An allnurses Fix On Healthcare

  1. Several months ago, many of you responded to a thread about fixing healthcare, collectively providing a wealth of well-thought-out ideas. You were asked simply what you would do to fix US healthcare, based on the assumption that any change was a possibility. Several clear themes dominated your responses.

    An allnurses Fix On Healthcare

    In his excellent book, "America's Bitter Pill," Steven Brill asks: "Do I wish that the National Labor Board had ruled in 1943 that health insurance benefits did, in fact, count as wages and, therefore, that adding them would not be allowed under the wartime wage control regulations?

    Sure. Along with the follow-on decision by the IRS that insurance benefits could be tax free, that was the fork in the road that set the United States off in the wrong direction-putting employers on track to be the primary providers of health insurance. That is a different path from that taken by every other developed country, all of which produce the same or better healthcare results than we do at a far lower cost. . .

    America's dysfunctional healthcare house, with the bad plumbing and electricity, leaky roof, broken windows and rotting floors would never have been built and become so entrenched in its special interest foundations that it could not be torn down." (Brill, 2015, p. 409).

    I started browsing allnurses.com in December of 2016. For the first couple of months, I mostly read and watched from the shadows. One sentiment repeatedly jumped off the pages of discussions. Nurses often expressed dissatisfaction and anger at unsafe staffing levels, increases in patient acuity, and system clutter limiting our ability to provide safe and appropriate care. There were rare complaints about pay or benefits. Some nurses mused that maybe they had chosen the wrong career. But the loudest voices from the community expressed anger at a system thwarting our best intentions to consistently provide excellent care.

    Some of the forces hurting our profession are on a department or hospital level, but many flow downhill from the legislative and structural failings in US healthcare. Patients are increasingly hurt, frustrated, and failed by our expensive and inequitable system, and nurses are the front-line absorbing a lot of the anger. "I can't fill this prescription. I'm homeless." "My blood pressure was fine until my husband changed jobs, and my new insurance won't cover my medication." "I know this isn't a real emergency, but the walk-in clinic wouldn't see me unless I could pay $40 today. I don't get paid until Friday and my gout is killing me." The ER will see him without payment today, but now he has an $800 bill for his twenty-minute stay that won't just vanish. Frustration and anger are common and palpable. While a few very wealthy people profit handsomely from our current dysfunctional system, everyone else loses.

    Nurses are uniquely positioned, hearing the story from hospital administrators, registration clerks, doctors, patients, and their family members. Our enlightened opinions carry intrinsic value. Several months ago, many of you responded to a thread about fixing healthcare, collectively providing a wealth of well-thought-out ideas. You were asked simply what you would do to fix US healthcare, based on the assumption that any change was a possibility. Several clear themes dominated your responses. Here is a distillation of the picture you painted:

    1. We need to go to a single payer system which eliminates dependence on private health insurance. The United States Federal Government should provide equal access to healthcare, including vision and dental care, free from financial and other barriers for all citizens, possibly through an improved and expanded version of Medicare with private providers competing for market share.

    Rationale: Our current inequitable, employer-based insurance model is complex, expensive, inadequate, and invasive in controlling medical practice. Nearly 30% of our spending is drained by administrative costs, nearly ten times the amount spent on administration by other industrialized countries. Most bankruptcies in the US are caused by medical bills, and over half of those bankruptcies are patients who were insured. Due to cost shifting and profiteering under the current system, those who pay are already overpaying for those who don't pay. A single payer would eliminate exploitive profiteering by pharma, equipment makers, insurance, and hospitals. Increased taxes to covers costs would be more than offset by the elimination of current insurance premiums, copays and other out of pocket expenses, reducing the total cost to citizens by about 40%.

    2. Primary decision-making authority needs to be returned to doctors and other direct care providers while removing incentives to order unnecessary testing and treatment.

    Rationale: Decisions in our current system are tainted or dictated by government incentives or insurance meddling. Remuneration needs to be based on appropriate applications of standards of practice and expected outcomes. Reimbursement should not be tied to patient satisfaction surveys. Evidence demonstrates patent satisfaction is a poor indicator of appropriate care.

