Why Hospitals Never Have Enough Nurses: The Explanatory Power of “Prasad’s Law” of Wealth Concentration

Yves here. In case you haven’t had the misfortune to acquire first-hand experience, what Vinay Prasad and Roy Poses say about chronic nurse shortages in hospitals appears to be correct. I have a good friend whose father was a doctor and who has spent big parts of her career in the medical biz (her first job was at the NIH) who says she would never go to a hospital in New York without bringing her own private duty nurses. And it is not as if she is flush.

Poses uses this sad fact to illustrate a more general pattern for what gets readily paid for in US medical circles: only services that direct income into the hands of the wealthy. And this is a big reason why incremental reform of the medical system will not deliver meaningfully better outcomes for patients or lower costs. The idea, for instance, that Big Pharma gets to free ride on government-funded basic and often applied research and then price gouges patients has to stop.

By Anne Peticolas. Originally published at Health Care Renewal

There’s a huge amount of money that floats around our medical system (about 18% of GDP), and yet, for some things, there is never enough money.

One of those things there is never enough money for is truly adequate nurse staffing in hospitals. A recent story in the Houston Chronicle about a recently released CMS report on MD Anderson relates how overworked nurses there are, resulting in problems such as inadequate monitoring that have led to deaths.

The report concluded that MD Anderson’s inadequate number of licensed registered nurses “to provide care to all patients to meet their needs” resulted in “an inability to provide care ordered for the patient.”MD Anderson is a very wealthy institution, but . . . that didn’t prevent this. There is seemingly never enough money for adequate nurse staffing.

In a similar vein, Andy Lazris laments in his book, Curing Medicare, that he can easily arrange, with the stroke of a pen, to overtest and overtreat and hospitalize his patients, but it’s impossible for him to arrange home assistance or meal delivery, and – though sometimes possible – crazy difficult and time-consuming for him to get home health visits or an electric wheelchair for his patients.

Vinay Prasad, the hematologist-oncologist who, with Adam Cifu, wrote Ending Medical Reversal and who hosts the Plenary Sessionpodcasts, complains in those podcasts that there are a number of things patients really need that he is powerless to get for them (e.g. rides to his office); but, with no problem, he can order up marginally effective and super-expensive chemotherapy regimens.

Prasad has a theory about which actions that would improve patient health will get paid for by the “system” and why. He elaborates on this (while acknowledging he doesn’t have proof) in a discussion with Dr. Stacie Dusetzina (Plenary Session podcast 1.67 from 44.50 minutes into the podcast onward) and in a discussion with Dr. Gilbert Welch (Plenary Session 2.21 1.55 into the podcast). He states, in the Welch discussion:

There are interventions that disperse wealth, … and they give people jobs, and they send them out in the community; and there are implantable drugs, implantable devices, there are drugs, there are cancer screening tests, and we will always prioritize interventions that consolidate money in the hands of the few, over interventions that disperse money to the hands of many, with the same levels of evidence.

And, in the Dusetzina discussion:

Because we would rather . . . and we will always, in healthcare, we will pay for interventions that consolidate or concentrate wealth in the hands of fewer parties than we would ever pay for interventions that disperse wealth, and one of the things that disperses wealth is if you have a labor force of people who would provide care, would go pick up my patients, and bring them here . . .and if we took all the money we spent on like marginal and useless and mediocre drugs, and we put all that money in that social system, you’re going to hire a lot of people and you’re going to spread wealth out, but you’re not going to concentrate wealth in the hands of a few investors and that kind of thing, and so that’s why – the way in which lobbying and pressure in the society work is always to push it the other way.

My briefer version of Prasad’s Law (as I’m dubbing it) is:  

  • Prasad’s Law: Medical goods and services that concentrate wealth can be paid for; medical goods and services that disperse wealth are “unaffordable.” I think this is an enlightening law with broad explanatory power; and I imagine each reader can think of their own examples.

It is not, in reality, a particularly surprising result, because the true purpose of the U.S. healthcare system is by no means to supply medical care (although that is indeed the goal of many who work within it), but instead to serve one overarching purpose – to make money for capitalists. Adequate nurse staffing does not make money for capitalists (even if it makes money for nurses); and crazy expensive, marginally effective, cancer drugs do make money for capitalists. It’s that simple.

