Cutting Care

At the heart of the Clinton health plan is reliance on insurers to cut costs. That puts them in charge of deciding on the care you'll receive. A look at existing HMOs is not encouraging.

When her first child was diagnosed with multiple neurological and genetic defects, Linda (not her real name) chose a pediatrician she knew and trusted to care for her child.

But in December 1991, the Commonwealth of Massachusetts passed a hospital-financing bill that gives health insurance companies the right to negotiate unlimited discounts with hospitals. Under the law, patients are forced to use the hospitals that give their HMO the best deal.

Linda's HMO contracted for pediatric services at a different hospital, and she and her child were forced to move as well. Continuity of care was not an issue. Cost was, and Hospital B was less expensive than Hospital A.

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At Hospital B, Linda recounted her son's medical history, and providers repeated a number of tests that had been taken at Hospital A. Later, after she had constructed a new set of relationships with a new set of physicians and nurses, she was informed that her HMO had cut an even better deal with Hospital C. Again, she was forced to explain her son's problems to physicians and nurses at a new institution. Once again, they repeated tests conducted at the other two hospitals.

How, she wondered, could this save money? And more importantly, how could bouncing from one hospital to another be considered quality care?

When Massachusetts passed its hospital-financing legislation, it contracted most state mental-health services to private companies--known in managed-competition lingo as "vendors." At one mental-health center, a new vendor laid off the ten registered nurses who had been responsible for following the psychiatric and medical problems of the facility's five hundred patients. To replace the ten nurses, the vendor hired two counselors with no medical training. When one of the nurses was rehired to work part-time at the center, she discovered that, of the fifty patients she had cared for, twelve had died of major medical complications.

One patient was a diabetic on insulin, and her untrained counselor could not recognize when her blood sugar levels became dangerously elevated. She died when she went into a diabetic coma. Another patient was found on the floor of his apartment suffering from an intestinal blockage. His psychiatric medication caused constipation that had gone undetected and untreated. He was forced to have an emergency colostomy and now has his bowel movements in a bag attached to his abdomen. His emotional condition has deteriorated to such a degree that no private vendor will treat him, and he's back in one of the few remaining state mental hospitals.

Since President Clinton announced his health-security plan, public attention has focused on rising administrative costs, choice of physicians, and the potential rationing of high tech treatment. But few have focused on how the administration's fear of attacking the private insurance industry has produced a health-care proposal that, as the anecdotes above illustrate, will cut costs by jeopardizing quality and continuity of care.

Treatment and care are not the same thing. Treatment includes the tests, surgeries, and therapies that are used to diagnose and cure disease. Care, on the other hand, comprises not only monitoring treatment, but also educating patients and families about the side effects and discomforts of treatment. Care requires attention to the patient's social context and lifestyle, and may extend far beyond medical treatment.

Almost all the recent media reports on so-called quality-of-care issues have relied on physicians as sources rather than on nurses. This is unfortunate. Because they have been trained in a disease-driven model with an emphasis on specific medical interventions, physicians are generally more focused on treatment. Nurses, on the other hand, are usually more expert on issues of care.

Of course, it's futile treatment--the hip replacement for the woman dying of cancer, the relentless attempts to rescue infants with no brain stem function--that is in great part responsible for escalating health-care costs. But the Clinton administration plan doesn't address the tricky ethical issues involved in limiting this kind of treatment. Instead, it polices care. For evidence, we need only look at the experience of Massachusetts and California--two states that have instituted the kind of "managed competition and care" that the president has proposed.

The core assumption of managed competition is that insatiable "health-care consumers" are sucking the system dry. To stop runaway costs, managed competition throws health care open to the marketplace. To compete for subscribers, managed-care groups must deliver services at the lowest price. Since administrative costs are on the rise, and fixed costs--heat, lights, bedpans, linens, tubes, and syringes--are increasing at the rate of inflation, the only way to lower costs is to cut the jobs of those who provide care.

Over the past two years, 1,500 registered nurses have been laid off from Massachusetts hospitals. They have been replaced with lower-wage licensed practical nurses, nursing assistants, and technicians who, despite their lower skill levels, are being asked to do the same level of work.

In California, so many experienced nurses have been fired that the nurses' unions are monitoring the effect of short-staffing on patient care. At Stanford Medical Center--one of the best in the state--patients have had to wait hours for their medications, baths, bedpans, and tests. "A lot of family members have said to the nurses that they are afraid to leave a loved one alone in the hospital, out of fear that medications will be missed or treatments not given because of low staffing ratios," says staff nurse Donalda Dunnett. "No one seems to understand that this problem is insurance-company driven. It is happening at every hospital in California, not just Stanford."

