Masschusetts Nurse | April 2000

Nursing's perspective on the health care crisis
By Karen Daley, RN, MPH

The following is the text of remarks made by Karen Daley at a teach-In on the Harvard Pilgrim Crisis hosted by the Ad Hoc Committee to Defend Health Care on Feb. 15 at Harvard Medical School. 

I am speaking to you tonight to add nursing's voice to the outcry against the current trends in health care. I spoke these words for the first time at a press conference held in December 1997 to announce our Call to Action and to warn of an escalating crisis in health care that was putting our patients at risk. The recent financial insolvency of Harvard Pilgrim is just the latest indication of the seriousness of the issues undermining the future of our entire health care system. As front-line caregivers who spend more time with patients and families than any other stakeholder in this debate, we had the first look at what the reformed health care system actually meant for patients and caregivers alike. For the last six years, we have seen the steady deterioration of our once-proud health care system; we have witnessed the needless suffering of our patients; we have watched our own ranks demoralized and penalized by a system that by its very structure and philosophy violates the basic tenets and principals of our professional practice. 

We knew then and we know now that the market competition mentality has never fit an industry entrusted to provide health care for all of our citizens — especially for the poor, elderly and disenfranchised. Circumstances that recently forced state receivership of Harvard Pilgrim only represent the latest crisis in a system that we believe, as it currently exists, is doomed to fail. 
Let me briefly describe for you where we are and how we believe we got here, how nursing's been impacted and where we need to go from here.

The managed care system was supposed to provide for more efficient health care financing and delivery. What managed care quickly became was a system that realized cost controls by focusing on enrollment of high volumes of patients, competitive under pricing, and restricted use of hospitals and specialized services. For provider systems, survival soon became the priority.Unbridled growth under pricing of products and services, and a shifting emphasis on keeping beds full and moving patients quickly through systems allowed hospitals to compete under managed care - at least initially. Those same strategies over time also led to the erosion of the quality and humanity of the health care system for thousands across the state on a daily basis. 

The dictates of managed care for speed and high volume undermined the fundamental value to the provider's work of having sufficient time with patients. And as patients were moved out of hospitals more quickly, promises to create a seamless continuity of care within the community were broken. It didn't take long for insurers to realize that home care, initially assumed to be less costly than high tech acute care, was not. But instead of responding to the greater need within the community as hospital stays shortened, insurers became increasingly unwilling to pay for desperately needed home care services. Problems were further exacerbated by slashed Medicare reimbursement rates with the passage of the Balanced Budget Act. As a result of this squeeze from the managed care industry and the federal government, home care agencies began to close under the burden of grossly inadequate reimbursement. 

Speed-ups previously seen in acute care were now commonplace in the community as VNA caseloads and acuity skyrocketed. Elderly patients and others with complex medical needs, previously stable in the home with regular visits by registered nurses, were now seen as too expensive to maintain and dropped. Many ended up in nursing homes where care cost more, but was covered by other equally inadequate reimbursement systems like Medicaid. As I speak, more than 50 percent of our state's nursing homes are in or on the brink of bankruptcy. 

Perhaps the greatest toll of this crisis has been on patients and on their families, who found themselves desperate as loved ones were left in their care after one or two approved visits with complex recuperative needs. Responsibility for delivery of services shifted away from insurers and was forced upon family members, who were often left feeling ill-prepared - and adding the additional burdens of stress and fatigue and lost time from work to already overtaxed family systems. 

And while managed care did appear to control costs for the past several years, it is now apparent that the artificial short-term savings from these shortsighted approaches are now ending. Escalating HMO losses are now resulting in increased premiums and decreases in coverage for many Americans. By 2008, national health care expenditures are expected to reach $2.2 trillion. The number of uninsured Americans has grown by 10 million over the past decade. Of the 44.3 million uninsured in this country, 11 million are children; 12 million are women of childbearing age and more than 47 percent are employed full time. 

Now, more clearly than ever, we are seeing the effects of a system that placed more emphasis on fiscal survival of insurers and institutional providers than it did on the health of its patients. And we are seeing a system, for all its shortcomings, that is failing those it should be designed to serve. As cost controls and profits rather than human need have driven the decision-making, public trust has eroded. True accountability and oversight have been sorely lacking. A preventive focus, long thought the most cost-effective approach to health care, still remains largely absent from this system. 

Control over decision-making and workplace conditions, taken out of the hands of providers, has had an even greater impact over time. Nurses caring for patients describe commonplace situations like these: 

An elderly woman with congestive heart failure who was able to manage her condition at home supported by twice weekly visits by a visiting nurse, destabilizes within a short time after services are suddenly terminated by the agency. 

