The American Gazette

Commonsense political and social commentary from "Flyover Country"

Location: Rural Michigan, United States

Wednesday, October 06, 2004

Politicians and American Health Care

As we move into the next debate likely to focus more on domestic issues, which will as a matter of course include health Care, I thought I would weigh in on that since I am a Registered Nurse.

I have been a nurse for 13 years. Through all of those years health Care has undergone some incredibly tumultuous times. Some to the benefit of patients, some not.

Let me start out with a story. About a month ago I got a patient in at about 2am with chest pain. By the time she reached my floor her chest pain was under control per the protocols of the ER. She was getting out of bed walking around etc... the patient was not in distress. Several family members had shown up on the floor with her. This family was disruptive to all of the patients I had on the floor that night. My unit is not large and is self enclosed, not the best place for people who are loud. After I had gotten this patient admitted one of the family members tracked me down in another patients room mind you, so he could ask me a question. He wanted to know where the ER was. I asked him if there was a problem? His response was to tell me that he thought he had an infected tooth, and that he wanted someone to look at it. I explained that the most the ER could do would be to perhaps prescribe an antibiotic but since there are not dentists in the ER they would not be able to do more, I also explained that he may be better off to wait a few hours and go to the dentist as the ER is the most expensive entry into the health care system. His response? He didn't care what it would cost because he had medicaid. He stated specifically "I just want some pain meds".

Let me explain something as if it were not obvious already. Someone is going to pay that bill, and boys and girls it is not going to be that man. It is you and I that pay for inappropriate use of the ER. What qualifies this person to have medicaid? I do not know. I did not ask. I can tell you that he appeared to be less than 30 years old, able to walk, talk and likely pee on his own. In my world that counts for alot. I also know that my 61 year old mother who is oxygen dependent, has had one heart attack that we know of cannot get coverage like this man has. My mom has a spend down version of medicaid. In other words she and my dad have to spend $800 a month on their health care before medicaid will pick up any of their health care costs. She and my step dad live on social security disablity only which means about two thirds of what they have coming in has to go to health care costs before my mom has any insurance coverage. My stepdad has medicare (and yes there is a difference between what medicare covers and what medicaid covers) because of his disability. He is diabetic, has lost site in one eye completely and has very poor vision in the other. He was a butcher and being able to see is an important thing so he doesn't cut off his arm. He has lost part of his foot to diabetes as well. My step dad has worked since he was 14 years old, stopped only when he was unable to work anymore. Yet someone who walks, talks and who should be able to take care of themselves is able to get more coverage than my parents are able to get.

Which leads me to this. The health care system needs fixing. Ok well duh, we all knew that. However what the democrats propose is for the govn't to cover everyone. Maybe not at this point like the fiasco that was Hillary care, but understand ultimately what the democrats are talking about is that exactly.

In my 13 years of practice I have seen more than my share of people who are just like the guy I described to you. When people do not have to pay something towards their own health care there is an incentive for them to be terribly caviliar towards how they use health care services. The other thing that happens is the non compliant patient. These are the patients that have already had some major problems, but instead of following what they are told to do they simply continue the lifestyle that put them into the hospital to start with and when they land back with us they have an expectation that you can wave a magic wand and make it all better. I have yet to meet a nurse or a physician who possesses that magic wand though.

Do I think that everyone should have health care coverage. I most certainly do. However I do not believe that it should come from the govn't. Medicare/medicaid is terribly inefficiant, the program is rife with fraud. Do a google search on Tenat health care and fraud, try the same for Columbia HCA and fraud. The results will astond you. Simply try health care fraud. Read enough and your blood will boil I promise you. For every act of fraud you pay more. You do so by taxes. For every patient who shows up in the ER for a problem that should go to a family physician and not the ER you pay. Every time your health care premiums rise you can count on the fact that you are not only paying your own health care, you are paying for those who have none.

The government system invites fraud, it is not so hard to do because no one is really looking. The system is so large and unwieldly that it is impossible for anyone to really be looking at it all. The more employers are forced to pay more for the health care they offer to their employees they less ability those employers have to hire new staff, or to expand their operations. As it stands now the way we cover people and they way we operate the financial end of healthcare is incredibly, horribly, terribly inefficient. And in the end it is only a very few people who profit. And I do not mean only from a monetary perspective.

In the late 80's most health care moved from fee for service type of payment. There were many abuses of the system as it stood then and reform was needed, I will never dispute that. However what we got is not what is working. When you go into the hospital and you get only two days for whatever, that is because of something called DRG's. Diagnotic Related Groups. Now one would think that DRG's was done by someone with healthcare experience. Sorry to disappoint but that is not the case. The idea and implementation of DRG's came from an accounting group located in Washington State. If I recall exactly out of Seattle. The first to pick up on DRG's was the govn't provided systems. Medicare/Medicaid. When DRG's rolled out from those systems, all private insurars took that lead, they always do. Most new things do not come from your private insurance, it is from medicare/medicaid. What the government decides is a good thing impacts your care and coverage immensely.

