The NYC nurses strike reveals a fundamental flaw in US health care

“The experts I’ve spoken with over the past few years generally agree that nurses are tremendously undervalued given the importance of their work in delivering quality health care. Research has found repeatedly that more nursing staff leads to patients reporting a better experience in the hospital and better health outcomes.
But the problem is, given the way health care in the US is typically paid for, hiring more nurses and making their work environment better doesn’t necessarily make good economic sense for these hospitals.”

“Nurses point to exorbitant executive compensation (which soared nationwide during the pandemic) and multimillion-dollar real estate deals to explain their decision to strike. They have a point: Hospitals behaving on pure altruism would spend more on clinical staff without their nurses needing to go on strike to force their hand.”

“Slashing executive pay (Montefiore’s CEO makes $6 million a year) can only pay for so many new nursing positions. Canceling a $38 million land deal in White Plains would make more money available, but when revenue depends on the number of services that a hospital system provides, buying land and building new facilities does make fiscal sense.”

“Under the fee-for-service model that still dominates American health care, where every physician service can be billed by the hospital where they work, hospitals have every incentive to expand their services but little incentive to hire more nurses to support that work. From a hospital’s accounting perspective, nurses are entirely a cost. They do not generate any revenue directly, even though they are necessary to providing quality medical care.”

““What we forget is when hospitals put profits over patients, they are operating well within the system of economic carrots and sticks that we created for them, and within the system we created, hospitals are acting completely rationally as any other economic agent would,” Olga Yakusheva, a health care economist at the University of Michigan, said. “There is no economic incentive, right now, for hospitals to invest in adequate nurse staffing, pay nurses well, or provide a good working environment for nurses.”

Until the US gives hospitals good financial reasons to invest in their nursing staffs, these labor disputes are going to occur again and again. As much as we want our health system to be focused on quality health care, in America, health care is a business.

Good health care and profitable health care are not always the same thing. The failure to value nursing in the way we pay for medical services, which laid the groundwork for NYC’s nurses strike, is a stark example of that.”

A nurse made a fatal error. Why was she charged with a crime?

“The argument here is not about whether nurses should be held accountable for their errors; everyone I spoke with about Vaught’s case agrees she bears responsibility for her actions and should face consequences. The real issue is that criminalizing a nurse’s error lets hospitals off the hook for the systemic changes that would improve patient safety.

“Almost no mistakes happen in a hospital by just one person,” said Gatter. Systems exist to prevent medical errors, he said. If those systems don’t work or exist only on paper, errors will happen.

In this case, the system failures were clear: During an unannounced visit to Vanderbilt University Medical Center in late 2018, federal investigators found multiple deficiencies, some of which placed patients at “serious and immediate threat,” according to the 105-page memo documenting the details. For example, hospital policies didn’t require that a second nurse sign off on the use of a highly dangerous medication like vecuronium, nor did it require that patients receiving sedatives be hooked up to a heart and lung monitor. Focusing the blame on one nurse’s error shifts the attention away from those deficiencies.

“I’m quite concerned that this nurse is getting thrown under the bus, and in the hubbub of giving her a jail sentence, that the system itself will escape close examination,” said Gatter.

Even if a nurse were solely responsible for a medical error resulting in patient harm, the way to prevent that nurse from causing further harm is to revoke their license, said Gatter. It’s much harder to explain how punishing a nurse with jail time further prevents them from endangering others.

However, it’s easy to see how that type of punishment can itself create and compound safety risks, he said.

That’s because severely punishing individuals for systemic problems has a chilling effect on others’ willingness to report mistakes.”

“Less transparency in error reporting also means hospitals have fewer opportunities to correct big problems. That means faulty systems stay in place, which translates into more vulnerability and stress for health care providers and less safety for patients.”

“The consequences for professional malpractice should ideally deter wrongdoing without discouraging people from entering the profession altogether — but finding that balance is challenging.”

“American nursing was under enormous strain well before the pandemic. But with the US population aging, surging retirements among bedside nurses and nurse educators, and nurse staffing levels reduced ever lower to contain costs, the pandemic has tipped parts of the country into a full-on nursing shortage.
The last thing the profession needs is another reason for nurses to leave jobs providing direct patient care, but that’s exactly the effect the Vaught ruling is having”

States gripped by Delta variant face case surge with fewer health workers

“Hospitals and lawmakers in states gripped by the Delta variant are offering nurses tens of thousands of dollars in signing bonuses, rewriting job descriptions so paramedics can care for patients and pleading for federal help to beef up their crisis-fatigued health care workforces.