A bipolar substance abusing teenager who is hospitalized after exhibiting violent behavior is only allowed a four-day inpatient stay - long enough to be put on meds, but not long enough to address the underlying family crisis or his substance abuse issues. 

One registered nurse caring for more than 50 patients in a long term care facility. 

A young man post-op after a craniotomy whose wife - a nurse with four young children at home - must stay with him in the hospital because staffing is so short on his floor.

A wife who must take an unpaid leave from work to care for her elderly father-in-law who was recently hospitalized and requires care that his insurance won't cover after one home visit.

A single mother who must quit her job and go back on welfare to obtain health care for herself and her children.

A nurse who has her license suspended after a medication error committed in the context of an extremely busy unit where short staffing had doubled the number and acuity of patients she was assigned to care for. 

An emergency department that is overflowing with patients - many of whom will lie on stretchers in hallways and not be assessed for hours - with pressure on the attending not to go on diversion because every hour they are closed means lost revenue for the facility.

To make matters worse, a serious nursing shortage is looming just around the corner. This shortage will not be like the one in the 1980's. It won't simply be about numbers; it will be about insufficient numbers of nurses with needed specialization, skills and experience. Jobs for registered nurses will grow by 23 percent by 2006 - that's faster than the average for all other occupations. Reasons range from an aging workforce – 50 percent of registered nurses are expected to retire in the next 15 years - to salary compression, decreased educational enrollments and a hostile work environment where short staffing, work speed-ups, forced overtime and floating of nurses to areas without adequate orientation or experience have become commonplace. An added concern now is that some employers will use the shortage as an excuse to further de-skill and devalue the roles of RNs. Instead of hiring more unlicensed personnel, hospital administrators and nursing leaders should be lobbying just as vigorously in Washington for nursing education and recruitment campaign funding as they have been to have their bills paid.

And cutting the number of registered nurses flies in the face of solid evidence that consistently demonstrates that when RN staffing is adequate, there are fewer adverse outcomes for patients. We know based on research that, with adequate numbers of registered nurses, the number of patient infections, complications, falls, hospital lengths of stay and even deaths are reduced. Medication errors and work-related injuries also decrease. 

In the recently published report from the Institute of Medicine, it was revealed that medical errors account for as many as 44,000 to 98,000 deaths per year. In our current system, more people die from medical errors than from breast cancer or AIDS or motor vehicle accidents. Those errors don't occur simply because the institution lacks a dispensing or a computerized order entry system. Human errors contribute and any plan to eradicate errors must recognize the need for a physician or nurse to have adequate training and time to spend with the patient. 

 Ask nurses throughout Massachusetts, and they will tell you this managed care experiment has already failed and that a few legislative band aids won't fix it. Ask them what they want and they will tell you they want what they need to care for their patients. What they want is to be allowed to be nurses again, not assembly line workers. They want to do more than survive the day thankful that a life wasn't lost - to have the time and resources to bring life and wellness and compassion back into a system at risk of becoming devoid of all. 

The opportunity for lessons learned will not be lost if this crisis is approached in a thoughtful and comprehensive way. This crisis does not end with a bailout or fiscal rebirth of Harvard Pilgrim. This crisis is not simply about creating a system where we make sure HMOs and others pay their bills - it can't be reduced to a cash flow problem. It might interest you to know that in his remarks regarding the current Harvard Pilgrim situation at a public forum last week, Robert Hughes, executive director of the Massachusetts HMO Association, was quoted as saying, "This is not a crisis. It is relatively small amounts of money in the universe of health care spending." He went on further to say that it was the HMOs who were being squeezed by the providers and purchasers and that the ballot initiative undoes what they are. Among his proposed solutions to the current situation were for people to stay calm and to "sink" the ballot petition. 

As long as the current flaws and shortcomings are allowed to persist, as long as cost remains the central focus - rather than one of three catalysts for health policy in this country, we will continue to engage in these same struggles and other crises will be sure to follow. This crisis will end only when there is an acknowledgement that a market-driven approach does not belong in health care and that the priorities within our health care system must place equal weight on access and quality and cost. It will end with the creation of a system with accountability for its failures and oversight that averts disaster before it strikes.

Health care must first and always be about the patient. We must build a system that provides access to quality health care for all in the most cost effective way possible. It is MNA's position that single payer is the best way to reach that goal. And as we provide access for all, we must create a system that at its very core respects, acknowledges and safeguards the dignity of every human being in need. Until that time, we will continue to hear the outcry from providers who may choose to leave health care rather than compromise their values and their mission. And we will be faced with patients whose health and quality of life are placed at risk instead of enhanced by our health care system.   

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