Then of course there were the HMO's. Put together to slow the cost of health care and make those DRG's work. And it did. But the down side to that is the people making the decisions regarding what you needed as a patient was no longer your physician, it was some faceless person on a phone deciding what they would pay for and what they would not. Horror stories abounded. The three year old little boy who will never be able to care for himself, let alone walk or talk because after falling and having a stick go up his nose his insurance company refused a CT scan. Lo and behold there was a small piece of stick that remained in his upper sinus cavity that lead to infection, that then infected this childs brain. A week after the initial accident this child was in a coma and he will never recover the brain function that he had. Beyond this terrible tragic incident, think of costs here. What did the insurance company save? Knowing the system as I do I am 99% sure that at some point this child will also be fully covered by medicaid, he fully qualifies and then who pays for his health care? YOU. Not the company that made the ill suited choice to not do simple CT scan. If you want more examples of this find the book "Making a Killing" not only does this book detail these types of instances they also show you how DRG's came into being, and who ultimately profits from it. And trust me it ain't you or I. Again I am not talking about just money here, I am talking about appropriate health care that should be given.

Next, let me go on to something near and dear to my heart. The nursing shortage. Folks we are looking at a nursing shortage that should scare the piss out of everyone in this country. Pop Media, also known as mainstream media want you to believe that the nursing shortage is because nurses are aging and retiring and the flow of new nurses does not keep up. That's part of the story. Yes, nurses are aging. The average age of an RN is now 47 years old. Most floor nurses do not keep nursing past 55 because it is physically too much to do so. Less young people are opting for nursing because it is primarily a female dominated field (0ver 90% female) and young women have more choices. Yes, true. But what Pop Media does not explain to you is that in the mid 90's as HMO's and "better streamlined health care" came into being there were merger and merger after merger of health care facilities. One of the most controllable costs in health care is labor costs, and some bright accountant thought the best way to bring health care costs down was to lay off nurses as facilities merged and services were combined. Over the last 13 years of me being a nurse, thousands and thousands of nurses were laid off. Most of them the older more experienced nurses because they cost the most. The loss of experience is profound when you are talking health care. The new nurse is NOT going to catch things that the experienced nurse will. I can also guarentee the new nurse is not going to be willing to argue with a physician about what a patient needs. Nurses are more than technicians, we are patient adovocates as well.

In California the nursing shortage got so bad that patients were calling 911 from their rooms to get someone to attend to them. In New York a patient bled to death because no one was able to look at him in a timely fashion following surgery. Many of the layoff's and facility closing across the country came after a consultant group called the Hunter Group came through a facility, they were supposed to make recommendations on how a facility could save money. Their fees are absolutely astrononical. After the Hunter group came through the facilites that are interconnected in Detroit they cut things are Detroit Regional so bad that a nurse from that facility was arrested after she was found taking IV poles out of a dumpster from another hospital with the intent of cleaning them up and sneaking them into her facility because Detroit Regional didn't have enough. Does that scare you? It should.

As the available nurses became less and less, the patients staying in the hospital became sicker and sicker. The patient who is now in ICU is the patient who ten years ago would have died. The patient on a typical med surg floor is the patient ten years ago who would have been in the ICU. Less nurses meant that we were taking a higher patient load, but with patients who were sicker and needed more attention that we can not give because we have too many patients. A vicious cycle. To add to the grief many nurses simply left the profession. They decided that they were being forced to practice in an unsafe environment which left them open to loss of license, lawsuits and potentially jail time. It is not an overstatement in the least to say this is true. As more nurses left, the pressures simply became more. Without enough nurses to cover the amount of patients and the shifts necessary the advent of mandatory overtime came in. Imagine in your own job will you that at the end of your day your boss came to you and said you could not go home,there was no one to replace you. No it doesn't matter that you have a child coming home on a bus to a locked empty home, no it does not matter that you have elderly parents that need your assistance. You must stay. And you may be forced to stay for up to 20 hours. This happened to thousands of nurses all across the country on a regular basis. The whip used to keep a nurse at the job was patient abandonment. It is part of our licensure. If you walk out and leave patients uncared for you may be brought in front of the state board of nursing and charged with patient abandonment. That can result in loss of license which means you can never again practice your chosen profession, and in my own case if something like that was to happen I would lose my home, my vehicles etc... because they couldn't be paid for.

It is noteworthy to understand that in America a semi truck driver cannot drive over the road for more than 8 hours at a time based on public safety, an airline pilot may not fly more than 14 hours and then only if there is a copilot, but a nurse can be forced to work up to 20 hours. It is your nurse who is adminstering potentially lethal drugs but we are such super humans we can do this on hour number 18 and not make a mistake, or at least the powers that be think so. In a study just done in July 2004 on patient safety in American Hospitals there is a figure of 159.000 patient death or injury cited from medical error. That's like a jumbo jet crashing every single day. Do not delude yourself and think that those errors have nothing to do with overworked nurses that have too many very ill patients, working on too little sleep.