And to change it – ever – will, in my mind, require a lot of change, not tinkering at the edges. As long as those who control our system now (now including private equity investors) continue to control our system, it cannot change. Wresting control from their hands will undoubtedly be a hell of a fight, but it is a fight essential to alleviate the serious issues that cause so much suffering.

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57 comments

  1. Vastydeep

    Prasad’s Law has great explanatory power for our healthcare system, and if you take the word ‘Medical’ out of Yves’ short-form description, it can also explain things like the F35.

    Reply
    1. Sol

      That was the very thing that struck me as well. It works for anything made captive to capital (any capital; from fiat earnings to political power). Without competition, market-share monopolists and One True Way industries no longer have their stated goal as the goal. The job is no longer about health, cutting-edge engineering, university education – the goal is capital, and tasks are arranged from there.

      Boeing. Sears. Student loan crisis. Opiods. Prasad’s Law is incredibly useful. It’s brilliant. My mind’s a little blown by the wide implications.

      Very good reading. Yves gives us gold.

      Reply
  2. Carl

    I wondered about to his a few years ago, as I watched our local, supposedly non-profit hospital construct a lavish new facility for itself, with a spectacular three story lobby, complete with a massive art installation, but with the same old excessively long waiting times for E/R visits. New building? More staffing? Sorry, no money for that. Enlightening.

    Reply
    1. Samuel Conner

      This seems to work as a description of higher education, too. Doubtless one could find other examples. Power transmission line right-of-way maintenance, perhaps?

      Perhaps it’s a general law of late-stage rentier-oriented “capitalism.”

      A deluge of some kind is in the offing, me thinks.

      Reply
      1. inode_buddha

        Yah, it’s called “the bosses are all getting their collective egos stroked”

        when in fact their collective egos need to be knocked back in.

        Reply
      2. Amfortas the hippie

        “Perhaps it’s a general law of late-stage rentier-oriented “capitalism.””

        lol.
        what echoes in my brain:

        “Translated into ordinary human language this means that the development of capitalism has arrived at a stage when, although commodity production still “reigns” and continues to be regarded as the basis of economic life, it has in reality been undermined and the bulk of the profits go to the “geniuses” of financial manipulation. At the basis of these manipulations and swindles lies socialised production; but the immense progress of mankind, which achieved this socialisation, goes to benefit . . . the speculators. We shall see later how “on these grounds” reactionary, petty-bourgeois critics of capitalist imperialism dream of going back to “free”, “peaceful”, and “honest” competition. ”
        (https://www.marxists.org/archive/lenin/works/1916/imp-hsc/ch01.htm)
        ….and so on. not a one to one correlative echo, mind you…but plenty of rhyming. replace “commodity” with “services” in this case.
        and again:
        ” Ash nazg durbatulûk, ash nazg gimbatul,
        ash nazg thrakatulûk agh burzum-ishi krimpatul.”

        Reply
    2. Arizona Slim

      And, let me guess: The artists aren’t paid for their work. Instead, it’s a rotating exhibit, complete with promises of exposure for those who have their work in the show.

      PS: You can’t pay your bills with exposure. Being an artist doesn’t exempt you from having bills to pay.

      Reply
  3. John B

    Prasad’s law is fascinating and clearly it is often true — in any system where wealth shapes the rules of the game, the rules of the game will favor wealth! There must be lots of other examples. US agricultural policy is notorious. Financial regulation? There are counterexamples, though — Medicaid and Medicare, public education … how do those survive?

    Reply
    1. Samuel Conner

      They aren’t thriving — are under assault. If they are to survive, it will be through political struggle… it least, I hope that the struggle is merely political.

      Reply
  4. Steve H.

    There’s an entire dimension which this doesn’t address, the (wage theft:care) ratios for nurses. Janet spends hours of unpaid time when her home-health visits run over the scheduled time. The worst is Wednesday, with five visits, four supposedly simple med-fills. Never are, generally one goes right and the rest are wrangling, for usually two to three extra hours. She does unpaid work today to do a pharmacy pickup that didn’t get filled yesterday. The EMR’s have had a perverse effect here. Then she comes home to do charting, off the books.

