For ordinary Americans, the original idea of health-care reform was not just expanded access to health insurance. There was also the promise of more contact with primary-care physicians, bedside nurses, nurse practitioners and physicians’ assistants--the people who, unlike expensive specialists, have the time and inclination to reach beyond their patients’ diseases and into their lives.
President Clinton’s initial focus on instituting balance in a system overly dependent on specialists thus gave cause for rejoicing. As the political debate has progressed, however, the presidential and congressional embrace of a pure marketplace health-care system dominated by HMOs, managed-care companies, giant hospital chains and insurers has produced a version of reform that will manage care-giving right out of health care.
All over the country--and particularly in states like California and Massachusetts, where managed care has achieved “great market penetration"--we are seeing the future in action. Hospitals are laying off bedside nurses and replacing them with untrained, unlicensed aides. Those nurses who remain operate under assembly-line conditions: The patient is a human widget who must be rapidly moved into and out of the hospital, no matter what the human and social cost.
These hospitals are paying tens of thousands of dollars to high-priced national consultants who apply business’ bottom-line imperatives to health-care delivery. Patients facing some of the most difficult dilemmas any human being encounters are turned into “customers” and health care is actually compared to the activity of filling the tank at the local gas station. The new goal is “turnaround"--or, as other hospital administrators and consultants call it, “through-put.” To maximize efficiency, corporate managers who have no understanding of the devastating realities of illness dissect the complex activities of care-giving, fragmenting it into a series of discrete tasks that can be delegated to less costly aides.
The California Nurses Assn. reports that just when hospitalized patients are more acutely ill than ever before and discharged at an increasingly rapid pace, the expert nurses who can quickly evaluate their conditions, intervene on the spot to prevent complications and help them make the transition from hospital to home are the first to go.
To cite an example, one of California’s biggest HMOs has proposed widespread substitution of “multidisciplined care-givers” for registered nurses. The very heart of nursing--the hands-on care essential to nurses’ ability to diagnose, educate and comfort patients--will be farmed out to aides. At some other hospitals, aides with only six weeks’ training and no health-care background already are asked to do complex dressing changes and electrocardiograms, insert catheters and intravenous drips and draw blood.
Hiring techs and firing nurses also allows hospitals to increase nurse-to-patient ratios. An intensive-care nurse who cared for one or two patients may now be asked to tend three or four, and a medical-surgical nurse with four or five patients may now be asked to care for seven or 10. How, nurses respond, can they manage the patient if they no longer have the patient contact that makes quality case management possible?
This assembly-lining of care has not only invaded the hospital, it is now increasingly common in HMOs and other settings where the caseloads of physicians, nurse practitioners and physicians’ assistants are exponentially enlarged. Family physician caseloads at some California HMOs are rising to 2,700 patients. The average for British doctors, who opponents of government-financed care cite as desperately overworked, is under 2,000.
HMOs that are increasing patient loads acknowledge that “the numbers are large,” but reassure physicians that their patients won’t be very sick. This is of little consolation to the patients, sick or well, who need time to describe their complaints and concerns. Such assembly-line conditions significantly compromise the very essence of prevention and early detection.
The irony of all of this is that managed care does not save money. With administrative and marketing overhead of 14% and profits running as high as 20%, managed care is one of the costliest alternatives in the system today.
The least costly is the kind of single-payer, Canadian-style health-insurance program championed by Sen. Paul Wellstone (D-Minn.) and Rep. Jim McDermott (D-Wash.) Congress, awash in insurance-industry campaign funds and lobbyists, is now trying to persuade the American public that single-payer is a political impossibility. What ought to be politically impossible is the kind of assault on real care that is now jeopardizing patients’ health and making a mockery of the ideal of health-care reform.