Let’s just say that it isn’t going to be pretty economically here in this state soon. I gotta get my 5000 word research paper done before I can work on a series of postings on my state. Although luckily a lot of the research stuff will apply.

My job is making me sick.  Well, I guess it isn’t the job itself, per se, it’s the fact that my level of work related stress is so incredibly high, and my ability to recover between shifts is non-existent, that my defenses are simply down for the count.

When I say sick, I don’t mean, “oh, well I just can’t face going to work today so I’m going to call out” kind of sick.  I mean, pulling over on the side of the road on the way to to work so I can puke, stopping in gas stations to purge myself in the bathroom kind of sick.  I’ve had dysentery and frankly I’ll take that over this.  It is without a doubt stress related but legitimate illness none the less.  Fevers, the whole nine yards.  Even water becomes a luxury because I can’t keep it down.  This is the second time in a month this has happened to me; I’ve also begun having migraines with disturbing regularity after a period of several years with less than one per year.  These too have picked up in severity; I never used to actually vomit with migraines although I would be nauseated.  I’m not so lucky any more.

As some of you might know from my previous posts, I work in a very busy metropolitan emergency room.  It means that we take care of a high volume of patients daily, regardless of whether or not the trauma services are needed.  I recently heard the numbers:  last year, we cared for an average of 150 patients per day.  This year, we are caring for an average of close to 200.  Now, fifty people doesn’t maybe seem like that much, but you multiply that by the fact that each nurse is caring for an average of close to 6 additional patients per day, it adds up.  Each of those people is another assessment; each more than likely means lab draws, IV’s, medications, re-assessments, other treatments as needed, final assessment, discharge, and escorting to the discharge area.  All of that needs to be crammed into the same time period as the previous patient load used to be, and means that everyone is constantly under time pressures as well as direct pressures by management to ‘move them through!’

When I went from being a firefighter paramedic and working 24 hour shifts to being a nurse and working 12 hour shifts, probably the biggest surprise to me was the fact that working a 12 hour shift is as mentally and sometimes physically taxing as working a 24.  That’s because as a nurse, you don’t get ‘down time’ in between patients.  You always have at least one, usually more, and you are always thinking ahead to what has been done, what still needs to be done, who is sitting in triage and will probably be your next patient and what will be need to be done immediately for that patient, and so on…for 12 hours.  Now, I’ve worked 24 hour shifts and worked two jobs at a time for nearly 20 years, but this is without a doubt the most stressful job I’ve ever done.

Add to that the fact that our administration is –wasting- hundreds of thousands of dollars on ‘consulting groups’ to *supposedly* increase our productivity, and we are in a constant state of flux because of that, and there are now constant and unrelenting pressures on us to produce as though we were assembly line worker s pumping out auto parts, and you can maybe understand that my level of stress has been bumped up by more than a few notches in the last eight months or so.  The fact that we are a not for profit organization, and that people come to our facility from all over the Valley specifically because of the reputation for quality care we have sustained for nearly 50 years, doesn’t seem to matter to our administration.  They have lost sight of the fact that we are non-profit, and only care about increasing the profit margins, I would guess so that their salaries remain completely OUT of line with the rest of the line staff, and so that they continue to accrue ridiculous bonuses for said ‘productivity’.  If you are getting the idea that I’m bitter about that you’d be right.  If you are getting the idea that I’m not alone in my feelings of stress and alienation you’d also be right on the mark.  Administration approved the purchase of pizza for the entire hospital last week….big whoop.  Yeah, that makes up for treating us like crap for the last year.  Totally.

As you might guess, it shows in sick calls, in short staffing, in the numbers of people – many of whom have been at our facility their entire careers – leaving for other places and jobs where they aren’t treated as cattle herders and brow beaten constantly.  Our facility got rid of the incentive pay for extra shifts a couple of years ago; I recently heard it is probably being brought back because it’s nearly impossible to get people to come in on their days off any more.  They can’t get pool people to stay because they can work elsewhere and be treated better (which is saying something very significant when you consider that our facility, for many years, was almost impossible to get hired into unless someone died) In fact, it’s now down to when they DO get someone to work extra, they send people home based on how much they make per hour rather than who is next on the go home list.