    But that’s her. The response from other nurses and aides (no real wage increase in decades, no health insurance…) is to slack off, which leaves more work for who’s in next. The company cannot keep nurses, and Janet’s blood pressure went stroke range about a month ago. They may lose her due to job stress. But the hospital, where she worked over a decade… At a celebration of life recently, two physicians were telling her it’s nothing like what it was, and a nurse friend was literally counting days to retirement.

    We were going over gratitudes for Thanksgiving and the big one was for what we don’t have. The biggest one was health insurance. We’ve had exert control on our health, putting our limited funds into things like good food. If we had insurance, we’d feel loss aversion if we didn’t use it. That would be more out-of-pocket, and a greater likelihood of testing and time in medical facilities. Another friend went in the hospital, got MRSA, then later was in the ambulance suffering heart attacks and wasn’t allowed in the facility – because she had MRSA.

    There may be nothing more inimical to real health than corporate profit. That includes not-for-profits, a perverse term which now means better tax leverage for the corps.

    Neoliberal Rule #2: Go die!
    Corollary 2.1: But not yet…

    Reply
  5. Mark

    Yves
    whilst the lack of RNs is highly visible the truth is that the levels below that are also underfunded and understaffed. We expect a hospital to be clean and sanitary, but the people tasked with accomplishing that goal are the lowest paid, worst trained and most overworked. They are also the first people to be laid off when the budget requires a reduction in head count.

    Hospitals that are not cleaned properly result in infections for patients, with a massive human toll and surprisingly these days large cost implications for hospitals, but we still skimp on personnel, materials and training for the people responsible they are a cost not a profit center and I have literally been told that preventing infections is “Cost Avoidance” thus not real savings….

    Reply
    1. paddlingwithoutboats

      I’ve worked in hospitals in the states, the minimum wage housekeeping positions are the dregs for those who do the work and the turnover of that staffing means they are always in turmoil. The turmoil leaves filth.

      I now work in a Canadian system and am glad to see that the minimum wage is higher, and, the outsourced housekeeping staff is miles above the quality of the system in the US.
      However, my question to colleagues in radiology about why isn’t housekeeping a part of the epidemiology dept is met with blank stares. It is the practical application of epidemiology, and collaboration of the lab and desk personnel with the boots on the ground could change the game of hospital infection. It would imprive the lives of housekeeping staff whovwant more from their jobs than toilet washing and cleaning up rooms.

      I despair of the tunnel focus people acquire in relation to how comfortable their indivual lives are, tip of the nose focus. Meanwhile, Canadian healthcare is clandestinely being formed with more US profit features. Think it’ll bite us all.

      Reply
    2. xkeyscored

      Do hospital-acquired infections in the USA have large cost implications for hospitals, as you say, or do they provide further opportunities for profiteering, as the patient requires further expensive interventions?

      Reply
      1. m

        Obamacare has it so that the hospital eats the cost for hospital acquired infections, also antibiotic microbes are everywhere now. Not sure about private insurance, applies to CMS.

        Reply
        1. xkeyscored

          antibiotic microbes are everywhere now
          True, but I think the situation is worse in hospitals than many places. First, sick people are often more easily infected. Second, hospital microbes face intense selection pressure to evolve or acquire resistance. And third, they don’t necessarily need to be antibiotic resistant to cause problems, including death.

          Reply
  6. Karen

    I am not one to deny the power of incentives, and I’m certain that the trend toward financing what can most easily be extracted–with plausible deniability–has a large role to play in this story. But I’m seeing another problem with scale/management in a beaureaucratic system. Because apparently we can’t just give money to people to secure these services with friends and neighbors and loved ones and other private parties. Oh, no–per the rules, these services must be supplied by mandated “professionals” with all the forms and approvals and other bureaucratic BS that’s applied. It’s CYA as far as the eye can see. Because god forbid some all-too-human but beloved friend collected a payment but didn’t deliver according to the rules. Because wherever there’s a large pot of money, fraud will follow–and our government seems not to be able to distinguish between trivial lacunae and large-scale abuse. Aargh.

