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Twin Town High (vol. 8)
A Strain on the System
Wednesday 23 March @ 01:43:04
Health Care Workers Under the Gun
by Jane Franklin
Most of us are born and die under a doctor’s care, and in the years in between there is no more basic need than health care, save food and shelter. In this country, however, the health care system is in jeopardy, its quality lagging far behind that of poorer nations. Medical care grows more expensive every decade. In this state alone, 335,000 lack insurance, and many more are underinsured.
But there is another piece of the story—the doctors and nurses themselves. Medical professionals these days face longer hours, fewer staff and budget cuts that mean less supplies, staff and programs. Insurance companies require more and more red tape, which eats away limited staff time.
by little, things are being carved away,” said Peggy Metzer, CEO of the
Cedar Riverside People’s Center Clinic in the West Bank.
“I see signs of stress in our docs that are just phenomenal,” a
nurse with 30 years of experience in seven different hospitals told me. These
days, said clinical pharmacist Joel Albers, doctors “just don’t
have time to do direct patient care.”
Clinics, pharmacies and hospitals have struggled to come to terms with the budget
cuts of 2003. But Governor Tim Pawlenty’s 2005 budget proposes even further,
deeper cuts. From a community clinic offering care on a sliding scale to the
wards of a major hospital to a local pharmacy, health care workers feel the
The offices of the Cedar Riverside People’s Center Clinic have Spartan
furnishings but brightly painted walls. A mini-refrigerator bearing the scraped-off
remains of a “biohazard” sticker does duty for staff beverages and
a small plastic basket of homemade cookies sits on a very basic round conference
Offering low-cost primary care to the West Bank, the People’s Center Clinic
is an institution characteristic of the area. It was the first community clinic
in Minnesota, founded in 1970 as a grassroots initiative to provide affordable
care for students and counterculture types. Over the years, its clientele of
mostly West Bank residents has changed with the neighborhood; about 40 percent
are African immigrants drawn by word of mouth, outreach programs, and the clinic’s
commitment to providing services in Somali and Oromo.
Only 10 percent of the clinic’s patients have traditional insurance. Fifty
percent are on medical assistance, and 40 percent are uninsured. Recently, after
Minnesota Care and Medical Assistance budgets were severely cut, the clinic
had to increase its minimum fee for a visit from $15 to $25.
medical director Dr. Stephen Vincent is a tall, soft-spoken man with a reassuring
manner, but when he talked about the impact of MN-Care cuts, his voice rose
and he became obviously upset. The clinic is short-staffed since its longtime
head nurse needed slightly more money than the clinic could provide.
The former head nurse was responsible for ordering birth control materials,
running birth control reports, keeping community programs current, and updating
patient files. She also oversaw tuberculosis screening and met with patients
on their first visits for prenatal care. For many of these functions, the clinic
has no one else, and other staff members are too busy to take on an additional
role. In the day-to-day functioning of the clinic, nurses are invaluable.
“A nurse,” says Vincent, “is the one who makes sure sick patients
The clinic’s daily schedule is usually full. Nurses make decisions when
sick patients call in, fitting in an extra appointment here and there to make
sure that immediate needs are met.
For community clinics like this one, cuts to MN-Care and Medical Assistance
have created a financial crunch. In 2003, the Minnesota Legislature cut Health
and Human Services spending by $6.6 million, with a corresponding loss of federal
matching funds. The legislature also limited eligibility for General Assistance
Medical Care, the last ditch program for low-income adults. For community clinics,
this has meant fewer insured patients to offset the costs of treating the uninsured.
But one of the biggest challenges is the new rule about Medical Assistance verification.
Prior to the 2003 budget cuts, said Metzer, “a person who didn’t
have an MA card could come to the clinic, we could do a kind of determination,
see the client, and help them process the Medical Assistance application. Now,
they need to have the MA card before they come to see us. That’s a big
one, right there.”
Increased regulations about reimbursement are a barrier to care for immigrants,
said Metzer. “More and more people are coming in our doors who do not
have information about Western medical culture. Some don’t speak English.
They don’t understand that they have to provide documentation.”