I actually think the way our facility’s administration thinks is related to our culture at large.  The dysfunctional value they place on themselves as being necessary to the functioning of the facility while they remain completely oblivious to the problems at the level of the baseline reason for the facility’s existence seems to be to be related to the profits and bonuses of Wall Street executives.  Their bonuses too are completely out of line with the line staff salaries.  They too value themselves as entirely too valuable while ignoring the fact that their companies wouldn’t work without the little people do actually do work for them.

I recently heard on BBC radio that a study was recently done using college level business students at a major university.  The premise of the study was to see if bonuses raised productivity or if the threat of punishment – to management – raised it.  It turns out the threat of punishment – not only losing bonuses, but losing position, motivated managers to do their job properly – to actually manage – and be involved in the day to day activities that were tied to the punishment.  Performance significantly increased for the group with the threat of punishment.  Now, what that says about human nature I wouldn’t like to guess, but I think it’s worth noting that our administration is utilizing the threat of punishment – for lower level staff – as a stick while keeping any and all bonuses for our increased productivity for themselves.

I have no good conclusion for this rant except to point out that I – someone who has been pretty resilient for a lifetime – am becoming as I get older, prey to stress related illness.  I shudder to think what that might mean if I were to become disabled.

Money Won’t Buy You Health Insurance :  “This isn’t the story of a poor family with a mother who has a dreadful disease that bankrupts them, or with a child who has to go without vital medicines. Unlike many others, my family can afford medical care, with or without insurance.

Instead, this is a story about how broken the market for health insurance is, even for those who are healthy and who are willing and able to pay for it.”

I absolutely LOVE this woman’s idea.  How about a nationwide petition to force Congress (and the President, BTW) to quit receiving health insurance at taxpayer expense and require them to purchase their own health insurance at market rates?

“If members of Congress feel so strongly about undoing this important legislation, perhaps we should stop providing them with health insurance. Let’s credit their pay for the amount that has been paid by the taxpayers, and let them try to buy health insurance in the individual market. My bet is that they all would be denied. Health insurance reform might suddenly not seem to them like such a bad idea.”

Our health care system is broken beyond repair, I know this to be true.  As someone on the front lines in an inner city emergency room, I can assure you that we are experiencing the slow, dreadful, halt of taxpayer supported health care; indeed health care as a consumer commodity period.  My job has a very limited life span, even were I the ideal “Rah! Rah!” employee (and if you’ve been reading this blog for any length of time you’ve had to realize I’m not).  Or at least, it has a limited life span in its present form–a full time job with benefits and retirement.  It may certainly continue to exist as a part time job, on a contract worker basis, with no benefits and no retirement.  And I am not certain in the least that my pay will continue to be what it is presently either; I anticipate at least a third reduction in my wage in the coming years.  If not more.

Yep, system’s broken.  Ain’t no fixin’ it neither.  But making Congress pay for their own damned health insurance is a good start.

I have come to the disturbing conclusion, bubbling below the surface of my consciousness for months and causing great mental distress, that my place of employment has passed its days of greatness.  The things – no, the thing – that made my employer unique is simply gone, and it left with the retirement of the previous president and CEO.  Sadly, even though it’s a non profit, it is run increasingly like a for profit institution and words like ‘throughput’ ‘efficiency’ ‘customer service’ ‘market share’ and more are on the lips of more and more people there.  The people at the top, who are supposed to have a clue, are completely out of touch with what transpires on a daily basis in the very departments that effect the raison de etre for the facility.  It really makes me sad.

It’s truly a sad thing when a mid level boss has to actually conduct a study and gather data to prove it’s not his department that is causing the holdup.  It’s a truly sad thing when admitted patients sit in the ED for hours because the floors have sent staff home because of lack of patient load and in the interests of ‘fiscal responsibility’. It’s even sadder when patients sit in triage for hours waiting because the beds they need are filled with patients who are already admitted and can’t be moved.

How can we seriously talk about ‘throughput’ when we’re talking about human lives?  Or market share?  Or efficiency?  People aren’t products!   We don’t manufacture people, we care for them, and those words seriously shouldn’t even be in the same paragraph as human medical treatment.  Any time you talk about efficiency when speaking of medical care you are talking about cutting staff and essential services in the interests of the bottom line, and don’t let anyone fool you into believing differently.  And I’m sorry, but the best way to give good customer service is to STAFF APPROPRIATELY AT ALL TIMES.  There’s simply no other way to do it.  Making people do more with less means that more errors will occur, and more lawsuits will ultimately come for the simple reason that workers are overstressed and hurried.  It’s a hard enough job to do with compassion and personal efficiency.  What’s more, staff are human. The entire efficiency model is based on a debunked paradigm of humanity and the world as machines.
Trying to make nurses and techs work harder than they already do is a losing proposition.