    I have a theory of scale, that the benefits follow an inverted U – things improve with some scaling, then plateau, then deteriorate badly. Why? Because at large sacle (think Dunbar’s number x 10) trust is lost. And when trust is lost, rules and bureaucracy seek to replace it. And the more rules there are, the less they suit individual situations–so we create more rules and complexity to accommodate diverse situations–and then more “accountability metrics” are needed to ensure they are followed–which in the end serves no one well.

    We’ve used technology to deal with increasing scale, and that’s been useful up to a point. But I believe we are well beyond that point. Per Tainter, we are due for a massive downscaling. I think that’s overdue, but hope we can maintain a rational and beneficial level of scale that does not lose the benefits of collected human wisdom.

    At the end of the day, the most efficient (and humane) solution is to dispense with all these rules and give everyone the money and services that everyone needs. Full stop.

    Reply
  7. Carolinian

    Isn’t this the problem with proposals like Medicare for all and free college? They don’t address the greed that is making everything dysfunctional. What we need is an NHS–the old NHS–and not M4A because capitalism, contra Elizabeth Warren, is not the solution to everything. When I was a sprout our county hospital was government owned and considerably less than deluxe but did the job. Now it is one of those “non-profit but not really” megaplexes that is spreading everywhere, has bought out the competing hospital, and is run by the county’s highest paid executive. Without deep down systemic reform M4A would merely add a strengthened medical industrial complex to the military one. Actually I think it was Proxmire who said it should be called the military industrial Congressional complex so we would know where the real problem lies.

    Reply
    1. Arizona Slim

      Agreed.

      And, gather around the campfire, because Arizona Slim has a story to tell. Right before Thanksgiving, I hosted a Bernie Sanders volunteer event at my house. One of my guests was on Medicare, and she’d been having trouble with one of her eyes.

      Well, her lovely Medicare HMO wouldn’t bestow a primary care appointment upon her for three months. She needed to go through primary care to get a referral to an eye doctor.

      Long story short, she couldn’t wait that long. So, she went to the emergency room to have that eye looked at. That ER visit cost $800, and, as she put it, the bill was paid for by our tax dollars.

      That’s why she’s skeptical of Medicare for All, and, quite frankly, so am I.

      Reply
      1. Shonde

        Lesson to all: Stay out of HMO’s. What you described is an HMO problem. We must work to make sure HMO’s are not a part of Medicare for All.

        Reply
      2. Spring Texan

        It’s critical to realize that real Bernie Sanders/Pramila Jayapal/Physicians for a National Health Program (PNHP) Medicare for All is an IMPROVED Medicare for all not today’s Medicare. Although not in either the House or Senate bill yet, PNHP is pushing hard for it to include a global hospital budget (which could potentially eliminate individual hospital bills), and I think that’s a great idea.

        Already, in the House bill (see section 903) M4A eliminates meaningful use incentives, as well as eliminating value-based and pay-for-performance programs previously encouraged by the ACA and MACRA.

        As well, if I understand Section 302b(2), Medicare Advantage programs will be abolished.

        Adam Gaffney of PNHP (@adamwgaffney on twitter) is good to follow to keep abreast of what real M4A proponents want. Some PNHP articles and podcasts here: https://pnhp.org/news-category/articles-of-interest/

        M4A can work, but it does have to be a changed Medicare.

        Reply
      3. davidgmillsatty

        She bought the Medicare Advantage scam (known as Medicare Part C). It is managed care covered by private insurance. It is not original Medicare (which is known as Part A and B). And taxpayers may not have paid for her ER visit. It might have been (probably was) her insurance carrier.

        This is why I think so many people don’t understand Warren. She realizes that the insurance industry has clearly permeated Medicare to the bone. Even if you don’t have Medicare Advantage, you still need a Medicare Supplement (used to be called Medi-gap) from a private insurer to cover what Original Medicare does not. And then you need private insurance to cover your Drugs (known as Part D).

