what Gawande does with his ahistorical cheerleading for the two-(or three?)headed calf that’s headed for birthing sometime this month on Capitol Hill. As a lont-time advocate of real health care restructuring, Gawande’s article, ironically, makes me even more worried about the future we face under ObamaCare. If it’s going to be just a replay of America’s costly, century-long, and still out-of-control experiment with “market reform” in agriculture, then will things get better or worse?