The alarming spread of new cases is draining the pool of available health workers in ways not seen since the pandemic’s winter peak, forcing officials to improvise and tear up rules dictating who cares for whom. Governors and hospital directors warn that the staffing crisis is so acute that patients, whether suffering from Covid-19, a heart attack or the effects of a car accident, can no longer expect the level of care that might have been available six weeks ago.”

” Hospitals can respond by adding beds and ordering more protective gear. But they’re stuck fighting over the same finite pool of nurses, lab techs, nurse assistants and front desk workers, whose ranks have already been depleted by retirements and resignations. The Delta variant’s transmissibility — the U.S. is averaging 140,000 cases per day, up from 12,000 six weeks ago — is leaving few regions untouched, making it harder to call for reinforcements.”

“Some nurses say hospitals facing surges are paying more to recruit new nurses, or hire temps from a staffing agency, than to retain the current staff. Some new hires can receive $20,000 signing bonuses while current staff get a $500 retention bonus, said Jamie Lucas, the executive director of the Wisconsin Federation of Nurses and Health Professionals, which is bargaining with multiple hospitals for bigger retention bonuses.”

Private equity ownership is killing people at nursing homes

“When private equity firms acquire nursing homes, patients start to die more often, according to a new working paper published by the National Bureau of Economic Research.

Private equity acquisitions of nursing homes is a pressing topic: Total private equity investment in nursing homes exploded, going from $5 billion in 2000 to more than $100 billion in 2018. Many nursing homes have long been run on a for-profit basis. But private equity firms, which generally take on debt to buy a company and then put that debt on the newly acquired company’s books, have purchased a mix of large chains and independent facilities — making it easier to isolate the specific effect of private equity acquisitions, rather than just a profit motive, on patient welfare.

Researchers from Penn, NYU, and the University of Chicago studied Medicare data that covers more than 18,000 nursing home facilities, about 1,700 of which were bought by private equity from 2000 to 2017.

Their findings are sobering.

The researchers studied patients who stayed at a skilled nursing facility after an acute episode at a hospital, looking at deaths that fell within the 90-day period after they left the nursing home. They found that going to a private equity-owned nursing home increased mortality for patients by 10 percent against the overall average.”

“the increased mortality is concentrated among patients who are relatively healthier. As counterintuitive as that may sound, there may be a good reason for it: Sicker patients have more regimented treatment that will be adhered to no matter who owns the facility, whereas healthier people may be more susceptible by the changes made under private equity ownership.

Those changes include a reduction in staffing, which prior research has found is the most important factor in quality of care. Overall staffing shrinks by 1.4 percent, the study found, but more directly, private equity acquisitions lead to cuts in the number of hours that front-line nurses spend per day providing basic services to patients. Those services, such as bed turning or infection prevention, aren’t medically intensive, but they can be critical to health outcomes.”

“The combination of fewer nurses and more antipsychotic drugs could explain a significant portion of the disconcerting mortality effect measured by the study. Private equity firms were also found to spend more money on things not related to patient care in order to make money — such as monitoring fees to medical alert companies owned by the same firm — which drains still more resources away from patients.”

“The researchers make a point in their opening to stipulate that private equity may prove successful in other industries. But, they warn, it may be dangerous in health care, where the profit motive of private firms and the welfare of patients may not be aligned”

Nursing homes need fixing. Here’s where to start.

“Although less than half of 1 percent of the U.S. population resides in nursing homes, they account for nearly 40 percent of all Covid deaths. Nursing homes are supposed to help residents remain safe and healthy, but the opposite turned out to be the case: When it came to the coronavirus, residents in nursing homes were more vulnerable, not less.”

“rebuilding nursing home facilities is an expensive and long-term solution to an immediate crisis. I’ve been studying long-term care settings for many years, and I think there’s a quicker and possibly even more effective approach we can take in the short term to ensure better care for our seniors in the post-Covid era: improve staffing.

It’s no secret that nursing home staff are paid relatively poorly for incredibly demanding work. Certified nurse aides who provide over 90 percent of direct resident care are often paid at or near minimum wage — the same wages as entry-level workers in retail establishments or fast-food chains. Nursing staff are also underpaid; registered nurses and licensed practical nurses who work in nursing homes are often paid below their counterparts who work in hospitals and other health care settings.