        Reply
        1. Arizona Slim

          Not surprising that my guest would fall for this scam. Reason: There are quite a few Medicare Advantage salespeople here in Tucson. Quite often, they set up storefronts with signs saying, “Medicare questions? We have answers!”

          Reply
          1. ambrit

            The local hospitals have such “Information Specialists” embedded within the staffs of the institutions now. I see big signs touting ‘Medicare Explained’ seminars and suchlike in the main hallway of the largest local Medical Clinic, which is ‘partnered’ with a large hospital, of course.

            Reply
        2. Phacops

          Exactly. Profoundly gullible for falling for the medicare advantage private insurance scam, but I would say that the person is even more stupid to equate it with actual Medicare. One wonders how such unthinking people ever managed to navigate through life?

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    2. NotTimothyGeithner

      An NHS would be good, but an NHS was put Into place during and after WW2 when UK society was far more regimented. The lack of a functioning civil service would be an additional hurdle. M4all would be built on the existing framework. I fear it’s the pragmatic option.

      The health outcomes aren’t the only issue at hand. The immediate shift of power to workers is a major benefit of single order. Plenty of lousy jobs instantly become good jobs. People afraid of leaving can leave.

      Reply
      1. Carolinian

        The problem with leaving the hard part for later is that it never gets done. Look at the original Medicare which was supposed to be followed by real health care reform for everyone In fact the half a loaf Medicare system has arguably made things worse from a cost standpoint by turning over control of much of the medical revenue stream from individuals to the pliable Congress. Surely it was the passage of Medicare that accelerated this spiral into corporate medicine and gigantism.

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        1. Spring Texan

          YES. Exactly right, “the problem with leaving the hard part for later is that it never gets done.” That’s why I was so disappointed in Warren’s “transition plan” that would guarantee we would only get changes that would overcomplicate the system even more instead of simplifying it. You have to fight for what would really work, not be put off with corporate-accommodating tweaks.

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    3. John Steinbach

      Actually That was Eisenhower’s original characterization. The Congressional part was removed by his handlers.

      Reply
    4. xkeyscored

      I think it was Eisenhower who called it the military-industrial-congressional complex, but only in a draft of his famous speech, not the final televised version.

      Reply
  8. Joe Well

    Applying Prasad’s Law to education:

    The one thing that reliably and incontrovertibly improves student outcomes, across many studies, is smaller student:teacher ratios, ie, hiring more teachers.

    And the billionaire-backed think tanks have fulminated against hiring more teachers more than anything else except teacher unions, advocating all kinds of unproven reforms that transfer power and authority away from teachers, like “entrepreneurial” principals who usurp lesson and curriculum planning responsibilities, and most hideous of all, “accountability” via standardized test scores.

    Reply
    1. Mark

      Be careful though about focussing on studies about what can readily be measured and ignoring what can not. Student/teacher ratios is easily quantifiable and it is nice and easy to do your research and get results you were after.

      The corrollary of this in a limitted funds environment is that having more teachers means having to pay teachers less and provide poorer working conditions. Thus you end up attracting poorer quality teachers.

      What produces better outcomes? 1 brilliant teacher than inspires children to learn and is highly knowledgable and intelligent. Or 2 mediocre teachers who don’t inspire their pupals and are in the position where half their student are more intelligent than they are.

      Reply
      1. Joe Well

        That is exactly the kind of argument the billionaire-backed think tanks are polluting the water with.

        The reality is that 1) teacher’s unions mean that you can’t just keep lowering salaries, and 2) we aren’t in a resource-constrained environment. In the 21st century, there has been broad agreement as to the need to spend more on education in the US, where education spending as a percentage of GDP is only about average for a highly developed country. The issue is where does the money go and who ultimately benefits.

        Reply
        1. Sastun

          Classic, treating correlation as causation while simultaneously ignoring other correlates.

          IQ is known to have a marginal genetic component but a significant economic/social one, so when we discuss the outcomes of individuals relating to IQ, what are we really talking about? And I’ll give you a hint, it’s not brain size. Sheesh.

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          1. KLG

            1. What psychometric evidence? Cyril Burt’s “study” of identical twins? Herrnstein? Jensen? Charles Murray? Eysenck (who was a graduate student with Burt IIRC)?