    3. A single payer will negotiate prices for pharmaceuticals and medical equipment, standardizing and reducing costs to the reasonable levels established in other developed countries.

    Rationale: In our current US system, drug prices and medical equipment are granted unchallenged profit margins. Direct advertising of prescription medications to the public should be eliminated, and decisions about appropriate prescriptions should be made by providers based on clinical evidence.

    4. Federal government will be the essential single payer, but not the single regulator. Regulation should be conducted by state review boards with a majority representation of active healthcare providers or providers with five or more years of direct patient care within the previous ten-year period.

    Rationale: Government has a long track record of inefficient bureaucracy and provider representation is needed to insure relevance. Current regulatory practices are overly complex and will be simplified as access and payment structures are simplified. Decluttering delivery by removing regulatory hurdles currently impeding delivery will simplify care and the regulation of care.

    5. Reasonable provider fees need to be established and standardized.

    Rational: Excessive profiteering by hospitals needs to be eliminated while maintaining competitive salary and staffing levels to attract and retain competent caregivers. The average salary for a CEO of a nonprofit hospital is about ten times the salary of the average physician. Financial losses currently tagged as "charity cases" will be replaced by covered patients resulting in reduced but predictable income. Shifting toward global payment for specific problems instead of fee for service could reduce unnecessary care.

    6. We need to adopt a much stronger focus on preventive care and improved lifestyle choices, increasing community services to reduce hospitalizations by solving more social problems upstream. We need to foster approaches which encourage and reward individual responsibility, shift care away from hospitals to in-home and community settings.

    Rationale: Developed countries who have much better health while spending far less on medical services outspend us on social services, solving social issues before they become medical problems. For example, giving a homeless man a pair of shoes, insulin, and a room in a shelter during cold winter nights is a cheaper and better use of resources than a massive bill for an amputation, rehab and lifelong complications from limited mobility resulting in comorbidities and multiple readmissions. Better access to addiction and psych care reduces expensive hospitalizations. Increasing day care respite centers for our aging population helps keep the elderly functional and able to live at home. Improved hospice services could reduce wasteful and costly end of life admissions.

    7. Healthcare providers need to be held to a standard of practice and should not be exempt from lawsuits for clear negligence. While cases of legitimate neglect or medical errors justify lawsuits, more tort reform is still needed. Lawyers who incite lawsuits deemed to be frivolous and without merit should be held responsible for defendant court costs.

    Rationale: Settlements and judgements constitute a small percentage of healthcare costs, but litigation is still frequently cited by providers as a costly driver of excessive defensive medicine. In cases of medical errors, the focus should be on restoring wholeness and function rather than massive multimillion dollar settlements or punitive financial damages for intangibles such as mental anguish.

    8. Nursing care will improve under a simplified system, but, as the providers of the majority of hands-on healthcare delivery, nurse staffing ratios already mandated in CA should be considered a minimum standard for safe care.

    Rationale: Safe staffing levels have demonstrated reduced wait times, fewer errors, better outcomes, and improved patient satisfaction.

    These eight points cover the broad strokes of the picture you painted. I believe our model is a major improvement over the current fragmented infrastructure controlling our practice. Several other organizations have come up with formulas like ours. Some organizations have been bravely championing their causes for years, even decades. But the complex, dysfunctional US system stumbles on because our politicians have repeatedly caved to the strong lobbies from pharma, equipment makers, insurance, and hospitals which drown out public clamor for change.

    The opening quote from Steven Brill lamenting that our "dysfunctional healthcare house . . ." has "become so entrenched in its special interest foundations that it could not be torn down" was published in 2015. I wonder what he would say now? While it is still true that uprooting and replacing our current system will be painful, anger and resolve are mounting. Grassroots support is gaining traction. Bill 676 legislating "Medicare for all" is working through the House of Representatives and is worthy of our attention.