Or consider the case of Bay State Health Care--one of the largest HMOs in Massachusetts. In late l992, Bay State abruptly removed hundreds of psychiatrists from its list of approved providers. Patients are generally referred to new doctors through a process that includes consultation and communication between the patient and both the new and old psychiatrist. In this case, the referral process was jettisoned. Thousands of patients received letters informing them that Bay State would continue to pay for their mental-health care only if they switched providers. The letter instructed them to dial an 800 number and describe their psychiatric difficulties to an anonymous voice. Based on that one phone conversation, they would be assigned a new mental-health professional.

Managed competition will not only ration the amount of attention patients receive in the hospital, it will also limit the time they can stay. The United States already has the shortest length of hospital stay of any industrialized country in the world--only 7.2 days--and it will probably get shorter. In California, for instance, the average hospital stay is 6.1 days, a full day less than the national average. In Massachusetts and California, Kaiser Permanente now allows pregnant women to stay overnight for a normal vaginal delivery and three to four days for a Cesarean-section.

What if a patient hasn't recovered and needs to stay longer? Under managed competition, the patient will be forced to leave the hospital and use community care. But brief home visits from a nurse--what managed-care groups generally provide--can hardly make up for round-the-clock professional care. The health-care experts in Washington seem to think that prematurely discharged patients will have family members who can take off work to care for them.

Consider Naomi Prochovnick's recent experience. Her thirty-seven-year-old partner had a hysterectomy at Mt. Zion Hospital in San Francisco. The day before she was to be discharged, her wound began to seep. "The whole wound burst open," Prochovnick said. "Blood came gushing out, and the nurse had to literally hold it with her unprotected hands to try to stop the blood."

The wound was infected, so it couldn't be stitched shut. Still, the doctor said he would discharge her partner as soon as her fever broke. Because the insurance company would only cover a minimum number of home-nursing visits, the doctor invited Prochovnick to learn how to change her lover's dressings. "She was bleeding on the bed, and I had almost passed out," Prochovnick recalled. "I told the doctor I was not a medical person and had no interest in becoming a medical person." The fever broke the next day, and sure enough, her partner was discharged. But Prochovnick was luckier than most--three of her friends are nurses, and they donated their care for almost a month.

"Today," says Christine Kinavey, nursing practice specialist for the California Nurses Association, "anxious family members and friends with no medical experience are being recruited to provide sophisticated levels of nursing care at home. They are being asked to do blood draws from permanently placed IV sites, to do dressing changes, and to monitor the patient's condition. Oftentimes families are given inadequate time to become comfortable with these procedures and technology before they're pushed out the door because the clock has run out in terms of payment."

It is clear that American health-care costs must be contained. But HMOs--which do nothing to contain the 23 percent of health-care dollars that cover the costs of administering 1,500 different insurance plans--are not the answer. Even the minuscule savings they claim in their first few years are not genuine: the General Accounting Office recently reported that some of the cost savings realized by HMOs are the result of skimming--subscribing healthier patients--rather than cost containment. And, insurance companies' concentration on the quarterly profit statement ignores the fact that patients denied care and treatment get sicker--and thus cost more--in the long run.

Studies conducted by the Congressional Budget Office, the General Accounting Office, and the Health Care Financing Administration have all shown that managed-care plans do not save money. Two states that have used managed-competition-style programs--California and Massachusetts--have not realized substantial savings.

There is a clear way to contain costs without jeopardizing care. Every other industrialized country has managed to contain costs by instituting some form of a single-payer health-care system. Moreover, several U.S. states have controlled hospital costs through regulation or by setting global budgets.

By appeasing the private insurance industry--while also proposing massive cuts in Medicare and Medicaid--the Clintons have missed a golden opportunity for real reform. This tragedy has been compounded by the failure of trade unions, nurses, consumer groups, and the elderly, to fight consistently for the kind of single-payer health-insurance system that can tackle administrative and clinical waste. Until that waste is squeezed out of the American medical-treatment system, patients and providers will shoulder the burden of balancing the health-care budget, and genuine health care and security will remain unobtainable.

Suzanne Gordon is author of Prisoners of Men's Dreams. Judy Shindul-Rothschild, RN, PhD, is an assistant professor at Boston College School of Nursing and specializes in health policy and economics.

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