            2. Considered a fraud by whom? R.L. Trivers is not a particularly disinterested observer regarding Stephen Jay Gould, his contemporary who has been dead for 17 years.

            3. R.L. Trivers in the news recently: “Another professor who has received funds from Epstein and defended him was Robert Trivers, a Rutgers University biologist who received about $40,000 from Epstein to study the link between knee symmetry and sprinting ability. Trivers questioned how bad the charges are, noting that girls mature earlier than used to be the case. “By the time they’re 14 or 15, they’re like grown women were 60 years ago, so I don’t see these acts as so heinous,” he told Reuters.” Uh huh. I have to ask why should we listen to anyone, about anything, who could make this statement…?

            Reply
            1. Sastun

              I’m not even sure what the intended implication was bringing Gould into things,
              an attempt to associate skull volume with races, and then make a racial IQ argument?

              It’s incoherent even without looking at Trivers.

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              1. RMO

                Well, my result on the Stanford-Binet when I was tested decades ago was around 130… and by all the standards considered important in our neoliberal hellscape “meritocracy” I’m a colossal flop so I don’t personally put too much stock in IQ tests. I did very well in elementary school and in post secondary education, but if it weren’t for the success of the business my parents started when I was young I might be living under an overpass right now.

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        2. JBird4049

          A person’s intelligence is not a simple thing like a car’s speed. It is an extremely complex thing of what can be considered multiple different kinds of intelligences, plus culture, environment, genetics, and even training and practice for understanding and best using one’s own personal “intelligence.”

          Considering that much of our already prosperous meritocratic elites are tutored, shepherded, well housed, fed, and clothed while being educated, while those ostensibly of lesser intelligence often have to work, perhaps full time, and go to class, sometimes being the few people in their family to.

          This whinging over how one’s “intelligence” is the determinant of success is 90% baloney.

          Reply
  9. LaRuse

    Another way the lack of nursing care results in “wage theft” is the time/money steals from the families of people who are hospitalized.
    When my husband had back surgery in 2012, he suffered a complication that required 4 days in the hospital completely flat on his back immobilized; this suddenly wasn’t the one day overnight stay we were expecting and that I had budgeted leave from my work for.
    His nurses were all lovely caring individuals who did all that they could to alleviate the miserable conditions of being immobilized for 4 straight days he experienced, but there was one problem. They only had time to see him every several hours and he needed assistance with the most basic of care, like using the portable urinal. Pushing a call button on the bed didn’t bring them around in a timely manner resulting in one humiliating episode that required everyone to work extra hard to clean him and his bed up. Sending me out to the nurses station didn’t bring any faster assistance.
    So I ended up handling 80% of his basic care while he was bedridden including recording his vitals, dispensing meds handed to me at the door, and bathing and restroom care. I was fortunate that a) I had the paid leave at all and b) that my unanticipated days out of the office didn’t overlap any huge deadlines or projects; those days away “only” generated extra scrutiny of my work and some resentment from my manager.
    I don’t blame the nurses. They did their best and I felt genuine sympathy for them but I was “working” 8-12 hours a day for those 4 days to care full time for him when he was inside. No one paid me a nurses salary – and the bill certainly didn’t reflect anything like a discount for my time or work.

    Reply
    1. TimH

      My experience is the same. Anyone staying in hospital needs a ‘patient advocate’ to ensure routine stuff, like changing IV bags, gets done. The nurses care, but are overloaded, so if you want your patient to get priority then you have to persist.

      Bring flowers or chocolates to the nurse station helps too.

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    2. stan6565

      It is not just the “lack of nursing care” but “lack of any care” that is creeping largely into the deified NHS here in UK.

      The local hospital managed to inflict life threatening injuries on a member of family. A typical bait and switch you see, with a doctor advertised to test around internal organs but a half -brained nurse doing the procedure instead. No apology from anyone from the Trust, and all hospital employees peripheral to the matter rushing to explain how injuries sustained at testing were not caused by testing but by a conspiracy between the victim and the aliens.