    I hope forces already in motion spark a revolutionary paradigm change to a better system. I'm hopeful that the NursesTakeDC effort will result in safe staffing ratios. I am personally writing to legislators to support S 1063/HR 2392 while arguing for other improvements. But, what if our democratic process continues to fail? Is it possible that the three million nurses caught in the crossfire of our unjust system may one day need to become our own means of last resort?

    The Japanese kanji for "trust" is a pictograph of words coming from an open mouth and a person standing beside the words. The idea is that a person who stands beside his/her words is trustworthy. Nursing has topped Gallup's poll as the most trusted profession since the poll started in 2002. The nation trusts us for good reason. Their lives are in our hands. What if the most trusted profession adopted a clear agenda, harnessed the energy of the hurting public, and drew a line in the sand demanding a legitimate fix for our disgraceful system?

    Author's note: While I did not directly cite these sources, I found useful background in "The America Healthcare Paradox: Why Spending More is Getting Us Less,' by Elizabeth H. Bradley and Lauren A. Taylor and "An American Sickness," by Elizabeth Rosenthal. Physicians for a National Health Program and National Nurses United are actively pursuing agendas which embody most of our points.

    References:
    Brill, Steven (2015). America's Bitter Pill. New York: Random House.
    Last edit by Joe V on Jun 14
    Do you like this Article? Click Like?

  2. Visit RobbiRN profile page

    About RobbiRN, RN

    I'm a dancer, traveler, lover of the beach, an ER RN and a published author as Robbi Hartford. In my ongoing quest to provide excellent care for my patients, I'm compelled to push back against forces that assail common sense in our workplace.

    Joined: Dec '16; Posts: 149; Likes: 781
    ER RN; from FL , US
    Specialty: 24 year(s) of experience in ER

    Read My Articles

    11 Comments

  3. by   Garden,RN
    I do not agree with going to single payer. Look at the other behemoth projects run by the government? Dare I mention the current public health system ? How about the public schools?How are those regulations senior care facilities working out? No way. I would, however take the power away from the insurance companies. Most of the other parts I agree with but this one is a non-starter for me.
  4. by   MunoRN
    Quote from Garden,RN
    I do not agree with going to single payer. Look at the other behemoth projects run by the government? Dare I mention the current public health system ? How about the public schools?How are those regulations senior care facilities working out? No way. I would, however take the power away from the insurance companies. Most of the other parts I agree with but this one is a non-starter for me.
    Are you maybe confusing single payer with government-operated healthcare? Single payer doesn't mean that you go to a doctor employed by the federal government or a government run hospital, all it means is that the administration of the payment process is consolidated to a single entity, which significantly decreases these administrative costs. In the private insurance industry we pay for overhead that's about 14% of the cost, our only quasi-single payer comparison is CMS, which has an administrative overhead cost of about 4%, and lower price inflation to boot.

    Maybe you could expand on "how about the public schools" and "How are those regulations senior care facilities working out".
  5. by   RobbiRN
    Quote from Garden,RN
    I do not agree with going to single payer. Look at the other behemoth projects run by the government? Dare I mention the current public health system ? How about the public schools?How are those regulations senior care facilities working out? No way. I would, however take the power away from the insurance companies. Most of the other parts I agree with but this one is a non-starter for me.
    I share your concern about government's inability to run things well. As MunoRN clarified, government as the payer does not make government the provider. Can you suggest another way to "take the power away from the insurance companies"? Ending insurance profiteering and meddling by denying or directing care were strongly targeted in the responses, but making government the single payer seems the only viable way to do it.
  6. by   nursej22
    Quote from Garden,RN
    I do not agree with going to single payer. Look at the other behemoth projects run by the government? Dare I mention the current public health system ? How about the public schools?How are those regulations senior care facilities working out? No way. I would, however take the power away from the insurance companies. Most of the other parts I agree with but this one is a non-starter for me.
    And yet we trust them with the military and nuclear weapons.
  7. by   Susie2310
    I think this article is a good attempt at tackling a complicated subject.

    I would need to see much more detail on most of these points before I could take a position on them.

