Uncaring
Thirty years ago I wrote Modern Medicine: What You’re Dying to Know to try to warn patients of the changes being brought to their care by corporate medicine, managed care, insurance companies, pharmacy companies, and lawyers. It was clear to me even then that these entities were in the process of removing medical decisions from the hands of physicians. Many books have appeared since then looking to what has changed our U.S. healthcare system into a money machine for large organizations. A notably good one is Elisabeth Rosenthal’s An American Sickness. As a physician working for Kaiser Permanente, she was a powerful voice against the chaos caused by big business medicine.
I have recently looked over Dr. Pearl’s book Uncaring. He too is associated with Kaiser Permanente, but as the CEO. Amazing how different his story of what’s wrong with healthcare differs from Rosenthal’s. Pearl was “in charge” of 10,000 doctors and 30,000 employees at Kaiser Permanente for 18 years. Pearl boasts that when he arrived at Kaiser Permanente, the organization had 2 days worth of cash on hand. Generally, an organization to be considered in good health, has to have 60 days or more of cash on hand. In his story, he fails to mention what his salary was during his 18-year tenure or the insurance hikes paid by the average consumer member at Kaiser Permanente to pay for his salary.
Uncaring is a misleading title. Pearl writes much more like an administrator than a physician. He blames doctors for 98 percent of what’s wrong with healthcare. With this perspective, he has blamed doctors for much of what they have no control over. It’s time to stop blaming doctors for what’s wrong with health care. Blaming doctors as he does, he ignores the opportunity to repair the other 85 percent of the healthcare delivery mess.
From my perspective, proliferation of non-essential administrative positions has created a tremendous increase in the cost of healthcare. In the last two decades, the number of doctors in healthcare has increased 150 percent. During that same time period, the number of administrative positions in healthcare has increased 3200 percent. The power administrators have to manipulate unwitting hospital boards to do their bidding is unholy. The CEO of CVS makes 22 million per year while the average salary of CVS employees is slightly less than $30,000 per year. That’s probably why is takes 30 to 45 minutes to talk with someone at CVS about a patient’s medications. We are probably trying to communicate with an LPN who can hardly speak English.
Big Pharma
About three years ago, CVS bought Aetna for 68 billion—not million—dollars and assumed another 8 to 9 billion in Aetna’s debt. Now, how can this Big Pharma, who claims to offer their clients “cost effective” medications come up with an extra 75 billion dollars? Who pays for that? Well, patients do. The public pays for it in the form of higher Medicare costs, higher insurance premium and higher medication costs.
Let’s look at what happened when CVS bought Aetna. The deal was good for Aetna which had a 40 percent increase in death payments because of COVID. So what’s in it for CVS? Well, Aetna was a pharmacy benefit manager (PBM). A PBM was designed by insurance companies to watch that Big Pharm didn’t overcharge insurance companies for medications. So now the fox is guarding the henhouse.
Who allows this kind of atrocious alliance? The Department of Justice (DOJ), which is supposed to have the best interest of the public in mind. The DOJ allowed this merger and justified it as “innovative.”
Primary Care Nursing
Several decades ago, the nursing hierarchy decided to create a new nursing persona called primary care nursing. This instantaneously quadrupled the need for nurses. Why? Because the orderlies and desk clerks were fired, to be replaced by adding their duties to the nursing schedule.
Fifty years ago, I worked in a rehab hospital while I was in med school. I was paid 95 cents an hour. With myself and other orderlies, one RN and one LPN per shift could care for 40-50 patients. Today, there would be nine nurses working each of these three shifts. In other words, the nursing shortage has been manufactured by the manipulation of normal hospital staffing roles.
Locums Nurses
In medicine, temporary stand-ins for physicians are called locum-tenens. The term is most commonly used for physicians, but the term is now also applied to nurses, LPNs, and even CNAs. The going rate for locums nurses is $100 an hour. For CNAs, $90 an hour. The nurses themselves may make $40 to $50 an hour. The company supplying the locums nurses keeps the difference. Who pays for these expensive substitutes? You do in the form of higher Medicare and insurance expenses.
You may be asking why any hospital would use locums staff. With locums, hospitals pay for no benefits as they would if the nurses were hired as regular employees. There is no overhead for these substitute positions. On the hospital books, the costs of the locums staff is a total write-off. What’s more, for a small rural critical access hospital (CAH), the federal government pays 90 percent of the cost of the locums.
And finally, the locums staff do not know the patients. While it’s true that some locums nurses are hired long-term, they often remain outside the social fabric of a small community and never really learn to know the patients as the nurses do who live in the community. In our community, the good local nurses drive 90 miles to work in a larger, metropolitan hospital to avoid working in the dysfunctional nursing environment of our local hospital.