      And then recovery process; temperatures, bodily fluid discharges, blood markers, all consistently made up as opposed to checked and recorded. Leading to continued wrong diagnosis and treatment.

      The surgeons who carried out the initial life saving operation refusing to record or explain what they did. No assigned consultant until two months after the event. A post operative complication recorded and advised by us, but ignored for four months. Dozens and dozens of clueless Junior doctors on an endless production line performing Chinese torture with numerous ever conflicting guesses which bit is next to be cut out of a hitherto perfectly healthy being.

      A complete abandonment of what has now turned into a very complex and very much life threatening situation with not a single “hospital consultant” stepping up with a proposal to resolve the mess their hospital created.

      And if I had not been around, personally, at a great cost to my business, every day for the last seven months, and if I had not spent tens of thousands of pounds on private paid consultants, nurses, dressing changers, special foods and so on, I would have had to be burying someone who was perfectly healthy back in April.

      And I am endlessly puzzled with this, for, I have met fantastic and caring nurses and doctors and consultants, but who seemed to be stopped from offering proper and timely care by exceptionally convoluted NHS rules of engagement. And I have met several times more deadbeats, utterly disinterested in any notion of “health provision”, happy to ride on the backs of the working ants.

      Crapification? Entropy? Don’t know what to call it, but it’s sure not what I have been paying taxes for, the last 30+ years.

      Reply
  10. Mike

    Having worked in nursing homes for a period of my life in the 90s, the critical movement there was toward cheaper labor cost and faster outcomes. To whit: RNs being drafted into administrative and bureaucratic work instead of floor duty/patient care; LPNs having the bulk of patient care and responsibility handed to them/forced upon them while earning a fraction of an RN’s wage; Nursing Assistants (NAs) having to do just about everything else, including some med dispensing, with giving notice to overworked LPNs of distress in room “x” when LPN was not available due to doing RN work. This allowed scurrilous operators to make a bundle while paying low wages for something I called “senior warehousing”. The “faster outcome” was produced by awful enough care to result in hospitalization and death at a faster rate to cycle waiting list recipients in need of warehousing but promising, eventually, the same or worse care. Doctors? Well, they visited once a month unless some trauma occurred, which seemed to bother said doctors, as they were busy helping other paying patients worth more to them (most nursing home patients ending up on Medicare payments that shorted these fine physicians).

    So, was this an experiment to be copied in broader healthcare, or just a criminals pasture in a field of grass aplenty? Oh, another factoid of note: most NAs were immigrants, some not having English enough outside rudimentary ESL courses to properly do the LPN work assigned, and who therefore received even lower wages. Efficient, legal – and deadly. Segue to the present…

    Reply
  11. Chris Hargens

    I work in a hospital and see the same thing to varying degrees. What’s not mentioned here is the under-staffing of nursing support staff (certified nursing assistants, CNAs). These are the people that do the grunt work — bathing the patients, taking them to the restroom or changing their diapers, spoon-feeding them when necessary, as well as checking some vitals and, when requested, helping the nurses carry out tasks.

    Reply
  12. roxan

    Some hospitals actually try to make the RNs do the cleaning, and reduce the actual housekeeping staff–so no cleaning gets done! On the topic of nursing staff shortage–during a staff meeting, I once got up and told a manager what a problem we were having. I stupidly thought he was clueless and would help! (I was new to nursing). He turned beet red and shouted, “We are staffed exactly the way we want it. Sit down and shut up!” After that, I realized there is not and never has been a ‘nursing shortage.’ Hospitals are saving money by short staffing. While nurses are crucial to running a hospital, the management views them as an expensive nuisance. The more money they can save by cutting staff and supplies, the more they are rewarded with bonuses.

    Reply
    1. m

      Totally agree. Forget a private nurse cause they can’t do anything in the hospital unless they are an employee, I would however talk to staff about a private aid. Won’t be covered, but it’s the little things that are hard to get to when people need it (bathroom).
      1 There is no nursing shortage, they just short staff.
      2 New grads make a run back to school once they see what the job is like
      3 Burnout with RNs & CNAs, too much work, no breaks
      No gifts required just be pleasant & understanding. We are not supposed to say this but it’s a hospital not a hotel and the worst are people who yell at you for petty reasons, which wastes time you don’t have!
      Mass just tried to pass a RN to patient ratio last year, didn’t get through. CA is only state ensures ratios & breaks.

