Profits versus patients: Putting Care Back in Health Care
Opinion Page
(Published October 19, 2003)

The health care system in the United States is broken. The fix, adequate care for everyone, is simple, but will be difficult to implement in this socio-political environment. It is also something upon which I have much to say, but not today.

A symptom of what ails our health care system is the conflict between labor and management. It’s not just the grocery chain clerks, the MTA, the sheriffs, the teachers, the AFL-CIO, the Teamsters or the UAW. Job security, health care benefits and who pays for what are often at the top or not far down on the list of grievances that need resolution.

Conflicts between labor and management are like an elaborate chess game with the end game being the acquisition or protection of money and power. Both sides create press releases and make comments couched in lofty misdirection touting their side’s commitment to integrity, protection of patients, and defense of quality of care. However, confrontations can also degenerate into name calling like characterizing management as immoral and uncaring, and unions are greedy and seek to get everything for nothing.

Unfortunately, the patient may get caught in the crossfire.

Insurance companies and hospitals need to make money to keep the doors open and provide services. But for-profit companies also have investors and stock valuations to worry about. They need to look profitable to their investors, but need to appear to be just barely making it to their employees. Creative accounting to minimize apparent profit just might be tempting and some for-profit hospital companies (as well as Enron and WorldCom) have been known to keep separate books for different audiences.

Unions are not entirely altruistic either. The absolute need to protect workers from mistreatment, abuse and unfair labor practices by wealthy and powerful companies has been the raison d’etre for unions. But unions have also used leverage to make the cost of business so high that businesses have closed and workers have lost jobs because it became unaffordable to compete with less encumbered rivals. It becomes a game of the unions trying to figure out the “real numbers” and negotiate for as much as they can.

Hospitals and insurers (to a lesser extent) make significant investments of capital in equipment, facilities and personnel, and must do so judiciously in order to remain profitable. The issue is how much profit in health care is enough? And how should that profit be used? Should it go to Wall Street or should significant portions be reinvested for the health care of the communities they serve?

In my estimation, of the investments in capital, facilities and personnel, the personnel are the most important. Ultimately, health care is about skilled and caring relationships. The patient needs help. A trained health care provider has the skills to deliver the help. Of course, the surroundings do matter, but not nearly as much as the person actually delivering the care. That’s why the health care provider can be in the best-equipped intensive care unit, the post-surgical recovery room, the hospital ward, the emergency room, at the accident site or on the battlefield. It’s the person with the skills and experience that ultimate counts. And that care should be delivered in a compassionate, competent manner because that’s what patients and their families remember. Health care marketing departments trot out testimonials to tout how great their facility or company is. It’s not the facility or the insurance company. It’s the personal interface between the patient and the doctor, the nurse, the rehab specialist, the respiratory therapist, the pharmacist, the transporter, the hospital volunteer and myriad others. It’s the touch. Patients ultimately don’t care if their heart monitor was the state-of-the-art. They care that someone cared, and was able to do their very best to help the patient in time of need.

This is why I do not get excited about the hospital administration of HCA Los Robles Hospital making a big deal about building a new hospital allegedly so they can deliver better care to our community. They HAD to build a new hospital to be in compliance with upcoming seismic codes. Hospital administrators pour stale, mediocre cereal into a new box and want you to buy it because it’s labeled “new and improved”. They seem not to understand that what is IN the box is important, not the box itself.

In the interest of the bottom line, hospital administrators deliver the least expensive programs that are adequate to meet mandates, even if better programs are available. They manipulate medical and department leadership positions based on their compliance being more valued than their competence. Nurses are just line items to be costed-out as expenses. Human resource departments fill job descriptions with the lowest skill sets (cheapest) that can be justified, and in the fewest number. So the health care providers are understaffed, underpaid, and underskilled. Because they are not valued, the turnover is high, so administrators farm out and hire “travelers” who need no benefits (again, much cheaper). And when they get burned out, the hospital will get others. One of the silliest maneuvers is to provide bonuses for signing a contract, not for performing and staying.

We need stable staff that knows the hospital, procedures and the patients. I submit that it is reassuring is it to see a familiar face and hear a familiar voice. But stability means that the staff wanted to stay. The best nurses deserve a premium. They need to be kept.

If the administrators choose to dispute these comments, then let us publicly debate the evidence for all of you to judge.

When caring is truly returned to health care, when all citizens can get necessary health care, and when objective accountability becomes the rule, the cost, quality and outcome of our health care “system” will improve. And the disputes between labor and management so centered on health care will become historical footnotes.



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