A few years ago when I was in the ER on call, we had a long-term locums nurse I heard around midnight talking to a patient on the telephone. She was telling the caller not to come to the ER. When she hung up, I asked her the name of the person she was talking to. To my shock and horror, she said “I don’t know.” And of course, she had no phone number either. I had no way to follow up with this patient to be sure there was no need for an ER visit, or the very least, a follow up appointment the next day. Fixing this kind of dysfunction requires a CEO and a nursing director who care.
Researching the Cost of Increased Administration
To my knowledge, no one has researched the cost of the 3200 percent increase in healthcare administrators to our healthcare. There is much talk now about transparency in healthcare costs. The consumer should ask the following questions:
1. How much has the cost of administration increased over the last 10, 20, 30, or 40 years?
2. How much do administrators, insurance companies, and manage care organizations spend to deny care?
3. What is the cost to the consumers when the patients are denied care physicians think is needed?
How Depriving Care Increases Costs
We have the most expensive healthcare in the world and we also have the highest maternal mortality rate of any developed country. Some third-world countries have lower maternal mortality rates.
Years ago when I was in private obstetrical practice, we could provide for all the prenatal care my patients needed. Even though I would be paid for 8 visits and one postpartum visit at six weeks, since I was the boss, I could give my patients as many visits as they needed. I would get paid for 8 visits even if I saw the patient 15 times. Many of my patients were Medicaid, for which I got a lump sum of $2000. I also gave my patients unlimited postpartum visits for a year. I believe my seeing my patients as often as needed was the reason why I was able to deliver 6000 babies without any maternal mortalities, no eclampsia seizures, no strokes, no liver failure, no kidney disease, and no patients in nursing homes.
I got into trouble with the insurance companies for providing care they didn’t cover. The insurance companies decreed that giving away care was unethical. So I had to send my patients bills, but I could tell them to ignore the bills and I wasn’t going to send the bills to collections. At that time, the maternal mortality rate was 8 or 9 per 100,000 births. The insurance companies, by denying care, have driven the maternal mortality rate in the U.S. up to 24 per 100,000 births. For Native Americans and Alaskans, that rate is 40 per 100,000 births. For non-Hispanic blacks, the rate is 55 per 100,000 births, and all these rates are on the rise.
Let Physicians Decide When Patients Are Ready to Go Home
When I first started practicing, the opinion of the doctors and nurses and the needs of the patients meant something. We could decide when a newly delivered mother and baby were ready to go home. On morning rounds we could listen to the nurses taking care of these patients. Some patients were ready to go home after three days. If a mother didn’t have enough breast milk at three days, or the baby still couldn’t latch on well, we could keep the new mother and baby in the hospital for another day of teaching.
Once hospitals in response to insurances demands started limiting postpartum stays, the opinions of the doctor and nurses no longer mattered. Mothers could watch any number of videos of how to manage once they left the hospital, but the hospital stay is now limited to 24 hours. Nurses don’t take care of a patient long enough to observe problems that could easily be remedied by more time in the hospital.
This situation is sad, dangerous, and far-reaching in ways no one is looking at, much less counting. Except the U.S. maternal mortality rate continues to go up, often leaving children without mothers.
What Needs to Be Done
All patients should have as much prenatal, delivery, and postpartum care at they need. Committees addressing the high rate of maternal mortality in the U.S. should be looking at how the Scandinavian countries keep their maternal mortality rates at 2-3 deaths per 100,000 births.
Medicare, Medicaid, insurances, and Big Pharma should be prevented from limiting health care for pregnant women. Women’s physicians should be the person making the decision about whether a woman who has delivered a baby needs care.
Some obstetrical groups have complained that women in these countries such as the Netherlands don’t see a physician as often as they do in the U.S. That’s because women in Scandinavian countries see midwives as well as obstetricians during their pregnancies. In these countries, women can choose to have a home birth, deliver in a birthing center, or go to the hospital to deliver. Midwives and physicians work together to provide what is obviously very effective healthcare for their patients.
When I was delivering babies, I was disliked by other obstetricians because I worked with the local midwives, both lay midwives and certified midwives. In fact, some of the patients of midwives chose to go to the midwife for prenatal care, and then deliver in the hospital. The midwife and her patient would come to the hospital when the patient was ready to deliver and I would allow the midwife to attend the birth as a doula. To me, this is the best of both worlds. It’s time those looking to reduce the maternal mortality rate in the U.S. peered beyond their professional biases.