There are several areas in the public sphere that really, honestly, should NEVER be left to a capitalist persuasion.  Life safety — OSHA, fire service, police, emergency medical services; welfare — trash, sewage, water, electricity; medical care — nursing, medicine, hospitalization, doctoring.  Any time it becomes a for profit career or institution it becomes corrupted.  Or at least in modern times, thanks to corporatism, have become corrupted.  Perhaps in the past the corruption was less simply because the sphere of influence was less.

All I have to say is that the economy better hold out til I get my graduate degree completed.

Several months ago I linked to an article in one of my state’s newspapers which outlined the difficulty retirees and people on Medicare are having getting doctors to accept Medicare assignments; patients are traveling as many as 100 miles to go to the doctor down in Phoenix because they can’t get seen by a doctor locally.

Well, there’s of course more to that story.  Realistically, none of those doctors has violated any law; they have simply begun telling patients that they will be happy to continue to see them — if they pay up front and deal with getting reimbursed from Medicare themselves.  Which of course patients are NOT willing to do.  I really think most people think Medicare is free  for them and that somehow mentally translates into meaning that the care is given for free.  Which of course is not true; health care is one of the biggest industries in this country.  Or, alternatively, people think they’ve earned it and that they should be entitled to all the health care they desire since they paid taxes while they were working.  I don’t think they stop to realize that pretty much, financially speaking, they paid for about one to two years worth of Medicare costs, if they have a chronic illness, and after that they’re getting health care based on MY (and your) tax dollars.  Theirs are already spent.

What does that mean in terms of doctors and Medicare assignments?  Well, it means that Medicare, being the biggest provider of health care payments in the nation, has the ability to set the standards for what and how much they’ll pay for something.  It also means that since they’re federally funded, there’s no recourse if you don’t get paid promptly, or at all, for a service you’ve provided – in some cases years ago.  And this lies at the crux of the doctor/patient problem.  Doctors aren’t willing to go months or even years without getting paid for services.  Since they’ve had to hire an entire staff devoted to simply dealing with Medicare and other health insurance companies — they all get on the bandwagon of what they see Medicare get away with regarding not just what and how much they’ll cover, but the bureaucracy as well — they simply can’t afford to continue to wait to get paid when they have to pay staff as well as malpractice insurance and their own bills.  Medicare has become quite adept at making the hoops a provider must jump through flaming and moving, with vague standards that are seemingly changeable at the whim of the claims processor (and the day of the week) which means that most claims must be sent in at least three times before Medicare will accept the claim (and this takes months to even get to this point) and months more before the claim will be paid out.

To make matters worse, because Medicare is functionally insolvent (because at this point our government is as well) they have an entire staff devoted to reviewing previous claims already paid out, and if they find ANYTHING  wrong with the original documentation, they make the provider pay back, with interest, (not to mention paying a fine for fraudulent submissions) the money already paid out.  Several hospitals I am aware of are now facing this even though some of the hospitalizations were two years ago.  This means that hospitals are having to hire entire staffs as well, to review all documentation dealing with any patient encounter, in order to prove they were entitled to the money.  Which means that an already financially strained system is being strained even more.  Co-incidentally, it means that nursing documentation on patient condition, which used to be mainly useful only for legal protection purposes, is now vitally important to the patient record as a whole; nurses may document something about the patient’s condition or response to treatment that makes the whole hospitalization justifiable even to Medicare where it might not be justifiable based merely on lab results or doctor reports.

These two are mainly why doctors are no longer accepting Medicare assignment.  They simply can’t face the possibility that, even if/when they DO get paid, they will have to face giving the money back at some point down the road.  If they make the patients responsible for payment up front, and the patient has to do the time consuming and redundant and frustrating work of trying to get reimbursed, the patients will also end up being responsible for paying that same money back (not sure about the fines or interest though).  The final reason providers are no longer accepting Medicare assignment is that reimbursement is set to go down another 20% (at last check) as of May 2011.  Many providers are barely covering expenses if they are in a solo or group practice (another financial incentive to work for a corporate group) and the reduction in eventual payment means it’s simply not worth it for them to accept Medicare.