    In regard to tort reform, vested interests have already made the filing of legitimate lawsuits very difficult in many cases, and in my state victims of medical malpractice only have a very few years to file a lawsuit from the time the injury took place. The state medical board has a similar very small window in which a claim of malpractice can be brought, requiring proof of malpractice such that even when significant offenses have been found to have been committed the physician continues to practice.

    I also disagree that patient satisfaction should not form part of the criteria for reimbursement. Patient satisfaction is appropriately factored into reimbursement. Patients experiences of their care should be listened to, and their experiences of the care they receive from their nurses and physicians should count for reimbursement purposes, and I believe it is very reasonable that the largest payor for health care, the Federal government, seeks this information. Many nurses and physicians are opposed to this, as the care they provide is scrutinized and evaluated by the patient, and reimbursement can be affected. The HCAHPS Survey that surveys patients who have been hospitalized about the care they have received from their nurses and physicians has questions that are very reasonable.

    I agree that there should be greater focus on preventive care.

    Reducing health care monopolies that exist in some states, which drive up the cost of insurance and of health care, is important, and I agree that very high levels of executive pay should be curtailed for the same reason.

    I am very much in favor of Medicare. I am strongly in favor of the ACA, which has helped many people to be able to have medical insurance and to receive comprehensive medical care, and I believe it can be improved on. Much of the implementation has been left to the electorate and politicians of individual states, e.g. the decision whether to expand Medicaid, and, as I said above, reducing health care monopolies and curtailing very high levels of executive pay is necessary in order to bring down the costs of health care and for the insurance markets to operate properly, so that more people can have access to affordable health care.
    Last edit by Susie2310 on May 8
  8. by   RobbiRN
    Quote from Susie2310
    I think this article is a good attempt at tackling a complicated subject.

    I would need to see much more detail on most of these points before I could take a position on them.

    In regard to tort reform, vested interests have already made the filing of legitimate lawsuits very difficult in many cases, and in my state victims of medical malpractice only have a very few years to file a lawsuit from the time the injury took place. The state medical board has a similar very small window in which a claim of malpractice can be brought, requiring proof of malpractice such that even when significant offenses have been found to have been committed the physician continues to practice.

    I also disagree that patient satisfaction should not form part of the criteria for reimbursement. Patient satisfaction is appropriately factored into reimbursement. Patients experiences of their care should be listened to, and their experiences of the care they receive from their nurses and physicians should count for reimbursement purposes, and I believe it is very reasonable that the largest payor for health care, the Federal government, seeks this information. Many nurses and physicians are opposed to this, as the care they provide is scrutinized and evaluated by the patient, and reimbursement can be affected. The HCAHPS Survey that surveys patients who have been hospitalized about the care they have received from their nurses and physicians has questions that are very reasonable.

    I agree that there should be greater focus on preventive care.

    Reducing health care monopolies that exist in some states, which drive up the cost of insurance and of health care, is important, and I agree that very high levels of executive pay should be curtailed for the same reason.

    I am very much in favor of Medicare. I am strongly in favor of the ACA, which has helped many people to be able to have medical insurance and to receive comprehensive medical care, and I believe it can be improved on. Much of the implementation has been left to the electorate and politicians of individual states, e.g. the decision whether to expand Medicaid, and, as I said above, reducing health care monopolies and curtailing very high levels of executive pay is necessary in order to bring down the costs of health care and for the insurance markets to operate properly, so that more people can have access to affordable health care.
    Thank you for your response. I have two questions: 1. Would you say that current levels of litigation are justified and no significant reform is needed?

    It is my understanding that the ACA did help those with pre-existing conditions to get insurance and those who qualified for medicaid to get medicaid. Many cheaper plans were wiped out because they were deemed insufficient under the law causing a lot of people to loose their plans. Locally, those with medicaid say that can't find any doctors who will take their "insurance." They just come to the ER instead for their minor and chronic problems.

    Those pushing the ACA through essentially gave up on containing costs by cutting backroom deals with insurance, pharma and the hospitals in order to get it passed. My premiums, copays and out-of pocket expenses have all increased since the ACA was implemented. Has anyone who has private insurance seen a decrease?