Metzer talked about turning people away from the clinic when they can’t
provide identification. She said that state and federal rules require compliance
even at the cost of turning away patients. “We have to show the government
that we maximize the opportunity to collect our fee.”
when all documentation has been completed, community clinics face another problem—getting
the state of Minnesota to pay its share. Federal dollars from Medicaid do not
cover all treatment for uninsured or medically underserved populations. The
state is supposed to make up the difference, but Minnesota is behind on its
payments—statewide, community clinics estimate that they are owed $4 million
on care provided up to four years ago. Some clinics have taken out bank loans
just to keep their doors open. At least one community clinic, Fremont Health
Services in North Minneapolis, has been denied such a loan. The state will eventually
pay what it owes, said Metzer, “but what happens to the interest on that
These delayed payments in Governor Pawlenty’s Republican Minnesota are
actually rather ironic, since community clinics are the backbone of President
Bush’s plan for health care. The People’s Center Clinic is a Federally
Qualified Health Center, receiving federal grant money so that it can operate
in a “medically underserved” area. “If we had not become an
FQHC [in 2003],” said Metzer, “we would not have been able to [stay
open].” By federal law, FQHCs must provide primary care to all patients,
regardless of insurance status. Tellingly, FQHCs must also “maximize all
sources of patient and third-party payment” and minimize the use of federal
Metzer remarked that to get FQHC funding, the clinic “has to jump through
a lot of hoops.” But she added that the FQHC procedures are not a problem;
rather, “it’s the squeeze locally, the squeeze the governor has
put on health care.”
Trying to negotiate the system of billing is difficult, she continued. “The
rules get changed every year. The bar keeps moving.” Dealing with constantly
changing regulations is not what the clinic is for, she said. “People
are in health care because they want to treat patients, not chase the money.”
But there’s something contradictory about the FQHC program, according
to Vincent. Federal statistics show that community clinics have a current capacity
to treat 20 million patients. There are 42 million uninsured in the U.S. And
even with additional funding, by 2010 projections show 50 million uninsured
and community clinic capacity for only 30 million.
“Even with their own projections,” stated Vincent, “we are
not really gaining any ground.” He added that the federal government is
giving money to start new community clinics at the same time that it is cutting
per-patient Medicaid reimbursement, the funding that community clinics rely
on. This is not, according to Vincent, a sustainable long-term model.
Clinical pharmacist, health care researcher, and community organizer Joel Albers
had a lot to say about chasing the money. He spoke with deep frustration about
insurance companies, drug manufacturers, and a system that, he said, “drives
a wedge between patient and practitioner.”
spend all this time on people’s insurance,” he said, sighing. According
to Albers, there are 646 licensed insurers in Minnesota—four big players
like Medica and Blue Cross/Blue Shield, and a host of smaller companies, each
with its own billing procedure. “People may be contracted with an HMO
from another area of the country ... somebody might come in and they have Blue
Cross/Blue Shield of California, and I have no idea how to program their [insurance]
card into the computer. This system just does not make any sense.”
With multiple insurers come multiple treatment plans. Each insurer has its own
list of acceptable drugs, called a formulary, which is constantly being updated.
“If it’s not on the drug list,” he said, “You have to
call the doctor, who makes a new prescription. Doctors can’t keep track
of this either.”
It is hard for a pharmacy to control its inventory because it must provide drugs
from the ever-changing formulary of each insurer. To Albers, the constant struggle
to keep up with billing procedures and formularies is an appalling waste. “Thirty-one
percent of total [health care] revenues is administrative costs—that should
not be the case,” he said.
He is deeply critical of the recent changes to Medical Assistance. Not only
have the rules been revised and made more complex, adding to the time spent
on administration, but the new co-pay rule prevents low-income Minnesotans from
filling their prescriptions.
“When you introduce co-pays, that becomes a barrier to care,” Albers
said. “I see this every day that I practice.”
Albers describes patients who take multiple drugs for chronic conditions struggling
to meet the co-pay, which is three dollars for a brand name drug and one dollar
for a generic. “If it’s just a couple of dollars, [pharmacists]
may just pay it, sometimes out of our own pockets.”
All public health programs have been contracted out to HMOs, which negotiate
with hospitals and clinics to receive discounts. “It has never been proven
that HMOs contain costs. About one-third of their profits come from public programs,”
Albers pointed out.
a blitz of paperwork,” said one hospital nurse with 30 years of experience.
She sees the paperwork from the other side —not the billing itself, but
the procedures hospitals adopt when billing doesn’t bring enough money.
She described a world where hospital administrators, ever anxious to cut costs,
are constantly revising procedures and adding documentation.
“Whole committees, tiers of committees ... working on efficient documentation,”
she said. “Three months later, they tighten standards again. Then, six
months later, they provide a whole new form.”
Computerization, she says, was intended to streamline procedures, but has generated
high costs—a laptop for every doctor—and has required the hiring
of a trainer for each nurses station to answer questions about correct documentation.
Day-to-day life for nurses has changed too. “We have to do more with less,”
said the nurse. “There is a push to absolutely clamp down on waste.”
Now, nurses in her unit reuse supplies when reusing does not jeopardize care,
she said. Although she stresses that this does not interfere with the quality
of care, she also characterizes it as “using something again when maybe
we shouldn’t.” Some supplies need to be sterile for each use, and
these are always fresh materials. But other supplies need only to be “clean”—the
way clean dishes are clean—and these get reused.