This last reason is important because whatever Medicare does, other health insurance companies, as previously stated, follow.  This means that other insurance companies will feel free to also reduce their payments.  And they already play the game of endless refusal of payment as we know.

This hits close to home in several ways.   I was at a HAM radio function with my husband recently and was asked by one of the other members if I knew of any jobs available at my hospital.  I was puzzled and asked why, as this guy is not a nurse, nor is anyone in his family.  He replied that one of his neighbors is a nurse at our local facility and isn’t able to make ends meet on his take home pay — because of low admissions, he gets sent home early too many days and doesn’t get a full paycheck.  This is because these patients can’t or won’t pay up front to be seen by a local doctor and travel to Phoenix for their doctor visits.  It also means that if they see their doctor down there, he’s going to refer them to a hospital that is local to HIM/HER, not local to the patient…which means that our local facility, which just built a satellite hospital to accommodate our growing population, sits more than half empty a great portion of the time, and what staffing they have doesn’t have enough work (patients) to justify their presence.  The only patients that get admitted locally come from the emergency room visits, for the most part.  This is NOT a good thing in many ways.  First, it means that our hospital may end up being closed or declaring bankruptcy, which means we won’t even have a local facility to go to.  Second, it hurts the local economy by taking the available dollars to spend by employees down further, and forces them to move to other areas in order to have steady employment.  This of course has a fall down effect in that every other business that depends on those employees is hurt further and may end up closing.

The second effect this has had is that local urgent cares and doctor’s offices are doing the same with private health insurance as well — if they can’t count on being paid at all, let alone in a timely manner, they simply aren’t going to accept insurance.  My friend went to the urgent care recently and was told that they no longer accept her insurance — in fact, didn’t even have a record of her insurance company existing on their records (never mind that it’s a state funded insurance company for small businesses, never mind that she’s already used this insurance at this urgent care before) and that, if she wanted to be seen there, she needed to pay for the full cost of her visit up front and submit herself for reimbursement. Her husband said that while they were waiting to get checked in, before they were told this, that six other people were told the same thing at the window…which tells me they are simply moving to a cash up front business model.

This is a destructive strategy in so many ways!  First of all, I don’t think there are enough people left in my area who have the couple hundred dollars to plop down for an unexpected expense that they will be able to continue to operate at present capacity, if at all.  Second of all, if people even do have the money stashed away for this, they won’t have the money for other expenses and other businesses lose out.  Ultimately, this is frankly a suicidal way of doing business.  The only positive thing I could perhaps see coming out of this turn of events is that providers lower their rates in order to draw in business, much the same way as all the cosmetic/elective surgery providers have been doing for the past couple of years in the Phoenix area.  Hey, if you want Lasik, now’s the time!  It’s never been cheaper!  I don’t know of too many people who are willing to lay out that kind of cash, no matter how cheap, if they’re not even sure they’ll have a job in six months though…but what happens when doctors lower their rates is that they fire staff, do more themselves, and reduce their contribution to the economy further both by reducing staff/services and by the knock on effect of creating further unemployment and increased job INsecurity.

I knew this was coming, I just didn’t know it would be so soon!

One of the doctors I work with says that the two groups who need to be given full government funded health care are the mentally ill and children.  The mentally ill, because they CAN be productive members of society if they are kept on their meds and kept cared for (not locked up, just helped out) and because when they are in crisis, they cost MUCH more than maintenance would have.  And children, because they don’t have the ability to choose for themselves, and also because a child given a healthy start is a more productive member of society as an adult.  I think that would be a great thing myself, if there were some way to overcome the inherent prejudices against both groups.  The mentally ill, because at least in this state it’s somehow implied that it’s a moral failure to have a true mental illness, and children, because it seems that the kids are blamed for their parents having the audacity to have children if they’re poor (never mind that those same people don’t want to fund birth control).

Like it or not, we need to begin CIVIL discussions about rationing of health care on a federal level.  Call them death panels, call them whatever you want, we need them.  We simply cannot continue to provide the level of care we provide now, with no attention paid to preventative care, without some attention paid to responsible stewardship of a limited resource (limited by funds, not by anything else).  We need to have these discussions now, before circumstance and ideology force unpleasant choices on us all.