John Kerry likes to focus on how many uninsured Americans there are. I will tell you that sick people do not get turned away. Non profit hospitals in particular must treat whoever walks in their door. Lack of health insurance means you pay for the care out of pocket, it does not mean you will not get care. Not real fair maybe, but the reality is you will get care, if nothing else an ER is always there. Is that a touchy feely statement. No it is not, but it is true. Understand that John Kerry has been in the Senate 20 years, tell me where was he when health care was being revamped? 4 years ago I went to Washington DC to rally for a bill that would prohibit mandatory overtime for nurses. I went to a senate subcommittee hearing on it. John Kerry was on that committee, so was Ted Kennedy. They listened, they nodded their heads and four years later and two bills later we still have nothing that bans the use of mandatory overtime to fill the holes left by not having enough nurses. Some of those holes come not because there is not enough nurses, but because a facility will not pay extra to have an agency nurse fill that slot. They force their own nurses to fill it. The use of mandatory overtime can also take the face of nurses being forced to sign up for extra shifts or hours, do not do so and your fired. It is not a matter of simply telling one facility to shove it and moving to another because so many places are using mandatory overtime that to find one who does not is nearly impossible. It's the same story all over the place.

Even if every single person in this country had cradle to grave health insurance provided by the govn't I want to know who is going to take care of them? I can't stress this enough, without nurses there is no health care!

Currently there is approximately 2.8 million RN's in this country. Only some 53% if I recall currently work full time. Some will work only part time, some have left the profession entirely and will not return unless there are some major changes. There are some 100,000 physicians in this country, so tell me who is actually providing your health care? By the way if the govn't would stop the use of artifically keeping the amount of people who go to medical school low they would increase the amount of physicians we have which would likely stimulate competition. Currently physicians do not have to compete by pricing. Most don't really need to compete at all, there is no incentive to.

The health care issues in this country are not simply getting everyone insured. It is how to do so and still expect people to have some buy in to their own health care and it's costs, those who do not consider that push costs up for all of us. It is not expecting the health care system to function on the backs of middle aged women who have a life outside of their profession. It is not allowing accountants and people outside of health care to make the decisions that affect your care or your childs or your parents. It is not allowing the head of Aetna to make 25 million dollars in one year while some rural and community hospitals have to close their doors for lack of money. It is not letting the Hunter group come through and decide to cut so much staff and equipment that a nurse goes dumpster diving to get needed supplies.

Do you know that every state in this country has minimum staffing guidelines for nursing homes? Let me cite one state. In the state of Michigan a nursing home has to provide 2.25 hours of nursing care to patients in a 24 hour period. That's all. Wonder why your elderly mother sits in a wheelchair for hours on end, has quit eating and has bedsores? That's why. It is physically impossible to spend enough time to take care of patients appropriately in a nursing home. I know I did it for 5 years until I could not take it emotionally anymore. Just like in hospitals where DRG's have forced such immense changes, nursing homes are also affected. The patient who used to stay in the hospital for rehab or long term antibiotics now gets kicked to the nursing home, and the minimum guidelines for hours of nursing care has not changed to reflect the changing patient population. As our baby boomer population ages further this is going to be an area that will be even more of a nightmare than it already is. And it is currently a horrid nightmare now.

Do not let the politicians of either party convince you that nothing is wrong in health care, and by all means do not let the democrats convince you that national health care will solve it. It will make it worse. The money will be even less than it is now which means more cut backs, less nurses even less housekeepers which means less appropriate cleaning which means more chance of a hospital borne infection. Ancillary staff gets cut so the nurse who hung your antibiotic may also be the same person who just took out the trash. Hope that nurse remembered to wash her hands then. I am not exaggerating, this is a fact in many facilities. In California the housekeeper may also be the one who starts CPR on you, cross training you know. Again I am not exaggerating.

If the people in this country want the best health care available for all people you must be prepared to pay for it. In that case there are chooses too, you can opt to pay for your own or under the democrats you can opt to pay for your own and everyone else's and not everyone else utilizes the system well.

I know this is long and bless anyone who read it to the end. At various intervels I will post some of the issues in health care, everyone should be aware of them and learn how to handle those issues and what politicians and health care adminstrators can do. As a country it would be good to learn that not everything can be perfect and not every life is savable and sometimes that life should not be saved because of the pain and suffering a patient goes through before they die anyway. A good death is as important as a good life. At least from my perspective.

I think next time we should talk about the docs and their role. Bless them, I actually like most physicians even consider a couple very good friends, but they have a huge role to play and no one is making them adhere to some fundamental ideas.



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