      Reply
      1. Furies

        Believe me, it sucks in California too.

        I was an RN. Didn’t stay an RN. Too much asked of me, too many risks and very little job satisfaction. The hours are terrible for any kind of life, and the demands of staffing interfering on one’s days off… Went home each evening feeling like a failure–cuz you’re set up to fail. Too many patients (15 and 3 admits is fing cra cra), not enough support (how in the heck and I suppose to allot time to administer an IV push chemo drug over 15 minutes??–yeah, right-ti-o).

        I personally never made the ‘big bucks’ due to my employment choices (County hospitals and free clinics) and that’s on me. But boy was I incensed when I found out a young neighbor of mine who is working as an *AIDE*, was making 20$ at our local hospital. She deserves it of course, but!

        I never made that much as an RN and I’m pissed.

        Reply
  13. Danny

    Why so many Filipino nurses?
    Prostitution, especially around Clark Air Base, in the Philippines was a big problem. How to fix it? And avoid paying American nurses a living wage?

    “The Philippines is the centre of a large, mostly private nursing education sector and an important supplier of nurses worldwide, despite its weak domestic health system and uneven distribution of health workers. This situation suggests a dilemma faced by developing countries that train health professionals for overseas markets: how do government officials balance competing interests in overseas health professionals’ remittances and the need for well-qualified health professional workforces in domestic health systems?”

    Health Policy and Planning-London School of Hygiene and Tropical Medicine

    https://academic.oup.com/heapol/article/28/1/90/645345

    Reply
    1. m

      Filipino nurse are some of the best I have worked with. Businesses pay them less and use them up. In NYS there was one that quit appropriately from home-care job that was mistreating her and the agency tried to charge her with patient abandonment.

      Reply
  14. rjs

    i get that nurses are overworked…but are there a lot of unemployed nurses to spell them?

    same questions relate to doctors..

    so what happens when you pass medicare for all?

    Reply
  15. Luke

    Joe Well
    December 6, 2019 at 9:06 am
    “Applying Prasad’s Law to education:

    The one thing that reliably and incontrovertibly improves student outcomes, across many studies, is smaller student:teacher ratios, ie, hiring more teachers.

    And the billionaire-backed think tanks have fulminated against hiring more teachers more than anything else except teacher unions, advocating all kinds of unproven reforms that transfer power and authority away from teachers, like “entrepreneurial” principals who usurp lesson and curriculum planning responsibilities, and most hideous of all, “accountability” via standardized test scores.”

    Nah. Not letting anyone with any Education degree, NEA membership (past or present) or anything they have ever written, set foot on school property would improve things much more. Further, getting rid of all social promotion and affirmative action, along with requiring actual degrees in the subject matter*, would make for much more of a meritocracy, where by definition there would be better workers doing a better job.

    Further, what’s the problem with standardized tests? If a kid is too stupid to be in a given class or grade, he shouldn’t be there. If the test is too lenient or off-subject, fix the test. You don’t have a problem with medical tests or tests for professionals (bar exam for lawyers, board tests for M.D. specialists, etc.), surely?

    *Yes, the Chemistry and Computer instructors would have to be paid way more than the P.E. or Social Studies teachers. That is not a wrongful thing.

    Reply
  16. Mitch Stanley

    Hi, Thanks for the article. I wanted to share my thoughts-
    Hospitals are importing foreign RN to work in hospitals –

    a. Spokane Wa, imported ~100 RN & then fired part of current staff

    b. Hospital in West Virginia imported nurses from India .

    c. RN I worked with in CA worked in Baltimore,MD ( from the Philippines ) .He stated he was paid $10/hr (5 Yr experience as a ICU RN) instead of $40 + ( He was locked in for 5 Year Contract) .

    I always thought I had Job Security but I did not think about foreign RN’s being brought in by the boatload
    resulting in wage suppression and …..

    Reply

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