Managed Care, Unmanaged Pain: Keeping Quiet on the ‘Tough Choices’ : Health care: You want skilled postoperative nursing in today’s cost-driven environment? Wake up!
The physician’s tone oscillates between frustration and despair. He is describing some of the patients at a major Northeastern hospital who undergo complicated kidney surgery. They have excruciating pain after the procedure. Fortunately, it can be almost totally alleviated with an epidural catheter that delivers pain medication directly to the nerves as they emerge from the spinal cord. However, this kind of pain medication needs expert supervision because of the catheter’s close proximity to the spinal cord and thus requires keeping the patient in the hospital for an extra two days.
Unfortunately, in today’s cost-driven health-care environment, the number crunchers who now run things want patients in and out of the hospital as quickly as possible. It won’t kill patients to be deprived of this kind of pain relief, they argue. “I can’t believe it,” the physician says. “You can bet I would never agree to have that kind of operation without an epidural catheter.”
Physicians and nurses, of course, know all about what is being ruthlessly slashed from our health-care system. They know what kinds of side effects occur following invasive high-tech medical procedures. They know what kinds of medications best bring pain relief, prevent infection and promote healing. They know how many days it will take a patient to recover and about the kind of intensive nursing care and monitoring necessary to assure that recovery.
But thanks to TV hospital dramas like “ER” and “Chicago Hope” and the health-care media, most patients and families don’t know that health care is a process, not a single event. When a patient has a lung removed because he has cancer, he needs more than a good surgeon. He needs a sufficiently long hospital stay and expert nursing staff to make sure he doesn’t develop pneumonia and die. When he has a complicated kidney operation or a coronary artery bypass graft, he needs systematic pain medication and scrupulous attention to his wound.
And this is just what hospitals and insurers are no longer willing to provide. In a huge scramble to offer the cheapest prices, hospitals--including America’s richest and most prestigious--are competing to attract managed-care contracts from large insurers, HMOs and large employers who self-insure. Engaged in what is called national competitive bidding, large self-insured employers like Delta Airlines, traditional insurers like Aetna and HMOs like Harvard Community Health Plan seek hospitals that will offer them cut-rate prices for surgical procedures like bypass and kidney operations or chemotherapy for cancer patients.
In order to deliver a particular treatment at a price that undercuts the competition, hospitals will bid so low that they may not even cover the costs of the procedure. When that happens, something has to give. What patients won’t get is what they don’t know about--an extra two days in the hospital so their pain can be managed, or an expert nurse at the bedside so infections and other complications can be prevented.
That’s why America now has the shortest length of hospital stay of any country in the industrialized world, why managed-care plans kick patients out of hospitals twice as quickly as traditional fee-for-service plans and why the United States has become a world leader in getting rid of expert bedside nurses in hospitals all across the nation.
Advocates of managed care insist that patients and families have to become educated health-care consumers, that they must accept tough choices if the system is to work. The trouble is, patients and families are never told what these choices really are. No one tells us that the price of the operation might include an outdated medical procedure that may increase the risk of infection. Or, if the latest high-tech method is used, that adequate pain relief may not be provided. Or they’ll get a bed, but on a floor short on expert nursing care. And there is no way that ordinary people can ever really predetermine these trade-offs and choices on their own.
In an even more alarming turn of events, HMOs and hospitals are now forbidding doctors and nurses to tell patients about alternate procedures or medications that might be more effective but are also more expensive.
Moreover, in this current version of market-driven health care, even if the consumer/patient did manage to acquire the most up-to-date medical education, it would do him little good. That’s because in our employment-linked health-insurance system, it is the purchaser of health-care services--the employer--not the user of health-care services--the employee--who calls the shots.
What our society fails to grasp is that applying the logic of the marketplace to a human service like health care is fraught with peril. The health-care exchange is not about acquisition, it’s about illness, aging, vulnerability and death. Once the health-care package is deprived of that essential moral content, what you get is a corporatized system in which the dollar sign replaces the caduceus and the pledge of the Hippocratic oath, to “do no harm,” becomes an artifact of antiquity.