    Question 2: Has the ACA made healthcare affordable for the country?
  9. by   Susie2310
    Quote from RobbiRN
    Thank you for your response. I have two questions: 1. Would you say that current levels of litigation are justified and no significant reform is needed?
    With respect, I find this question very vague. You are asking if the current annual level of litigation (malpractice lawsuits) is justified? Justified relative to what? Relative to the estimated annual number of deaths/injuries due to medical errors? Relative to the number of patients who receive medical care in a year? The absolute number of medical malpractice lawsuits filed does not indicate a need for tort reform if there is a legitimate basis for the lawsuits. One cannot presume that even if there is what one considers to be a high number of malpractice lawsuits (relative to whatever), that a majority of the lawsuits are baseless. I am not aware of a surfeit in frivolous malpractice lawsuits; the burden of proof that is necessary for the complainant to bring is already very high, as are the financial costs (and often the personal costs) for the complainant.

    As already mentioned, in my state the time window for filing a malpractice lawsuit is small, and the time window for filing a malpractice complaint with the state Medical Board is also small; in my opinion a longer time period would be more reasonable and realistic, particularly as it often takes a number of years before the full extent of an injury is apparent.
    Last edit by Susie2310 on May 9
  10. by   Susie2310
    Quote from RobbiRN
    Question 2: Has the ACA made healthcare affordable for the country?
    As already mentioned, healthcare monopolies in some states have reduced the number of insurers willing to participate in the state exchanges or even within the state as a whole, and have driven up costs for patients/consumers both in the costs of insurance and the ability to purchase insurance, and in the costs of care, and have negatively affected the functioning of the insurance markets. Very high levels of executive pay have also driven up the cost of health care. Some health systems are very profitable. Political action is necessary to address this.

    Also, some states have chosen not to expand Medicaid, so are not benefitting from the ACA in this regard.

    I live in a state that expanded Medicaid. While there is a shortage of insurers, I believe that the ACA is working well for the majority of people. I agree that health care costs have risen significantly for many people due to the ACA, and I agree that the ACA can and should be improved on in that regard - I already mentioned three aspects that can be improved on.
    Last edit by Susie2310 on May 9
  11. by   cgw5364
    I think it should be a single payer system. I fight with insurance companies every day to get services approved and denials overturned. I watched a documentary called Fix It Healthcare At The Tipping Point and the money spent on administrative cost is 30-35% of health care cost. Going to a single payer system would bring that down to 3-5%. I live in a state that did not expand Medicaid under ACA and if you make less than $12,000 a year you can't get insurance on the health care exchange. When filling out the application income under $12,000 is supposed to qualify you for Medicaid but in the states that did not expand you can't get it. The health care exchange plans offered in our state by one company have monthly premiums of over $500.00 if you don't qualify for a subsidy. And these plans are high deductible in addition to high monthly premiums. I encourage everyone to watch the documentary Fix It Healthcare At The Tipping Point.
  12. by   RobbiRN
    Quote from cgw5364
    I think it should be a single payer system. I fight with insurance companies every day to get services approved and denials overturned. I watched a documentary called Fix It Healthcare At The Tipping Point and the money spent on administrative cost is 30-35% of health care cost. Going to a single payer system would bring that down to 3-5%. I live in a state that did not expand Medicaid under ACA and if you make less than $12,000 a year you can't get insurance on the health care exchange. When filling out the application income under $12,000 is supposed to qualify you for Medicaid but in the states that did not expand you can't get it. The health care exchange plans offered in our state by one company have monthly premiums of over $500.00 if you don't qualify for a subsidy. And these plans are high deductible in addition to high monthly premiums. I encourage everyone to watch the documentary Fix It Healthcare At The Tipping Point.
    Most of those who responded to the original thread stated the need to go to single payer. Just a reminder, this article is not a a summary of my opinions, it is a distillation of this thread: What Would You Do to Fix the Failings of Healthcare Delivery ?

    The "Fix It Healthcare" site and the movie are excellent. Here's the link: Fix It Healthcare At The Tipping Point |
  13. by   Daisy Joyce
    I like number six, but good luck convincing people to snack on carrots rather than Twix bars

close