When Leonard Abramson, CEO of U.S. Healthcare merged his company with Aetna in
l996, his personal fortune jumped to $990 million -- which in the United States
is enough to pay for the salaries of 25,000 nurses for a year.
Meanwhile money spent on advertising and marketing has skyrocketed. Between
1968 and 1993, the administrative and clerical sector of health care grew by
692%. In l968, administrative occupations comprised 18.1% of healthcare FTE's
and 27.1% in l993. In l968, nursing personnel comprised 40.6% of FTE's and
36.3% in l993. One sees concrete evidence of this trend whenever one opens a
morning paper, or watches television in the evening, or visits a physician's
office. The amount of advertising for health care companies has grown
dramatically. The New York Times and other major newspapers constantly
run full page ads -- at up to $75,000 a shot -- for hospitals and health care
companies that proclaim their "caring;" prime time television has spots
proclaiming the virtues of competing companies.
And any patient walking into a physician's office is struck by the number of
staff sitting behind a glass partition whose time is exclusively devoted to
figuring out which insurance form to fill out for which patient, which blood or
urine test to send to which lab (depending on what deal a particular insurer
has worked out with what particular laboratory); which drugs can be prescribed
to which patient (depending on the drug formulary the company uses);if the
patient can be sent to a specialist and which one (depending on MCO policy);
how many days a patient can stay in the hospital; and where that patient will
be sent post hospitalization -- to home or to one of the new so-called
sub-acute facilities in this burgeoning industry that has grown thanks to
market driven managed care.
Meanwhile patients in hospitals are being sent home quicker and sicker -- and
thus denied expert nursing care when they need it -- through dramatic
reductions in the average length of hospital stay and through dehospitalization
-- not allowing patients to go into the hospital when they may need to. As
economist Uwe Reinhardt has pointed out, "Between l980 and l995 total
inpatient admissions per thousand population and average length of stay
declined by about 20 percent each; consequently, inpatient days per thousand
declined by about 40 percent." Although this is supposed to be saving us
money, as Reinhardt points out during the same period real per
capita spending on hospital in-patient care rose by nearly 53 percent.
Because managed care has resulted in many nursing lay-offs, and has shortened
length of stay and runs patients through the system so quickly, the patients
are much sicker. At the same time, nurses are now dealing with extremely high
nurse-to-patient ratios. Some nurses on general medical or surgical floors may
be dealing with eight to ten patients on the day shift or up to fifteen at
night. Intensive care nurses who used to do one-to-one nursing are now caring
for two and three extremely ill patients. And of course, patients are
routinely sent home while they are very unstable and the burden of their care
is put on the shoulders of ill-prepared family caregivers at home.
This latter phenomenon is very distressing because people pay for nursing care
in their insurance premiums and now they are asked to deliver that care
themselves in the home, as well as bear the financial (lost pay when they take
time off work, lost promotions and even lost jobs), emotional and physical
consequences of delivering that care themselves.
It is no wonder that those who are sick increasingly report that
they have been sent into no-care zones both in the hospital and at home. The
American Hospital Association and the Boston based Picker Institute, for
example, sent out questionnaires to 37,000 patients and held 31 focus groups
with patients in 12 states. In a publicly released report, "Eye on the
Patient," the two groups reported that almost 33 percent felt they were sent
home from the
hospital too early. Thirty percent said that, when discharged, they were not
warned about possible danger signals related to their condition. Thirty-seven
percent were unsure about when they could resume daily normal activities.
Between 23 and 29 percent reported problems with continuity of care or lack of
coordination between various providers. One quarter wanted more emotional
support. Twenty-three percent cited insufficient information and education
about their condition.
From the point of view of nursing, however, the findings released in
a report privately circulated by the American Hospital Association are more
interesting. This document, entitled "Reality Check," said the following:
"The key indicator that people referred to as a measure of quality of their hospital care was the nurse. They hold a strong belief that skilled nurses are being systematically replaced by poorly trained and poorly paid aides. Their perspective on the 'thinness' of hospital staffing was reflected in a universally mentioned experience: 'If I hadn't stayed in the hospital room with my mother, child or spouse, they would never have gotten the correct medication or care on time.' People believe that the profit motive is behind the reduction in nursing care. They are angry at the reversal in health care priorities that they believe this represents."
The backlash against mismanaged care is strong indeed. There are efforts to
repeal the ERISA loophole, to enact Bills of Rights for patients, among many
other challenges to our market driven system. Our ability to construct a
viable, rational health care system that spent money on patients not profits
would be enhanced if more patients and families, health policy experts, and
political representations truly understood the contributions nurses make in
our health care system. Managing care is a worthy goal. But mismanaged care
is not only affecting patients ability to get high quality medical care, it is
making it very difficult for them to get the kind of high quality nursing care
which makes high quality medical care possible.
In the early days of the American hospital, patients were afraid to
enter those venerable institutions because they were terrified they would leave
dead. It was the development of modern nursing that in fact made hospitals
safe for patients. Today, we are truly going back to the future. More and
more patients are afraid to go into the hospital because the nurses are either
not there or unable to do their job.
It is time we recognized that health care is a collaboration
between medicine and nursing. Managed care is not only making it difficult
for patients to gain access to good medical care, it is denying them access to
high quality nursing care. What is needed is serious reform of the market
system (in my view what is truly needed is a universal health care system).
But no reform will be complete if it targets only medical care -- choice of
physician and specialist, emergency room treatment, medication of choice, etc.
It must also target policies like radical reductions in length of stay,
replacement of nurses by poorly-trained and poorly-paid aides, cuts in home
care services, and the increased nurse-to-patient ratio that makes it
impossible for nurses to weave the tapestry of care that is the real life
support in health care.