What’s more, nursing home staff often lack essential benefits, like health insurance and paid sick leave. That means nursing home workers are incentivized to come to work even when sick — how does that make sense when they are caring for medically vulnerable residents during a pandemic?

Nursing homes are also very hierarchical workplaces with lower-level staff having little autonomy and control in their jobs. Not surprisingly, being undervalued and unempowered makes it hard to recruit and retain individuals to work in nursing homes.

The result is that many facilities around the country often have dangerously low levels of staffing. Additionally, the average U.S. nursing home was recently found to have an annual staff turnover rate of 128 percent. This suggests an average facility’s staff completely changes over the course of a year, and many nursing homes have even higher turnover rates — as much as 300 percent — suggesting the staff changes every four months. If some part of good nursing home quality depends on the relationship between staff and residents, it’s hard to see how those relationships can develop when staff keep changing.”

“There are a number of things we can do to improve this situation. Here are a few ideas”

“One solution would be to increase the number of direct care workers by raising the federal minimum staffing standards in nursing homes. The federal standards are relatively low and have not been updated in over 30 years. Many states set staffing levels above the federal standards and these state policies have generally been found to increase staff.”

“Another idea is to raise minimum wages to increase nursing home staff pay. Many certified nurse aides would see their hourly wages increase under the $15 minimum wage proposed by the Biden administration. In the absence of a broader minimum wage hike, policymakers could also increase wages specifically for nursing home and other long-term care workers.”

“The elephant in the room is what additional Medicaid or other public funding would be necessary to pay for greater staffing and higher wages. The nursing home industry will inevitably push back against any “unfunded mandates.” The Medicare Payment Advisory Commission has found overall nursing home operating margins are currently thin based on the Medicare cost reports. However, there is quite a bit of variability in profitability across facilities. It is also unclear whether some facilities are accurately reporting their costs. Resident advocates have questioned whether a sufficient amount of existing public nursing home funds are spent on staffing. Thus, higher Medicaid funding will be necessary to improve staffing levels and wages, but it needs to be paired with the next suggestion.”

“We currently lack transparency in how nursing homes spend public dollars on staffing and other areas. Nursing homes are required to submit Medicare cost reports each year to detail their revenues and spending, but these data are known to be incomplete, especially in the context of increasingly complicated corporate ownership arrangements. A series of financial reporting and oversight steps need to be taken to tighten the requirements for facilities. The bottom line is that regulators need to be able to follow the public’s money and ensure it is being spent on staffing as policymakers intended.”

“Beyond putting more money into wages, policymakers might also consider ways in which they could provide financial support to allow additional education and training to certified nursing assistants and licensed practical nurses seeking upward mobility within a facility. For example, some nursing homes currently have ladder programs that provide nursing assistants with financial support in seeking nursing degrees. These programs could be expanded through direct reimbursement via Medicare and Medicaid.”

“Improving wages and benefits is a necessary but insufficient step towards valuing nursing home caregivers; we also need to begin to value the work these individuals do and the individuals that do it. If you can believe it, this might be harder than increasing staffing standards and wages. Finding additional money is one thing — changing the culture around nursing home staffing is another.”

The US needs foreign doctors and nurses to fight coronavirus. Immigration policy isn’t helping.

“Right now, the biggest worry is whether the medical system has enough ventilators and protective equipment to treat patients with Covid-19, the disease caused by the novel coronavirus.
But another troubling shortage is on the horizon: doctors, nurses, and other health care personnel.

As patient demand continues to ramp up nationwide and more health care workers are unable to show up for work, either because they contract the virus or because they have to self-quarantine, doctor shortages are a real possibility”

“One solution is to make it easier to bring in doctors and nurses from abroad.”

“even before the current crisis, the immigration system made it difficult for foreign doctors and nurses to work in the US and go where they’re needed. Doctors may face long wait times for green cards, restrictions on where they can settle geographically, and limitations on where they can practice while they’re waiting for a green card. Nurses, meanwhile, also face long waits for green cards and can’t come to the US under temporary skilled worker visas.

The implications of a shortage would be devastating, both to overworked personnel and to the patients for whom receiving medical attention could be a life-or-death matter. But it’s a problem that more immigration could easily fix”

“Not only does the current system make it exceedingly difficult for doctors to stay in the US long-term, but it also severely restricts where in the US they can go.”