Nurses used to run tests as often as they felt necessary, without counting the
cost. Now cost is a major factor, she said, and a test that would have been
run every six hours now may be run every 12.
In a high pressure critical care unit, small stresses add up. For example, supply
carts—when a nurse needs a bandage or a piece of tubing, it comes from
a big wire cart on wheels full of standard materials. Currently, the supplies
in the cart have been cut—down to the “barest, barest minimum,”
said the nurse. Extra supplies—that is, supplies that were once freely
available—have to be special ordered. Once the order is in, the nurse
must check back over the course of the day to see whether the order has been
filled. “The cost is the same, but so much time is wasted,” sighed
At the moment, nurses find that their time is at a premium. “Nurses are
constantly on the move ... they don’t even have time to go to the bathroom,”
says Jan Rabbers of the Minnesota Nurses Association.
The critical care nurse too reminiscesdabout an earlier time, a time when nurses
could take a break once in a while, stop by the nurses’ station, sit down,
chat. This was when informal mentoring could happen, they said, when new young
nurses could talk to those with more experience, picking up the ins and outs
of a complex profession with lots of judgment calls. The critical care nurse
said that now older nurses don’t really have time to teach and mentor;
they have to do it on the fly, in addition to doing their own work.
“Mentoring? There’s just no time,” said Rabbers. “Nurses
don’t even have the time they want to educate patients.”
American health care presents more challenges for nurses. As might be expected,
uninsured and underinsured people are coming into the hospital much sicker,
requiring more time and effort from nurses. And morbid obesity, the result of
a society built around sprawling suburban developments, high-stress jobs, ever-increasing
work weeks, and a lot of cheap calories, takes its toll on nurses. A morbidly
obese patient has to be lifted and turned in bed every two hours, a task that
may require up to six nurses. “When I get home after an eight hour shift
I am totally exhausted,” said the nurse. “And that’s new.”
Even hospital doctors, formerly the top of the medical heap, are under pressure
to perform. In many hospitals, the number of doctors has been cut, and hospital
doctors in general are under pressure to see more patients in less time.
“Doctors are supposed to note the amount of time they spend on each patient
in the corner of the chart for billing the insurance companies,” said
the nurse. “These are people we’ve worked with for long periods
to time and they are just wearing out.” She described “hospitalists,”
the doctors who coordinate all aspects of a patient’s care during a hospital
stay, working long shifts and often falling behind because of demand. In one
situation, she said, a hospitalist was behind by 17 new admissions.
Recent changes in the Emergency Room at Methodist Hospital in St. Louis Park
illustrate the changing nature of medical labor relations—but also some
light at the end of the tunnel. Like most hospitals, Methodist contracts with
a physicians’ group to provide emergency room care. In Minnesota, such
groups are either nonprofit or collectively run for profit by the doctors involved.
Last September, Methodist Hospital unceremoniously announced that it would be
replacing EPPA, its longtime provider, with a Texas-based, publicly-traded group
called EmCare. In 1997, EmCare paid a $7.5 million settlement to resolve allegations
of false billings to Medicare, Medicaid and other federal programs. When Methodist
made its announcement, several doctors around the metro area expressed concern
over for-profit staffing, commenting that for-profit groups tend to emphasize
cost-effective care over best practices.
In Minnesota, in fact, it is illegal to hire doctors through a for-profit corporation
not owned by the doctors themselves. The American Academy of Emergency Medicine
filed a complaint with the State Attorney General.
In January, EmCare physicians began working at Methodist. Problems occurred
right away. According to the nurse, EmCare provided half the number of physicians
normally in the emergency room. Rabbers described problems with integrating
doctors into the routine of Methodist. ER nurses reported several egregious
situations: a half-hour block with no doctors in the emergency room because
one doctor was taking lunch and the other was outside smoking, and a situation
where the emergency room doctor did not begin treating a patient with a stroke
and instead simply telephoned a neurosurgeon.
could have been simply another chapter in the corporatization of medicine, but
in February EPPA was rehired. Many of the people involved cited the negative
publicity, behind-the-scenes labor negotiations, and particularly strong pressure
from nurses were cited by many as factors in the change.
“Nurses were very cognizant of the situation,” said Rabbers. “[They]
documented these situations and demanded a meeting with the hospital administration.”
In its public commentary, Methodist hospital has simply stated that EmCare could
not provide enough staff for the emergency room.
Will doctors, nurses and the public work together to create a sustainable healthcare
system, or do we all face a world of overworked doctors, frazzled nurses and
31 percent administrative costs? Methodist Hospital is an example of what can
happen when concerned employees and citizens finally say, “No more.”
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